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THE 


Practice  oe  Surgery 


A  TREATISE  ON  SURGERY  FOR  THE  USE  OF 
PRACTITIONERS  AND  STUDENTS 


BY 

HENRY  R.  WHARTON,  M.D. 

CLINICAL   PROFESSOR   OF   SURGERY,   \VO:«AN'S   A\EDICAL    COLLtGE   OF    PENNSYLVANIA;    SURGEON   TO   THE 
PRESBYTERIAN   AND  THE    CHILDREN'S    HOSPITALS;     CONSULTING   SURGEON  TO  ST.  CHRISTO- 
PHER'S   HOSPITAL    AND   THE    BRYN    MAVVR     HOSPITAL;     FELLOW    OF    THE 
AAIERICAN   SURGICAL   ASSOCIATION 

AND 

B.  FARQUHAR  CURTIS,  M.D. 

PROFESSOR   OF   CLINICAL   SURGERY   AND    ADJUNCT    PROFESSOR    OF   THE    PRINCIPLES    OF    SURGERY    IN   THE 

UNIVERSITY   AND    EELLEVUE    MEDICAL    COLLEGE    OF    NEW   YORK;     SURGEON   TO  ST.    LUKE'S 

HOSPITAL,    BELLEVUE    HOSPITAL,    AND  THE   MEMORIAL    HOSPITAL;   FELLOW 

OF  THE    AMERICAN    SURGICAL   ASSOCIATION 


PROFUSELY     ILLUSTRATED 


THIRD  EDITION 


PHILADELPHIA   AND   LONDON 

J.    B.    LIPPINCOTT    COMPANY 
1902 


(%hiM^ 


Copyright,  1897,  by  J.  B.  Lippincott  Company 


Copyright,  1899,  by  J.  B.  Lippincott  Company 


Copyright,  1902,  by  J.  B.  Lippincott  Company 


^. 


PREFACE  TO  THIRD  EDITION. 


In  the  present  editiou  of  this  work  the  authors  have  endeavored  to 
maintain  its  practical  character  ;  the  articles  have  been  thoroughly  revised, 
and  much  new  matter  has  been  introduced.  They  recognize  the  fact  that 
to  give  a  synopsis  of  the  science  of  surgery  in  one  volume  becomes  each 
year  a  more  difficult  task,  owing  to  the  extension  of  the  field  of  surgery 
since  the  adoption  of  aseptic  methods.  It  appeared,  however,  feasible  to 
condense  within  that  limit  the  infornration  necessary  to  enable  the  general 
practitioner  or  the  student  to  carry  on  or  begin  the  successful  practice  of 
the  art  of  surgery.  It  seemed  to  them  that  the  essential  information 
included  (1)  a  description  of  the  various  injuries  and  surgical  diseases 
sufficiently  full  to  enable  the  practitioner  to  recognize  them  when  met  with 
in  practical  work.  (2)  Pull  directions  for  the  treatment  of  such  injuries 
and  diseases  as  would  usually  be  attended  by  the  general  practitioner. 
(3)  A  sketch  of  the  treatment  of  the  more  difficult  conditions,  such  as  would 
allow  the  piactitioner  to  advise  patients  intelligently  in  obtaining  special 
skilled  surgical  attention.  (4)  An  outline  of  the  accepted  facts  and  theories 
of  the  etiolog'y  and  pathology  of  the  various  surgical  affections  sufficient  to 
form  a  foundation  for  the  clinical  picture  and  give  directions  for  the  treat- 
ment. Even  with  these  limitations  the  material  is  so  bulky  as  to  require 
great  condensation  and  the  most  careful  choice  of  those  subjects  which  were 
to  receive  detailed  treatment.  The  authors  cannot  hope  that  all  their  critics 
will  agree  with  them  in  the  decision  of  the  relative  proportions  assigned  to 
the  various  topics,  but  they  trust  that  the  practical  conclusions  will  be  found 
conservative  and  yet  thoroughly  modern.  They  hope  that  the  book  will 
prove  a  useful  guide  to  the  student  in  the  beginning  of  his  work  in  the 
complicated  science  of  surgery,  and  that  it  may  also  serve  as  a  ready  help 
in  the  solution  of  the  surgical  problems  which  confront  the  busy  general 
practitionei". 

Although  the  authors  have  signed  their  individual  articles,  they  jointly 
endorse  the  practical  conclusions  arrived  at  throughout  the  work. 

It  has  seemed  advisable  to  limit  the  chapter  on  Surgery  of  the  Eye,  by 
Professor  George  E.  de  Schweinitz,  to  Injuries  of  the  Eye  and  its  Appendages. 


iv  PREFACE  TO  THIRD  EDITION. 

The  majority  of  the  illustrations  used  are  original,  and  were  made  from 
photographs  or  drawings.  When  illustrations  have  been  taken  from  other 
sources,  the  authors  have,  where  it  was  possible,  credited  the  source  from 
which  they  were  taken. 

The  authors  desire  to  express  their  thanks  to  Dr.  Timothy  Matlack  Chees- 
man,  Chief  of  the  Department  of  Bacteriology  in  the  College  of  Physicians 
and  Surgeons,  Columbia  University,  New  York,  for  valuable  assistance  in 
the  preparation  of  some  of  the  illustrations  of  bacteria,  and  to  Dr.  Francis 
Carter  Wood,  late  House  Surgeon  to  St.  Luke's  Hospital,  of  New  York,  for 
drawings  of  bacteriological  and  histological  subjects.  They  also  desire  to 
express  their  thanks  to  Dr.  J.  H.  Jopson,  of  Philadelphia,  for  careful 
revision  of  the  proof-sheets. 

Henry  E.  Wharton, 
B.  Farquhar  Curtis. 

Philadelphia,  August,  1902. 


CONTENTS. 


CHAPTER   I.  PiGE 

SUBQICAL   BACTEKIOLOGT 1 

CHAPTER   II. 
Patholoot  op  Inflammation  14 

CHAPTER    III. 
Symptoms  and  Treatment  of  Inflammation  25 

CHAPTER    IV. 
Sapb^mia,  Septicaemia,  PT.a:MiA  31 

CHAPTER   V. 
Ulceb,  Sinus,  Fistula  37 

CHAPTER   VI. 
Inflammation  of  Special  Tissues  43 

CHAPTER    VII. 
Special    Fobms    of    Infection— Erysipelas — Malignant    (Edema — Anthkax — 
Glanders — Actinomycosis — Tuberculosis — Leprosy — Tetanus  —  Hydbo- 
PHOBIA    49 

CHAPTER   VIII. 
Repaib  of  Wounds — Eegenebation  of  Tissues   75 

CHAPTERIX. 
Conditions  affecting  the  Results  of  Operations  and  Injuries  84 

CHAPTER   X. 
Shock,  Traumatic  Feveb,  Deubium  Tremens,  Traumatic  Neurasthenia,  Fat 
Embolism   91 

CHAPTER   XI. 
Gangrene — Senile  Gangrene — Embolic  Gangrene — Diabetic  Gangrene— Tbau- 
matic   Gangrene — Infective   Gangrene — Gangrene   prom   Pressure — Sym- 
metrical Gangrene 101 

CHAPTER   XII. 
Asepsis  and  Antisepsis 1 12 


vi  CONTENTS. 

CHAPTER    XIII. 

PAGE 
MiNOB    SUHOEBT BANDAGING PlASTEE-OP- PARIS    BANDAGE COUNTEBIEBITATION— 

Abtificial  Respiration — Hypodeemoolysis  132 

CHAPTER   XIV. 
Wounds— Gunshot  Wounds — Gunshot  Feactures — Burns  and  Scalds — Frost- 
bite— Injuries  from  Electricity — Lightning  Stroke — Diseases  of  Cica- 
trices     ■  ■  ■  \ ^"^^ 

CHAPTER   XV. 
Anaesthetics — Local    Anaesthesia — Regional    Anaesthesia — General    Anaes- 
thesia      201 

CHAPTER    XV L 
Amputations  216 

CHAPTER    XVI  L 
Plastic  Surgery 260 

CHAPTER    XVII  L 
Tumors 266 

CHAPTER    XIX. 
Surgery  of  the  Lymphatic  System  317 

CHAPTER    XX. 

SUEGEBY   OF   THE    BlOOD-VESSELS WoUNDS    OP    ARTERIES HEMORRHAGE DISEASES 

OP  Arteries — Aneurism — Wounds  op  Veins — Diseases  op  Veins   322 

CHAPTER    XXL 
Ligation  op  Arteries 379 

CHAPTER   XXI  L 
Suegeey  op  the  Nerves   396 

CHAPTER    XXII  L 
Suegeby  of  Muscles,  Tendons,  FascIaE,  and  BuesjE   410 

CHAPTER    XXIV. 

Subgery  of  the  Osseous  System — Fractures — Separations  op  the  Epiphyses 
—  Ununited  Fracture  —  Pseudoarthrosis  —  Periostitis  —  Osteitis  and 
Osteomyelitis 424 


CONTENTS.  vii 

CHAPTER   XXV.  p^^^. 

suegebr    of   the   joints wotjnds    op   joints dislocations synovitis 

Arthritis  557 

CHAPTER    XXVI. 
Operations  upon   the  Joints  and  Bones — Excisions  and  Resections — Oste- 
otomy       642 

CHAPTER   XXVII. 
Orthopedic   Surgery    665 

CHAPTER   XXVIII. 
Surgery  of  the  Head — Fractures  of  the  Skull — Injuries  of  the  Brain — 

Meningitis — Abscess  of  Brain — Cerebral  Localization   697 

CHAPTER    XXIX. 
Injuries  and   Surgical  Diseases   of   the   Face — Harelip — Carcinoma   of   Lip 

■ — Diseases  of  Nasal  Sinuses 742 

CHAPTER   XXX. 
Surgery  of  the  Tongue,  Cheeks,  Gums,  Jaws,  and  Soft  and  Hard  Palate — 
Cleft  Palate    760 

CHAPTER    XXXI. 
Surgery  of  the  Neck — Abscess — Tumors — Diseases  of  the  Salivary  Glands — 
Diseases  of  Tonsils — Diseases  of   Pharynx — Diseases  of  CEsophagus — 
Diseases  of  Thyroid  Gland  788 

CHAPTER    XXXII. 
Surgery  of  the  Air-Passages — Tumors  of  Larynx — Thyrotomy — Excision  of 

Larynx — Teacheotomy^ — Intubation  of  the  Larynx  808 

CHAPTER    XXXII  L 
Surgery  of  the  Chest — Injuries  of  the  Lung — Thoracotomy — Thoracoplasty 

— Pneumonotomy — Pneumonectomy — Injuries  of  the  Heart  833 

CHAPTER    XXXIV. 
Surgery  of  the  VERTEBEiE  and  Spinal  Cobd — Fractures  and  Fracture-Dislo- 
cations   of    the    Spine — Spina    Bifida — Injuries    of    Spinal    Cord — Lam- 
inectomy       848 

CHAPTER   XXXV. 
Surgery  of  the  Breast — SIastitis — Abscess  of  the  Breast — Tumors  of  the 
Breast  860 


viii  CONTENTS. 

CHAPTER    XXXVI.  p^^e 

Injuries  of  the  Eye  and  its  Appendages  882 

CHAPTER    XXXVII. 
Injuries  and  Diseases  of  the  Ear  839 


CHAPTER  XXXVIII. 
Suegert  of  the  Abdomen — Peritonitis — Subphrenic  Abscess — Abscess  of 
Liver — Hydatid  Cyst  of  Liver — Diseases  of  Gaix-Bladder  and  Biliary 
Ducts — Gastrotomy — Gastro-Enterostomy — Fecal  Fistula — Enterotomy 
— Enterostomy  —  Colostomy — Appendicitis  —  Intestinal  Obstruction  — 
Intussusception — Volvulus — Diseases  of  Pancreas — Diseases  of  Spleen 
— Diagnosis  of  Abdominal  Tumors — Hernia  899 

CHAPTER  XXXI  X. 
Surgery  of  the  Urinary  Organs — Hypospadias — Epispadias — Urethritis — 
Stricture  of  Urethra — Urethrotomy — Exstrophy  of  Bladder — Rupture 
of  Bladder — Cystitis — Tuberculosis  of  Bladder — Hypertrophy  of  Pros- 
tate —  Prostatectomy  —  Vesical  Calculus  —  Litholapaxy — Lithotomy 
— Tumors  of  Bladder— Cystoscopy — Movable  Kidney — Pyelitis — Perine- 
phritis— Tumors  of  Kidney — Renal  Calculus — Nephrotomy — Nephrec- 
tomy— Nephrorrhaphy — Diseases  op  the  Ureter  995 

CHAPTER    XL. 
Surgery   of   the   ISIale    Genitals — Congenital   Malformations — Phimosis — 
Paraphimosis — Ectopic     Testicle — Tumors     op     Testicle — Hydrocele — 
Varicocele — Prostatitis — Vesiculitis — Impotence — Sterility  1 064 

CHAPTER   XLL 

Surgery  of  the  Female  Genitals — Congenital  Malformations — Laceration 
OF  Perineum — Laceration  of  Cervix  Uteri — Vaginal  Fistula — Vaginitis 
— Endometritis — Pelvic  Peritonitis — Tumors  of  Vulva — Prolapsus  of 
Uterus — Tumors  of  Uterus — Hysterectomy — Salpingitis — Tumors  of 
Ovary — Pelvic  Hematocele — Extra-Uterine  Pregnancy 1096 

CHAPTER   XLIL 
Surgery  of  the  Anus  and  Rectum — Congenital  Malformations — Fissure  of 
Anus — Epithelioma    op    Anus — Stricture    of    Anus — Proctitis — Ischio- 
rectal Abscess — Fistula  in  Ano — Hemorrhoids — Ulceration  of  Rectum 
— Stricture   of   Rectum — Prolapse   of   Rectum — Polypus   of   Rectum — 
Tumors  of  Rectum — Proctectomy   1156 

CHAPTER   XLIII. 
Venereal    Diseases — Syphilis — Chancre — Inherited    Syphilis — Chancroid — 
Gonorrhcea — Chronic  Urethritis — Gonorrhoea  .in  Female — Condylomata, 
OR  Venereal  Warts   1194 


THE 

PRACTICE   OF  SURGERY. 


CHAPTER    I. 

SURGICAL    BACTERIOLOGY. 

By  B.  Paequhae  Curtis,  M.D. 

A  MiCEO-OE&ANiSM,  Or  micTobe,  is  a  minute  plant  or  animal — too  small, 
as  a  rule,  to  be  visible  to  the  unassisted  eye.  Tlie  word  germ  may  be  used 
to  designate  any  micro-organism  which  is  the  cause  of  disease,  but  it  has  so 
many  other  meanings  and  has  been  so  loosely  employed  even  in  this  sense 
that  it  cannot  be  used  for  accurate  scientific  description.  Bacteria  are  minute 
plants  of  the  order  of  fungi,  many  of  which  are  able  to  produce  fermenta- 
tion, decomposition,  or  disease.  Although  the  word  bacterium  by  deriva- 
tion has  the  same  meaning  as  bacillus,  and  indicates  a  rod-shaped  fungus, 
it  has  been  so  loosely  employed  that  it  may  very  well  be  applied  to  the 
entire  family,  retaining  the  term  bacillus  in  the  narrower  seuse. 

Very  few  of  the  unicellular  animal  micro-organisms,  usually  called  pro- 
tozoa, have  been  proved  to  cause  disease,  and  the  only  imxjortant  ones  thus 
far  discovered  are  the  malarial  germs  of  Laveran,  the  dysenteric  amoeba  of 
Koch  and  Kartulis,  which  is  also  said  to  cause  abscesses  of  the  liver,  and, 
finally,  tlie  sup^josed  "parasites"  (sporozoa,  psorospermise,  or  coccidia)  of 
malignant  tumors,  the  real  nature  of  which  is  still  uncertain. 

The  vegetable  micro-organisms  which  are  surgically  important  are  the 
schizomycetes  or  bacteria,  the  saccharomycetes  or  yeast  plants,  and  the 
actinomyces  or  ray-fungus.  The  last-named  appears  to  be  a  mould-fungus 
rather  than  a  bacterium,  although  its  exact  relations  are  not  yet  settled,  and, 
as  it  is  the  only  one  of  its  kind,  we  refer  for  its  description  to  the  section  on 
actinomycosis.     The  saccharomycetes  are  of  little  surgical  interest. 

Description  of  Bacteria, — The  schizomycetes,  however,  include  aU 
the  bacteria  of  putrefaction  and  disease,  the  former  being  called  saprojihytic 
and  the  latter  pathogenic  bacteria.  They  are  minute  fungi,  each  consisting 
of  a  single  cell,  enclosed  in  a  cell-membrane  of  cellulose,  that  can  be  demon- 
strated by  iodine,  which  causes  the  ijrotoplasm  to  retract  from  the  cell  wall. 
There  is  no  nucleus.  Some  of  the  bacteria  are  colorless,  others  pigmented, 
— yellow,  blue,  or  red.  The  cells  vary  in  shape  and  size  in  the  different 
species,  as  well  as  in  their  mode  of  growth,  and  are  named  in  accordance 
with  these  peculiarities.  The  round  or  oval  cells  are  called  cocci;  the  rod- 
shaped  organisms,  bacilli.     The  cocci  are  called  micrococci  or  macrococci, 

1 


2  HABITAT   OF  BACTERIA. 

according  to  their  size  ;  diplococci  or  tetracocci,  according  to  the  production 
of  pairs  or  groups  of  four  iu  their  multiplication  ;  and,  finally,  certain  spe- 
cies are  called  streptococci,  because  in  their  growth  they  always  form  chains 
of  cells,  while  others  are  known  as  staphylococci,  because  they  grow  in 
irregular  clusters  resembling  bunches  of  grapes.  Some  of  the  bacteria  have 
the  power  of  motion,  generally  produced  by  cilia  or  flagella  (Plate  I.,  Fig.  8), 
and  some  are  motionless. 

Habitat. — The  air,  the  water,  the  ground,  our  clothing,  our  food,  even 
our  own  bodies  contain  these  omnipresent  micro-organisms,  among  which 
pathogenic  germs  may  be  found.  Every  species  has  its  particular  habitat, 
where  the  conditions  especially  favor  its  growth,  just  as  any  of  the  larger 
plants  requires  to  be  suited  in  the  soil,  the  supply  of  water,  the  temperature, 
and  the  proper  amount  of  light  in  order  to  make  its  growth  and  multiislica- 
tion  possible.  The  bacteria  in  the  air  are  more  numerous  in  dry  weather, 
being  carried  up  as  dust  by  the  wind,  for  a  moist  surface  holds  any  bacteria 
which  may  lie  upon  it.  The  effect  of  moisture  is  shown  by  the  fact  that  air 
which  contains  many  micro-organisms  when  inspired  may  return  from 
the  hmg  with  almost  none,  the  moist  respiratory  surfaces  catching  the 
bacteria,  so  that  the  expired  air  is  practically  sterilized ;  and  this  is  true 
even  when  the  lungs  are  diseased.  The  act  of  coughing,  however,  may 
expel  bacteria  in  the  mucus  ejected.  Thorough  drying  kills  the  majority 
of  germs,  but  some,  for  instance  the  bacillus  of  tuberculosis,  will  live  in  the 
dry  state  for  many  days.  The  number  of  bacteria  in  the  air  is  very  vari- 
able, but  it  is  greater  in  houses  than  out  of  doors,  and  is  naturally  increased 
by  attempts  to  clean  the  rooms,  the  air  in  a  hospital  being  found  to  contain 
from  forty  to  eighty  microbes  in  ten  litres  immediately  after  sweeping,  and 
several  hours  later  only  from  four  to  ten  microbes  in  the  same  quantity.  In 
Billroth' s  clinic-room  the  air  contained  most  germs  just  after  the  students 
had  left,  stirring  the  dust  with  their  feet.  Durante  found  that  the  air  con- 
tained the  greatest  number  of  microbes  at  a  level  of  about  a  yard  above  the 
border  of  the  beds  in  a  hospital  ward,  while  close  to  the  floor  it  was  almost 
sterile.  The  bacteria  which  are  found  in  the  air,  however,  belong  chiefly 
to  the  innocent  varieties,  and  the  danger  of  infection  of  wounds  from  this 
source  is  very  slight.  There  has  been  much  dispute  as  to  the  presence  of 
bacteria  iu  healtliy  human  blood,  and  it  has  finally  been  settled  that  in  per- 
fect health  it  contains  no  bacteria.  But  if  we  consider  how  small  a  wound 
or  ulcer  will  allow  the  entrance  of  the  pyogenic  germs,  and  that  this  lesion 
may  be  concealed  iu  the  mouth,  rectum,  or  elsewhere  in  the  interior  of  the 
body,  it  will  readily  be  seen  that  many  persons  who  appear  to  be  in  perfect 
health  may  have  bacteria  circulating  in  the  blood,  ready  to  implant  them- 
selves in  any  bone  or  other  part  of  the  body  the  vitality  of  which  may  be 
impaired.  Bacteria  are  very  sensitive  to  temperature,  few  being  able  to 
live  below  50°  P.  (10°  C.)  or  above  104°  F.  (40°  C),  and  the  pathogenic 
varieties  thrive  best  at  about  the  normal  temperature  of  the  blood.  Direct 
sunlight  retards  their  growth,  and  may  kill  them. 

Effect  of  Oxygen. — The  germs  require  carbon,  water,  and  nitrogen. 
Some  also  need  free  oxygen,  but  to  others  this  is  not  absolutely  necessary, 
and  there  are  some  which  cannot  grow  in  the  presence  of  free  oxygen. 


GROWTH  OF  BACTERIA.  3 

Those  -which  require  oxygen  are  called  aerobic;  those  which  do  not,  anae- 
robic ;  and  the  intermediate  class,  including  most  of  the  pathogenic  A'arieties, 
are  called  fa.ciiltative  anaerobic,  as  they  grow  either  with  or  without  oxygen. 

Parasitic  Nature. — ^The  number  of  species  of  pathogenic  germs  is 
comj)aratively  small  compared  with  the  total  number  of  all  the  varieties  of 
germs,  for  the  latter  are  practically  innumerable  ;  and  it  is  simply  by  reason 
of  this  fact,  and  the  power  which  the  animal  tissues  possess  of  resisting  the 
fungi,  that  wounds  left  without  care  and  protection  sometimes  heal  by 
primary  union,  and  that  any  animals  are  able  to  exist.  The  schizomycetes 
are  unable  to  extract  nitrogen  from  the  air  or  the  soil  like  the  higher  vege- 
tables, and  must,  therefore,  be  provided  with  the  higher  nitrogenous  com- 
Xjounds,  such  as  are  produced  by  vegetable  and  animal  life.  Some  of  them 
are  able  to  live  upon  dead  organic  matter,  while  others  cannot  exist  with- 
out living  tissues  to  feed  upon,  and  are,  therefore,  true  parasites.  There 
are  some  which  are  able  to  live  either  on  dead  or  living  tissues,  and  they 
are  known  as  facultative  parasites,  a  class  which  includes  the  majority  of 
pathogenic  germs. 

Growth.  Spores. — Bacteria  multiply  by  division,  each  cell  dividing 
into  two,  which  then  grow  as  separate  individuals,  although  they  may  remain, 
connected  in  chains  or  clumps.  A  number  of  cells  together  sometimes  throw 
out  a  gelatinous  material  which  binds  them  into  one  mass,  called  a  zoogloea. 
Some  of  the  bacteria  also  grow  by  the  production  of  spores,  which  are  endo- 
genic or  arthrogenic.     The  rapidity  of  their  growth  is  astounding. 

The  endogenic  spores  appear  as  minute  round  or  oval  bodies  in  the  centre 
or  at  one  end  of  the  bacillus,  which  is  usually  distended  by  the  growth  of 
the  spore.  The  parent  dies,  and  the  spore  is  set  free.  Under  favorable 
conditions  the  latter  will  germinate,  but  if  the  proper  soil  or  food  and  tem- 
perature are  not  at  hand,  it  remains  quiescent,  like  the  seed  of  a  plant, 
waiting,  it  may  be  for  years,  until  proper  conditions  are  present.  The 
spores  have  such  a  thick  envelope  and  such  great  vitality  that  it  is  much 
more  difficult  to  kill  them  than  the  developed  cell,  a  temperature  of  212° 
r.  (100°  C.)  moist  heat  being  required  to  destroy  the  spores  of  anthrax,  for 
instance,  whereas  130°  F.  (55°  C.)  will  kill  the  bacillus. 

The  arthrospores  are  not  so  resistant.  The  cocci  never  xjroduce  endogenic 
spores,  but  are  limited  to  the  arthrospores,  while  the  latter  are  rarer  in  the 
bacilli.  But  little  is  known  of  the  arthrospores,  and  they  appear  to  be 
simply  larger  and  more  resistant  than  the  ordinarj-  individual  cocci.  The 
growth  of  spores  is  a  sign  of  deterioration  of  the  bacteria,  for,  while  other 
fungi  produce  spores  under  any  conditions,  the  bacteria  grow  by  division  so 
long  as  the  conditions  are  favorable ;  and  it  is  only  when  a  lack  of  food- 
material,  a  change  in  temperature,  or  an  accumulation  of  their  own  poisonous 
products  threatens  them  with  extinction  that  the  more  resisting  form,  the 
spore,  is  produced. 

Toxines. — As  bacteria  grow,  certain  poisonous  chemical  substances 
aijpear  about  them,  either  produced  by  them  directly,  like  the  excretory 
matters  of  other  plants,  or  formed  in  the  organic  matter  or  tissues  in  which 
they  live  as  a  result  of  their  presence.  Some  of  these  substances  are  alka- 
loidal,  and  are  known  as  ferments  ov  ptomaines,  while  others  are  albuminous 


4  CULTIVATION   OF  BACTEEIA. 

in  nature,  and  are  called  toxalbwmins.  The  word  toxine  is  employed  by 
some  writers  as  equivalent  to  ptomaines,  and  by  others  as  synonymous  with 
toxalbumins.  The  ptomaines  and  toxalbumins  are  exceedingly  powerful 
poisons,  producing  local  necrosis,  inflammation,  and  even  suppuration, 
when  introduced  alone,  entirely  free  from  living  germs,  into  the  tissues  of 
animals.  The  local  and  general  symptoms  of  this  intoxication  depend  upon 
the  xDarticular  toxine  emj)loyed,  and  a  large  number  of  these  poisons  have 
been  isolated  and  studied.  Those  of  the  surgically  important  pathogenic 
germs  produce  inflammation  locally,  with  general  symptoms  of  fever,  chills, 
cardiac  depression,  irritation  of  the  kidneys  and  bowels,  and  cerebral  symp- 
toms, such  as  delirium  or  coma.  The  toxalbumins  also  appear  to  have  the 
effect  of  destroying  the  bacteria  to  which  they  owe  their  origin  when  they 
have  been  produced  in  sufficieutly  large  quantities. 

Cultivation. — Bacteria  are  cultivated  for  study  in  the  laboratory  in 
meat  extracts,  in  gelatin  or  agar-agar  (a  sort  of  vegetable  gelatin),  on  raw 
potato,  in  blood-serum,  and  in  other  materials.  While  some  species  grow 
readily  in  all  these  media,  others  are  exceedingly  diificult  to  cultivate, 
especially  those  which  require  the  exclusion  of  oxygen.  Temperature  is  a 
.very  imjportant  factor  in  their  cultivation,  and  most  varieties  require  a  tem- 
peratuj-e  of  86°  to  95°  F.  (30°  to  35°  C.)  in  order  to  flourish.  The  simijlest 
method  of  cultivation  is  in  bouillon,  sterilized  in  flasks  with  cotton  plugs. 
(Plate  I.,  Fig.  1.)  The  bouillon  is  inoculated  with  a  sterilized  needle  or 
loop  of  platinum  wire,  which  is  made  to  pick  wp  a  minute  quantity  of  the 
substance  to  be  cultivated,  and  is  then  dipped  in  the  bouillon,  and  the  flask 
well  shaken  in  order  to  distribute  the  material.  The  flask  is  placed  in  an 
oven  where  a  suitable  even  temperature  is  maintained  by  a  thermostat, 
and  the  growth  of  the  bacteria  is  shown  by  a  cloudiness  aijpearing  in  the 
bouillon.  Gelatin  and  agar-agar  are  used  in  test-tubes  or  on  flat  glass 
saucers.  They  may  be  simply  melted  and  allowed  to  solidify  in  the  test- 
tube,  usually  placed  at  an  angle  so  as  to  increase  the  extent  of  surface 
available  for  inoculation.  Esmarch's  method  of  "  roll- culture"  consists  in 
quickly  cooling  the  gelatin  by  placing  the  tube,  i^rotected  with  a  rubber 
cap,  in  cold  water,  or  in  a  groove  on  a  block  of  ice,  while  a  rapid  i-otation 
is  kept  up  in  order  to  spread  the  gelatin  over  the  inner  surface  of  the 
tube  in  a  thin  layer.  When  gelatin  or  agar  is  used  in  the  saucers,  or 
Petri's  dishes,  to  iovm.  plate-cultures  (Koch),  it  is  simply  melted  and  poured 
into  the  shallow  saucer  so  as  to  form  a  very  thin  layer,  and  protected  with 
a  glass  cover.  The  agar  can  be  sterilized  by  steam  for  any  necessary 
time,  but  this  would  decompose  the  gelatin ;  therefore  the  latter  must 
be  sterilized  by  the  "fractional"  method,  which  will  be  described  below. 
When  potato  is  employed,  it  is  cut  up  with  a  sterilized  knife,  sterilized 
by  the  fractional  method,  and  the  cut  surface  used  for  cultivation.  In 
all  these  last-mentioned  methods  the  mode  of  inoculation  or  soioing  is  the 
same  ;  the  material  to  be  sown  is  picked  up  with  the  sterilized  needle,  and 
the  latter  is  then  thrust  into  the  media  to  be  inoculated,  making  a  stah- 
culture,  or  is  drawn  over  the  surface.  Gelatin- cultures  may  also  be  made 
by  melting  the  gelatin,  inoculating  it  like  bouillon,  and  disseminating  the 
germs  by  shaking  before  it  hardens.     The  culture  media  must  be  kept  from 


INFECTION  BY  BACTERIA.  5 

all  contact  witli  the  air  by  using  cotton  plugs,  or  some  sort  of  cover,  and  by 
the  greatest  precautions  during  the  necessary  exposure  in  sowing.  The 
growth  of  bacteria  is  very  rapid,  one  individual  being  capable  of  producing 
over  sixteen  million  within  twenty-four  hours  (Cohn). 

The  different  varieties  of  bacteria  are  recognized  by  the  way  in  which 
they  grow  in  the  media,  by  the  shape  and  color  of  the  colonies  (as  the  small 
masses  which  they  form  are  called),  and  by  their  power  of  liquefying  the 
gelatin  and  other  chemical  reactions.  A  pure  culture  is  one  in  which  only 
a  single  species  of  bacteria  exists.  It  can  be  obtained  by  making  a  very 
long  series  of  bouillon-cultures,  but  far  better  by  the  method  introduced  by 
Koch  of  using  solid  media  for  cultures.  If  a  plate-culture  is  made,  as  the 
needle  is  lightly  drawn  over  the  surface  of  the  gelatin  it  spreads  the  mate- 
rial to  be  "  sown' '  all  along  the  line.  The  various  bacteria  will  be  present 
in  varying  quantity  at  different  jjarts  of  the  line,  and  in  a  few  hours  the 
different  colonies  can  be  recognized  with  a  magnifying-glass.  The  one 
which  is  most  like  the  x^articular  germ  sought  is  then  touched  with  the 
needle,  and  another  plate  sown  in  the  same  manner  with  this  colony.  This 
second  culture  will  naturallj^  contain  a  larger  proportion  of  the  bacteria 
desired,  and  after  several  repetitions  of  this  process  a  plate  will  finally  be 
obtained  which  will  contain  only  the  one  species  desired. 

Anaerobic  germs  are  cultivated  in  the  deeper  parts  of  the  solid  media, 
or  by  covering  the  surface  with  a  thin  sheet  of  mica,  which  is  sealed  to  the 
tube  with  paraffin,  or  by  maintaining  an  atmosphere  of  pure  hydrogen  gas 
around  the  culture. 

Inoculation. — Another  method  of  studying  bacteria  is  by  inoculation 
in  animals.  Either  the  original  material  or  a  pure  culture  obtained  from 
it  is  introduced.  The  material  inoculated  may  be  injected  under  the  skin 
or  into  a  vein,  or  inserted  into  the  anterior  chamber  of  the  eye,  or  into  the 
peritoneal  cavity,  according  to  the  effect  it  is  desired  to  produce  or  the  germ 
to  be  studied.  If  the  lesions  produced  are  the  same  as  those  of  the  original 
disease,  we  obtain  a  proof  of  the  causal  relation  between  the  germ  and  the 
disease.     The  effects  of  the  toxines  can  also  be  studied  by  these  means. 

Infection. — Bacteria  gain  admission  to  the  living  tissues  of  animals 
under  natural  conditions  by  penetrating  any  of  the  mucous  membranes 
which  they  can  reach  or  by  entering  open  wounds.  Some  of  the  pyogenic 
varieties  can  be  made  to  infect  the  sebaceous  ducts  and  the  hair-follicles  by 
being  vigorously  rubbed  into  the  skin,  or  even  by  being  kept  long  in  con- 
tact with  it  in  a  moist  dressing  ;  but  this  mode  of  infection  is  probably  rare 
in  nature.  It  may  be  said  in  general  that  an  intact  epidermis  is  almost  a 
complete  protection  against  infection,  and  that  an  intact  mucous  membrane 
is  a  good  protection.  This  difference  in  vulnerability  between  the  mucous 
membranes  and  the  skin  is  important,  and  is  probably  due  to  the  cornifica- 
tion  of  the  epidermal  cells  and  to  their  numerous  layers,  as  well  as  to  the 
protection  afforded  by  the  thick  corium,  the  single  layer  of  soft  mucous 
cells  being  much  more  easily  penetrated  and  having  no  strong  basement 
membrane  beneath  it.  Some  pathogenic  bacteria  do  not  prevent  primary 
union  of  wounds  (tetanus,  syphilis). 

When  bacteria  have  entered  the  circulation  they  collect  and  grow  in  any 


6  EFFECT   OF  BACTERIA. 

organ  or  part  of  the  body  in  which  the  blood-current  is  retarded  or  in  which 
the  vitality  of  the  tissues  is  impaired  by  inj  ury  or  otherwise.  A  slight  in- 
jury appears  to  be  more  apt  to  provoke  their  colonization  than  a  severe 
one,  a  fracture  being  less  likely  to  result  in  osteomyelitis  under  such  circum- 
stances than  a  contusion  of  the  bone,  and  it  is  supposed  that  the  severer  in- 
juries excite  so  strong  a  reparative  reaction  tliat  the  tissues  are  more  ready 
to  resist  the  bacteria  than  when  they  have  not  been  so  thoroughly  aroused. 
Such  an  injured  place  is  called  a  locus  minoris  resistentim,  a  weak  place  in  the 
defences  of  the  body.  It  has  been  found  that  the  circulation  of  ptomaines 
or  toxines  in  the  blood  weakens  the  natural  resistance  of  the  tissues,  and 
parts  which  were  previously  able  to  resist  infection  yield  to  it  wlien  these 
are  present,  a  fact  which  is  a  strong  argument  against  making  fresh  wounds 
when  suppuration  is  present  elsewhere,  and  an  argument  also  for  the  speedy  , 
evacuation  of  jjus  in  any  case.  Certain  toxines,  however,  increase  the  resist- 
ing power, — give  immunity.  Bacteria  may  enter  the  body  of  a  foetus  through 
the  placental  circulation,  the  animal  being  born  infected  with  germs  which 
had  been  present  in  the  mother's  circixlation,  an  hereditary  transmission  of 
germs  which  has  been  observed  in  erysipelas,  tuberculosis,  and  anthrax. 

Elimination, — When  bacteria  are  circulating  in  the  blood  they  can  be 
eliminated  in  various  ways.  The  kidney  is  the  organ  which  most  frequently 
throws  them  out,  the  bacteria  of  typhoid  fever,  septictemia,  and  pytemia 
having  been  actually  observed  in  the  urine.  This  process  generally  involves 
the  infection  of  the  kidney  itself  by  the  microbe  in  question,  but  some  cases 
of  pyismia  are  on  record  in  which  the  bacteria  were  excreted  by  the  kidney 
without  the  development  of  any  abscesses  in  that  organ.  The  bacteria  may 
also  be  eliminated  with  the  bile  (B.  typhosus,  B.  coli,  B.  anthracis,  and  the 
pyogenic  cocci)  or  thrown  out  by  the  intestinal  mucous  membrane.  The 
salivarj^  glands  have  been  observed  to  excrete  the  germs  with  the  saliva, 
and  it  is  supposed  that  this  circumstance  partly  explains  the  frequency  of 
metastatic  abscesses  in  those  organs.  The  bacteria  of  puerperal  septicaemia 
and  of  typhoid  fever  and  tuberculosis  have  been  found  in  the  milk  of  nursing- 
mothers,  proving  that  the  mamma  may  also  take  part  in  this  purification  of 
the  blood.  It  is  supposed  that  the  sweat-glands  also  eliminate  both  bacterial 
toxines  and  the  bacteria  themselves. 

Effect  on  the  Body. — The  introduction  of  living  bacteria  into  the 
tissues  is  followed  in  most  cases  by  the  local  phenomena  of  inflammation,  and 
later  by  general  symptoms  of  poisoning  caused  by  the  entrance  into  the  cir- 
culation of  the  living  bacteria  or  the  ptomaines  or  toxines  produced  by  their 
growth.  The  symptoms  depend  upon  the  particular  variety  introduced. 
The  saprophytic  bacteria  (those  of  decomposition)  cannot  live  unless  dead 
tissue,  blood,  or  purulent  fluids  be  i^resent,  and  cannot  survive  in  the  cir- 
culation, but  if  they  find  material  in  the  body  to  live  upon,  their  poisonous 
ptomaines  may  be  absorbed  and  cause  dangerous  symptoms.  The  majority 
of  the  disease-producing  germs  cause  local  inflammations,  and  the  pyogenic 
varieties  cause  the  j)roduction  of  pus.  Some,  however,  excite  very  little  or 
no  local  reaction,  but  enter  the  circulation  at  once.  These  various  j)henom- 
ena  will  be  studied  at  length  under  the  head  of  inflammation.  It  would 
seem  as  if  the  constitutional  danger  to  be  feared  from  any  pyogenic  germ 


RESISTANCE  TO   BACTERIA.  7 

were  in  inverse  proportion  to  the  amount  of  inflammation'  it  excites,  the 
local  inflammatory  changes  appearing  to  limit  the  growth  of  the  invading 
bacteria  and  to  prevent  their  entrance  or  the  entrance  of  their  toxiues  into 
the  circulation. 

Resistance  offered  by  the  Tissues.— The  tissues  have  considerable 
poAvers  of  resistance  to  infection  under  ordinary  circumstances,  although 
the  exact  sources  of  this  power  are  not  well  understood.  Phagocytosis, 
which  is  the  power  of  destruction  and  removal  of  bacteria  sup]30sed  to  be 
possessed  bj^  the  leucocytes  emigrating  from  the  blood-vessels  (as  will  be 
described  in  the  chapter  on  inflammation),  explains  it  in  part,  but  the  ma- 
jority of  pathologists  are  unwilling  to  give  this  mode  of  action  the  full  credit 
which  Oohnheim  and  Metchnikoff  claim  for  it.  It  is  also  partly  accounted 
for  by  the  germicidal  prox)erties  of  blood-serum,  which  can  be  compared  to 
that  property  of  the  serum  by  which  it  dissolves  the  blood- corpuscles  of 
another  animal,  as  shown  by  Landois  years  ago.  It  has  been  found  that  if 
the  serum  is  gently  heated  to  131°  P.  (55°  C.)  it  loses  the  power  of  destroy- 
ing corpuscles  and  germs,  which  proves  that  their  destruction  is  not  due 
merelj"  to  the  specific  gravity  of  the  serum  or  to  its  proportion  of  inorganic 
salts,  for  neither  is  altered  by  the  heat.  It  has  also  been  shown  (Buchner) 
that  this  power  is  destroyed  by  adding  distilled  water  to  the  serum,  although 
it  remains  intact  when  the  serum  is  diluted  with  physiological  salt  solution 
(one  part  sodium  chloride  to  five  hundred  i)arts  water),  and  can  be  restored 
to  the  serum  diluted  with  plain  water  by  the  addition  of  a  sufficient  quan- 
tity of  sodium  chloride.  Certain  experiments  (Eoger)  indicate  that  there 
must  be  some  difference  between  the  two  actions  of  the  serum  in  dissolving 
corpuscles  and  destroying  germs,  for  it  appears  that  the  streptococcus  of 
erysipelas  grows  as  well  in  the  serum  of  immunized  as  of  normal  animals, 
but  that  it  loses  its  virulence  in  the  former.  These  facts  make  it  certain 
that  the  germicidal  power  resides  in  some  proteid  body  analogous  to  the 
antitoxines,  to  be  described  below.  Bactericidal  substances  (alexines)  are 
produced  by  the  leucocytes  and  other  cells,  and  are  taken  up  by  the  serum, 
so  that  the  latter  is  more  capable  of  destroying  germs  in  parts  which  are  the 
seat  of  an  inflammatory  cell-production.  The  resistance  of  the  tissues  may 
in  some  cases  be  due  to  the  absence  from  them  of  some  particular  element 
necessary  to  the  growth  of  a  particular  micro-organism.  This  refractori- 
ness varies  in  every  species  of  animal  in  its  relation  to  every  form  of  germ, 
and  different  individuals  of  one  species  also  vary  in  their  susceptibility, 
and  even  difi'erent  parts  of  the  body  vary  in  the  same  individual.  Thus, 
inoculations  of  cultures  of  a  certain  strength  will  produce  suppuration  in 
the  eye  but  not  in  the  cellular  tissue,  while  stronger  ones  will  act  in  the 
latter  but  not  in  the  peritoneum.  The  resistance  of  the  human  tissues  to 
the  pyogenic  germs  is  usually  less  than  that  of  the  lower  animals.  Any 
cause  which  depresses  the  system,  such  as  exhausting  disease,  anaemia, 
diabetes  mellitus,  arteriosclerosis,  alcoholism,  obesity,  hunger,  fatigue,  and 
even  exijosure  to  cold,  is  apt  to  favor  the  growth  of  germs,  although 
experiments  have  as  yet  failed  to  prove  the  influence  of  exposure. 

The  tissues,  therefore,  are  able  to  destroy  bacteria,  but  in  most  cases  it 
will  be  found  that  there  is  a  definite  limit  to  their  resistance,  and  that  if  the 


8  EESISTANCE  TO  BACTERIA. 

number  of  bacteria  iutrodueed  passes  tliat  limit,  the  resistance  will  be  over- 
come or  the  germicidal  power  of  the  tissues  exhausted.  We  may  almost 
speak  of  a  normal  dose  of  certain  cultures,  as  we  speak  of  the  dose  of  pow- 
erful drugs.     The  quantity  of  bacteria  present  in  any  case  is  most  important. 

The  variations  which  are  found  in  the  virulence  of  the  bacteria  con- 
cerned must  also  be  taken  into  account.  Esmarch  showed  that  some  spores 
of  anthrax  were  killed  in  one  minute  by  exj^osure  to  steam,  while  others 
survived  up  to  twelve  minutes,  and  Welch  observed  one  specimen  of 
staphylococcus  which  would  cause  suppuration  and  death  from  septicaemia 
in  twenty-four  hours,  while  fifteen  times  the  amount  of  another  specimen, 
which  was  apparently  identical  in  other  respects,  failed  to  produce  any  effect 
either  locally  or  generally.  These  variations  in  virulence  occur  both  in 
natui-al  and  in  artificial  cultures  of  the  germs,  although  much  more  marked 
in  the  former,  and  often  without  any  assignable  reason.  Probably  in  some 
cases  the  result  is  to  be  explained  by  the  confusion  of  various  species  of 
bacteria,  but  the,  majority  must  be  due  to  variations  of  one  species  caused 
by  differences  in  the  soil  in  which  they  grew  or  by  some  other  external 
influences.  Cultures  of  the  diphtheria  bacillus  can  be  made  more  or  less 
virulent  at  will  by  altering  the  alkalinity  of  the  culture  media.  Eepeated 
inoculations  of  certain  bacteria  in  animals  will  sometimes  increase  their 
virulence,  a  fact  which  explains  why  pus  is  more  virulent  than  the  floating 
germs  of  the  air  identical  with  those  present  in  the  pus.  The  occurrence 
of  more  than  one  species  of  bacteria  in  a  culture  sometimes  increases  and 
sometimes  diminishes  the  virulence  of  their  effect,  according  as  the  two 
encourage  or  retard  each  other's  growth,  just  as  is  seeu  when  two  of  the 
higher  plants  are  sown  in  one  field.  The  pneumococcus  is  antagonistic 
to  the  bacillus  anthracis,  as  is  also  the  streptococcus  of  erysipelas.  The 
bacillus  of  tetanus  is  anaerobic  and  will  not  grow  when  exposed  to  oxygen 
unless  another  organism  capable  of  actively  absorbing  the  free  oxygen 
is  growing  in  the  same  tissues.  The  virulence  of  dijphtheria  is  increased 
by  the  presence  of  the  streptococcus,  and  the  latter  is  more  virulent  when 
accompanied  by  B.  coli  or  B.  prodigiosus. 

It  has  also  been  proved  that  the  soil  in  which  the  inoculation  takes 
place  is  of  prime  imj)ortance  for  its  success.  The  bacillus  of  diphtheria  will 
only  grow  on  the  surface,  that  of  tetanus  only  in  parts  excluded  from  the  air. 
The  presence  of  dead  or  injured  tissue  at  the  place  of  inoculation  favors 
germ-growth.  Bacterial  growth  is  favored  by  the  presence  of  blood-clot  or 
foreign  substances,  and,  above  all,  by  some  of  the  substances  in  which  the 
germ  has  already  been  growing  at  the  time  of  its  inoculation  and  containing 
some  of  its  toxines.  Thus,  a  certain  amount  of  pyogenic  germs  may  be  intro- 
duced into  the  peritoneal  cavity  without  effect,  and  sterilized  potato  can  also 
be  inserted  without  exciting  inflammation  ;  but  if  the  two  are  introduced 
together,  the  bacteria  multiply  at  once  in  the  potato  and  then  easily  invade 
the  organism  from  that  base  of  supply  or  storehouse  of  energy.  The  view 
that  the  presence  of  blood-clot  favors  the  infection  of  wounds  needs  some 
limitation,  for  recent  clinical  experience  proves  that  wounds  which  are 
slightly  infected  will  sometimes  heal  by  i^rimary  union  when  their  cavities 
are  full  of  blood  and  no  drainage  is  employed ;  and  it  has  been  shown  that 


IMMinSflTY   AGAINST  BACTERIA.  9 

under  such  circumstances,  as  well  as  In  the  coagulated  blood  used  In  labora- 
tory experiments,  the  pyogenic  germs  remained  alive,  but  did  not  multiply. 
This  arrest  of  development  may  be  due  to  the  germicidal  or  germ-inhibiting 
powers  of  the  serum,  and  it  certainly  depends  upon  freedom  from  the  bac- 
teria of  putrefaction,  for  decomposing  blood  is  one  of  the  most  infectious  of 
substances. 

Irnmunity. — An  animal  which  is  able  to  resist  the  invasion  of  any 
species  of  bacteria  is  said  to  be  refractory  to  or  immune  against  that  variety 
of  germ.  In  many  cases  this  immunity  is  constant  in  certain  animals  for 
certain  bacteria  :  thus,  gonorrhoea  and  syphilis  cannot  be  transmitted  to  the 
lower  animals,  and  man  is  refractory  to  the  virus  of  mouse-septicsemia  and 
many  other  diseases.  In  many  infectious  diseases  one  attack  protects  an 
individual  for  a  lifetime,  and  one  form  of  disease  may  even  protect  in  future 
from  another  and  more  virulent  form,  as  vaccination  protects  against  small- 
pox. Pasteur  supposed  that  the  bacteria  in  their  growth  exhausted  from 
the  body  some  material  necessary  for  their  existence,  but  this  theory  is  now 
rejected.  By  others  this  protection  is  supposed  to  be  due  to  the  production 
of  certain  substances  by  the  bacterial  growth  which  remain  in  the  body  and 
render  it  immune  against  that  particular  form  of  infection.  It  has  been 
shown  that  a  definite  chemical  change  occurs  in  the  blood-serum  of  animals 
which  have  been  subjected  to  experimental  infections.  In  favor  of  the  lat- 
ter theory  also  is  the  fact  that  if  the  serum  of  an  animal  which  has  been 
rendered  immune  against  a  certain  bacterium  be  injected  into  another  sus- 
ceptible animal,  the  same  immunity  can  be  temporai'ily  reproduced  in  the 
second  animal, — passive  immunity.  An  auimal  may  also  be  rendered  immune 
against  a  certain  bacterium  by  injecting  it  with  toxines  obtained  from  a 
sterilized  culture  of  that  germ, — active  immunity.  The  exact  nature  of  these 
immunizing  substances  is  uncertain,  but  it  is  supjjosed  that  the  circulation 
of  the  toxines  of  bacteria  in  the  body  stimulates  the  latter  to  produce  another 
albuminoid  substance  in  the  blood-serum  which  is  an  antidote  to  the  toxiue, 
and  therefore  called  an  antitoxine.  The  production  of  this  substance  must  in 
some  cases  go  on  indefinitely,  for  the  animal  remains  permanently  immune 
against  the  germ  in  question  ;  but  if  the  serum  of  such  an  animal  be  intro- 
duced into  a  second  one,  as  just  mentioned,  the  immunity  of  the  latter  is 
only  temporary,  for  the  substance  ajjpears  to  be  eliminated  after  a  certain 
interval.  Immunity  against  tetanus  produced  in  this  way  (by  serum)  can  be 
transmitted  by  an  immune  mother  simply  by  descent,  although  not  to  the 
full  strength  in  which  she  possesses  it ;  and  it  can  also  be  transmitted  to 
some  extent  by  the  milk  of  an  immune  animal.  The  male  parent  appears  to 
have  little  part  in  this  hereditary  transmission.  Immunity  has  also  been 
exj)lained  by  the  theory  of  phagocytosis  (Metchnikoff).  According  to  this 
theory,  the  power  of  the  leucocytes  to  destroy  bacteria  is  more  active  in 
immune  individuals  than  in  others,  and  that  function  can  be  cultivated  by  a 
sort  of  evolutionary  process.  Whatever  the  explanation,  the  demonstrated 
facts  of  immunity  and  of  the  possibility  of  producing  it  by  injecting  the 
serum  of  immune  animals  have  formed  the  basis  of  the  newly  introduced 
serum- therapy,  for  it  has  been  found  that  this  serum  will  not  only  confer  im- 
munity against  infection,  but  may  iissist  the  animal  to  throw  oft'  an  infection 


10  METHODS   OF  STERILIZATIOISr. 

which  has  already  taken  place.  Diphtheria,  hydrophobia,  tetanus,  anthrax, 
glanders,  and  even  pneumonia,  are  instances  in  which  partial  success  has 
been  obtained  by  this  method,  but  it  is  rarely  that  any  effect  can  be  obtained 
except  at  the  very  beginning  of  an  infection. 

Methods  of  Sterilization. — Most  important  to  the  surgeon  is  the 
question  how  to  exclude  or  destroy  micro-organisms,  a  question  which  is 
very  difficult  to  answer  definitely  on  account  of  the  variations  in  the  vitality 
of  the  germs  and  the  possibility  of  numerous  errors  in  the  experiments. 
Thus,  it  was  long  thought  that  a  solution  of  bichloride  of  mercury,  1  to 
1000,  would  kill  germs,  and  even  spores,  with  certainty  and  rapidity,  three 
minutes  being  the  longest  time  of  exposure  supposed  necessary  ;  but  these 
conclusions  have  proved  erroneous.  The  usual  method  of  testing  such 
solutions  was  to  put  in  them  a  thread  impregnated  with  the  germ  to  be 
tested,  and  then  inoculate  suitable  media  with  the  thread,  concluding  that 
if  the  culture  medium  remained  sterile  it  i^roved  that  the  germs  had  been 
killed.  But  it  has  been  fouud  that  the  negative  results  thus  obtained  were 
worthless,  for  enough  of  the  chemical  remained  in  the  thread  and  the  germs 
to  prevent  the  latter  from  developing  and  to  keep  the  culture  sterile, 
although  the  bacteria  were  still  alive.  Washing  with  water  and  alcohol 
proving  insufficient  to  remove  the  antiseptics,  it  was  found  necessary  to 
neutralize  them  by  chemical  action,  such,  for  instance,  as  the  use  of  sulphide 
of  ammonium  to  precipitate  the  bichloride  of  mercury,  and  then  it  was  dis- 
covered that  experiments  which  had  given  negative  results  under  the  old 
methods  produced  abundant  cultures  (Geppert).  By  this  method  it  was 
found  ihat  anthrax  spores  survived  ten  and  even  twenty-four  hours'  immer- 
sion in  a  1  to  1000  bichloride  solution,  and  that  even  the  staphylococcus 
pyogenes  aureus  would  survive  after  being  kept  for  twenty  minutes  in  the 
same  solution.  Exactly  how  the  chemical  antiseptics  act  in  thus  suspending 
growth  in  living  organisms  and  yet  leaving  them  capable  of  restoration  is 
not  understood,  the  most  probable  explanation  being  that  the  antiseptic 
enters  into  combination  with  the  capsule  of  the  cell,  and  can  be  freed  from 
it  by  breaking  up  this  chemical  combination.  It  has  long  been  known  that 
very  minute  quantities  of  germicidal  substances,  and  some  substances  which 
are  not  germicidal,  would  prevent  the  growth  of  bacteria,  so  that  it  is  not 
surprising  that  chemical  disinfectants  should  act  in  this  prolonged,  inhibitory 
way.  It  must  be  remembered  that  in  operative  surgical  work  no  such  sec- 
ondary reagents  are  used,  and  that  germs  which  do  not  develop  within  a 
short  time  after  inoculation  will  be  destroyed  generally  by  the  action  of  the 
tissues.  If  nonabsorbable  materials  such  as  silk  sutures  are  buried  in 
wounds,  however,  quiescent  germs  contained  in  them  might  be  protected 
from  the  germicidal  action  of  the  tissiies  long  enough  to  recover  from  the 
temporary  inhibition  of  the  sterilizing  agent,  and  might  begin  to  grow  and 
cause  infection  weeks  or  months  after  the  wound  had  healed.  While,  there- 
fore, these  results  do  not  entu-ely  invalidate  the  present  methods  of  steriliza- 
tion for  operations,  they  should  stimulate  us  to  the  discovery  of  better  means, 
and  especially  to  the  thorough  ap]Dlication  of  the  methods  upon  which  we 
are  now  dependent,  in  order  to  obtain  the  best  possible  results  from  them. 
We  should  avoid  the  introductioa  of  non-absorbable  material  into  wounds 


CHEMICAL  ANTISEPTICS.  11 

as  far  as  possible,  and,  moreover,  we  should  be  particularly  careful  not  to 
employ  corrosive  sublimate  in  wounds,  or  in  the  disinfection  of  substances 
(fteces)  in  which  sulphur  compounds  are  likely  to  occur,  lest  they  decompose 
the  chemical  and  set  free  the  bacteria. 

Chemical  Antiseptics. — Micro-oi^ganisms  can  be  destroyed  by  depri- 
vation of  food  or  water,  by  chemicals  (including  toxines,  etc.),  and  by 
heat.  For  practical  disinfection,  however,  only  chemicals  and  heat  need 
concern  us.  We  take  from  Koch's  experiments  the  following  list  of  the 
principal  chemical  antiseptics  in  use  and  their  effect  on  germs :  Complete 
prevention  of  growth  of  anthrax  spores  was  produced  by  bichloride  of  mer- 
cury, 1  to  300,000  solution;  mustard  oil,  1  to  33,000;  arsenate  of  potash, 
1  to  10, 000 ;  salicylic  acid,  1  to  1500 ;  carbolic  acid,  1  to  850 ;  boric  acid, 
1  to  800  ;  alcohol,  1  to  12.5.  It  is  yet  an  open  question  whether  iodoform, 
as  emj)loyed  in  wounds,  has  any  antiseptic  effect ;  it  certainly  has  none  in 
laboratory  cultures.  To  destroy  completely  the  vitality  of  anthrax  spores 
requires  the  ijrolonged  action  of  any  chemical,  and  among  the  ordinary 
germicides  only  bichloride  of  mercury,  pure  iodine,  and  cresol  (with  the 
addition  of  sulphuric  acid)  can  accomplish  this  within  twenty-foiir  hours. 
Carbolic  acid  in  1  to  20  solution  has  failed  to  kill  these  spores  in  thirty-five 
days ;  hj^drochloric  acid  requires  ten  days,  and  ether  thirty  days,  to  destroy 
them.  The  power  of  all  these  substances  is  greatly  increased  by  heat,  the 
bichloride  of  mercury,  for  instance,  killing  staphylococci  in  five  minutes  at 
the  temperature  of  the  body,  whereas  it  requires  over  five  times  as  long  at 
the  ordinary  room  temperature.  Grease,  oil,  mucus,  and  even  blood,  will 
cover  germs  with  a  coating  which  prevents  chemical  germicides  from  reach- 
ing them.  Another  source  of  error  in  the  direct  application  of  these  ex- 
periments to  practical  surgery  is  the  fact  that  many  of  these  chemicals  are 
decomposed  or  rendered  inert ,  by  combinations  with  the  albuminoids  of 
blood  and  i^us,  mercuric  bichloride  being  transformed  into  an  indifferent 
substance,  and  even  carbolic  acid  being  altered.  The  proportional  amounts 
of  the  germicidal  solution  and  of  the  matter  to  be  sterilized  are  to  be  con- 
sidered, the  action  of  the  former  being  much  more  intense  when  it  is 
abundant.  The  age  of  the  solutions  is  also  important,  and  fresh  solutions, 
even  of  so  permanent  a  salt  as  the  bichloride,  have  a  greater  power.  We 
have  limited  ourselves  to  a  discussion  of  the  meaus  of  destroying  patho- 
genic germs,  but  those  of  decomposition  are  often  more  obstinate  and  tena- 
cious of  life,  some  of  the  saprophytes  being  able  to  multiply  even  in  a  1  to 
44,000  solution  of  bichloride  of  mercury. 

Sterilization  by  Heat. — Heat  is  the  surest  and  quickest  method  of 
destroying  germs,  even  the  spores  being  killed.  Anthrax  spores  are  killed  in 
two  minutes  in  boiling  water,  and  the  various  bacilli  and  cocci  in  from  two 
to  five  seconds.  When  a  substance  is  to  be  sterilized  by  heat  which  wUl  not 
bear  so  high  a  temperature,  the  method  of  fractional  sterilisation  is  emjiloyed, 
the  fluid  to  be  sterilized  being  raised  to  140°,  160°,  or  175°  F.  (60°,  70°,  or 
80°  C.)  for  from  fifteen  to  thirty  minutes  every  day  for  from  three  to  seven 
days  ;  the  theory  being  that  the  adult  germs  are  killed  by  the  first  heating, 
and  that  any  spores  which  develop  subsequently  are  destroyed  in  their  adult 
state  at  the  next  heating.     The  fluid  meanwhile  must  be  kept  at  an  even 


12  VARIETIES   OF  BACTERIA. 

temperature,  whicli  will  encourage  tlie  development  of  any  spores  it  may 
contain.  Even  antkrax  spores  can  be  killed  by  heating  to  167°  or  185°  F. 
(75°  or  85°  0.)  in  a  one  and  four-tenths  per  cent,  solution  of  sodium  car- 
bonate for  from  eight  to  twenty  minutes.  Dry  heat  is  not  so  efficient  as 
moist,  for  a  temperature  of  284°  F.  (140°  0.)  dry  heat  continued  for  three 
hours  is  needed  to  kill  anthrax  spores.  For  this  reason  superheated  steam 
is  not  so  effective  as  saturated  steam  at  the  pressure  of  the  atmosphere. 

Staining  Methods, — In  order  to  detect  micro-organisms  in  the  tissues 
or  elsewhere  the  use  of  staining  is  almost  indispensable,  and  the  bacteria 
stain  readily  in  the  various  basic  aniline  dyes,  such  as  gentian-violet  or 
methyl-blue  and  fuchsin.  Fuchsin  is  much  used  for  coloring  tubercle  bacilli 
in  a  solution  known  as  ZiehVs.  Methyl-blue  will  give  a  very  good  counter- 
stain,  contrasting  with  the  red  bacilli. 

Grain's  method  is  commonly  used,  and  especially  because  certain  germs 
are  first  stained  and  then  decolorized  by  it,  and  thus  distinguished  irom 
other  forms.  The  specimen  is  stained  for  one  or  two  minutes  in  gentian- 
violet  or  methyl-blue.  It  is  then  put  in  a  solution  of  iodine  one  part,  iodide 
of  potassium  two  parts,  and  distilled  water  three  hundred  parts,  for  one 
minute.  It  is  decolorized  with  alcohol,  dried,  and  a  counterstain  applied  if 
desired. 

Varieties  of  Bacteria. — We  proceed  to  a  brief  enumeration  of  the 
bacteria  which  are  surgically  important,  beginning  with  the  varieties  which 
are  able  to  produce  pus,  the  chief  of  these  being  the  cocci. 

Staphylococcus  pyogenes  aureus  (Ogston,  Eosenbach)  (Plate  I.,  Fig. 
2)  is  a  globular  organism,  about  0.7  to  0.9  micromillimetre  in  diameter, 
growing  in  clusters,  found  very  widely  diffused,  but  especially  upon  the 
skin  and  in  the  pharynx,  and  causing  about  eighty  per  cent,  of  all  the  in- 
stances of  supj)urative  inflammation.  It  is  the  almost  universal  cause  of 
acnte  osteomyelitis.  It  grows  upon  all  the  ordinary  culture  media  at  ordi- 
nary temperatui-es,  but  best  at  from  86°  to  98°  F.  (30°  to  37°  C.)  In  plate 
cultures  it  forms  small  circular  colonies,  with  sharp,  smooth  outlines,  often 
white  at  first,  but  generally  yellow  in  color,  deepening  to  orange  as  they  grow 
(Plate  I.,  Fig.  1,  A).  It  liquefies  the  gelatin,  and  forms  small  depressions, 
into  which  the  colony  sinks.  When  growing  in  bouillon  it  is  diffused 
through  the  fluid  as  a  cloud.  It  also  has  the  power  of  peptonizing  albumin 
and  coagulating  milk.  This  coccus  can  be  inoculated  in  animals,  causing 
local  suppuration  and  general  septicsemia.  It  grows  both  with  and  without 
free  oxygen,  and  does  not  form  spores,  unless  they  be  arthrospores.  It  can 
be  stained  by  any  of  the  methods,  including  Gram's. 

Staphylococcus  pyogenes  albus  (Eosenbach,  Passet)  and  S.  p.  citreus 
(Passet)  resemble  the  foregoing  species  in  every  respect,  except  that  one 
forms  white  and  the  other  lemon-colored  colonies,  and  that  neither  of  them 
is  so  virulent  as  the  orange  variety  (Plate  I.,  Fig.  1,  B). 

Staphylococcus  epidermidis  albus  (Welch)  is  probably  only  a  modi- 
fied and  less  virulent  form  of  the  S.  p.  albus,  and  is  found  in  the  deep  layers 
of  the  cutaneovis  epithelial  cells.  Its  situation  renders  it  very  difficult  to 
destroy,  and  it  is  liable  to  cause  abscesses  around  cutaneous  sutures. 

Streptococcus  pyogenes  (Plate  I.,  Fig.  3)  is  a  globular  organism  oc- 


Fig.  1. 


PLATE  I. 


Fig.  3. 


A,  staphylococcas 
pyogenes  aureus. 


B,  staphylococcus 
pyogenes  albus. 


Tubes  of  agar-agar,  showing  .e:rowth  of 
micro-organisms.    (Pepper.l 


Fig.  7. 


staphylococcus  pyogenes 
aureus.    (Robb.) 


Micrococcus  gonorrhceee. 
(F.  C.  Wood,  M.D.) 


Bacillus  pyocyaneus. 
(Robb.) 


Streptococcus  pyogenes. 
(Robb.) 


Fig.  9. 


Bacillus  cliphtberiK. 
(Da  Costa.) 


Fig.  6. 


Bacillus  coli  comu 
(Robb.) 


The  pneumococcus  of  Friinkel ;  the  cocci 
are  stained  dark  blue,  the  capsules  are  un- 
stained.   (After  Jaksch.) 


Bacillus  typhi  abdominalis,  showing 
flagella.    (F.  C.  Wood,  M.D.) 


VARIETIES   OF  BACTERIA.  13 

curring  in  chains,  from  J  to  1  micromillimetre  in  diameter,  especially  common 
in  the  exposed  mucous  cavities  of  the  body,  such  as  the  urethra,  vagina, 
and  mouth.  It  grows  in  the  usual  culture  media,  slowly  at  ordinary  tem- 
peratures, most  freely  at  about  the  body  temperature.  In  gelatin  it  forms 
small  circular  (rarely  oval)  colonies,  which  are  at  first  yellow  and  later  turn 
brown.  The  gelatin  is  not  liquefied,  and  the  colonies  project  above  the  sur- 
face, especially  at  their  centres  and  on  the  edges.  When  growing  in  bouillon 
it  usually  settles  to  the  bottom  of  the  fluid  as  a  cloudy  sediment.  The  strep- 
tococcus peptonizes  albumin.  It  produces  arthrospores,  grows  best  with  free 
oxygen  present,  and  can  be  stained  by  all  the  aniline  dyes,  including  Gram's 
method.  Experiments  on  animals  appear  to  indicate  that  the  streptococcus 
is  less  virulent  than  the  S.  p.  aureus,  but  clinically  it  is  found  to  excite  a 
more  dangerous  form  of  supi^uration,  with  much  sloughing  and  a  tendency 
to  spread  without  limitation.  It.  also  causes  erysipelas,  for  Pehleisen's 
streptococcus  of  erysipelas  is  probably  identical  with  the  ordinary  strepto- 
coccus pyogenes,  in  spite  of  Eosenbach's  efforts  to  distinguish  them,  although 
it  may  be  a  peculiarly  modified  form  of  that  germ.  The  staphylococci  are 
never  found  in  erysipelas.  The  streptococcus  occasionally  causes  osteomye- 
litis, but  much  more  rarely  than  the  staphylococcus. 

Micrococcus  gonorrhcEse  (or  gonococcus)  (Neisser)  (Plate  I.,  Pig.  4) 
will  be  described  with  the  disease  which  it  produces. 

Bacillus  pyocyaneus  (Gessard)  (Plate  I.,  Pig.  5)  is  a  rather  common 
pyogenic  germ,  which  occurs  in  the  skin  and  perspiration  as  a  motile  body. 
It  grows  in  cultures  at  ordinary  temperatures,  and  has  the  power  of  liquefy- 
ing the  gelatin,  producing  a  bluish-green  color  in  free  oxygen.  It  is  found 
in  pus,  to  which  it  gives  a  blue  or  green  color,  sometimes  quite  vivid. 

Bacillus  coli  communis  (Emmerich)  (Plate  I.,  Pig.  6)  is  an  important 
bacterium  found  in  the  intestinal  contents,  in  peritoneal  exudates,  in  the 
urine  with  cystitis,  and  occasionally  in  abscesses.  It  is  a  short  rod,  1  to 
3  micromillimetres  long  and  0.4  to  0.6  micromillimetre  thick,  sometimes 
oval  in  shape  and  resembling  a  micrococcus,  motile  (having  flagella),  and 
occurring  in  pairs  or  chains.  It  stains  with  the  ordinary  dyes,  but  is  de- 
colorized by  Gram's  method.  It  is  easily  cultivated,  and  forms  a  thin 
film  or  a  projecting  mass  on  the  surface  of  the  medium,  of  lobulated  shape, 
yellow  color,  and  granulated  appearance.  It  grows  either  with  or  withput 
free  oxygen.  The  cultures  are  acid,  do  not  liquefy  gelatin,  but  decompose 
sugar,  ]5roducing  carbonic  dioxide  and  hydrogen  gas.  No  spores  have  been 
seen.  It  can  be  inoculated  in  animals,  causing  the  same  local  suppurations 
or  general  infections  as  in  man,  but  is  very  variable  in  its  virulence. 

Pneumococcus  or  micrococcus  lanceolatus  (Prankel)  (Plate  I.,  Pig. 
7)  and  B.  typhi  abdominalis  (Plate  I.,  Pig.  8)  are  also  capable  of  causing 
suppurative  inflammation  in  the  cellular  tissues  and  elsewhere,  but  do  not 
need  description  here.  Bacillus  diphtheriae  (Klebs,  Loeffler)  (Plate  I., 
Pig.  9)  has  a  certain  amount  of  surgical  importance,  as  it  has  in  rare  instances 
been  observed  in  wounds,  but  so  seldom  that  it  merely  requires  mention. 

The  bacteria  of  malignant  oedema,  anthrax,  etc.,  will  be  described  with 
the  diseases  which  they  produce. 


CHAPTEE    II. 

PATHOLOGY  OF  INFLAMMATION. 
By  B.  Paequhae  Cuetis,  M.D. 

Definition. — Inflammation  may  be  defined  as  the  reaction  of  the  tissues 
against  injurious  influences.  This  definition  is  satisfactory  from  the  clinical 
standpoint,  but  not  entirely  so  from  a  pathological  point  of  view,  for  it  is 
difficult,  if  not  impossible,  to  draw  a  sharp  line  between  the  changes  which 
take  place  in  the  tissues  as  a  result  of  their  efforts  to  repair  damage  done  by 
injuries  and  the  alterations  which  occur  as  a  result  of  true  inflammation, 
although  it  is  important  not  to  confuse  the  two.  An  aseptic  wound  heals 
without  any  of  the  clinical  signs  of  inflammation  or  any  ' '  reaction, ' '  and 
the  definition  is  therefore  satisfactory  clinically.  But  if  we  study  the  minute 
tissue-changes  about  such  a  wound,  the  resemblance  between  the  processes 
of  wound-repair  and  those  of  slight  inflammation  becomes  evident. 

Etiology. — The  cause  of  inflammation  is  any  injury  to  the  tissues  by 
mechanical,  thermic,  or  chemical  means,  by  the  effect  of  electricity,  or  by 
the  growth  of  bacteria.  The  action  of  bacteria  and  of  electricity  can  prob- 
ably be  explained  by  referring  it  to  mechanical  effect,  heat,  or  chemical 
action.  The  invasion  of  the  tissues  by  bacteria  is  the  universal  cause  of  such 
inflammations  as  come  under  the  surgeon's  notice,  with  the  exception  of  those 
due  to  rheumatism  and  gout,  so  that  one  is  almost  tempted  to  say  that  there 
can  be  no  inflammation  without  bacteria.  Bacteria  may  act  upon  the  tissues 
mechanically  by  their  i^reseuce  as  foreign  bodies,  and  perhaps  also  by  the 
obscure  influence  known  as  vital  force,  but  it  is  daily  becoming  more  evi- 
dent that  their  main,  and  perhaps  their  only,  action  is  the  chemical  effect 
of  their  toxines  and  ferments,  which  have  been  shown  capable  of  producing 
pus  when  injected  free  from  living  bacteria  into  the  tissues.  The  peculiar 
inflammations  found  in  the  altered  trophic  conditions  associated  with  cer- 
tain nervous  diseases,  such  as  sclerosis  or  other  changes  in  the  spinal  cord, 
are  due  merely  to  the  ordinary  causes,  although  acting  with  greater  force 
upon  tissues,  the  resistance  of  which  is  iinx^aired  by  these  conditions. 

The  various  causes  of  such  forms  of  inflammation  as  the  sm-geon  is  apt  to 
meet  with  may  be  thus  classified  : 

A.  Mechanical.     1.  Contusions,  wounds,  fractures,  ruptures. 

2.  Foreign  bodies,  necrotic  tissue  (sequestra),  calculi. 

3.  Friction,  long-continued  j)ressure. 

B.  Heat,  cold,  electricity. 

C.  Chemical.     1.  External — irritants,  caustics. 

2.  Internal — gouty  and  rheumatic   poisons,  urine,   bile, 
and  digestive  secretions. 

D.  Bacteriological. 
14 


INFLAMMATORY  CONDITIONS   CAUSED  BY   BACTERIA. 


15 


The  first  three  classes  are  of  little  importance  except  as  predisposing 
causes,  and  we  may  call  the  reaction  excited  by  them  simple  inflammation.  In 
the  list  of  inflammatory  affections  produced  by  bacterial  infection,  on  the 
other  hand,  we  find  nearly  every  serious  inflammatory  condition  known  to 
surgery.  The  conditions  known  as  septicemia  and  pytemia  are  not  included, 
because  we  look  upon  them  as  sequelte  to  bacterial  infection  and  not  as  dis- 
tinct diseases ;  the  first  being  found  with  any  germ,  the  second  only  with 
the  pyogenic. 

Inflammatory  Conditions  caused  by  Bacteria.— 

1.  Inflammations  caused  by  pyogenic  germs  (including  B.  coli,  B.  typhi 
abdominalis,  gonococcus,  pneumocoecus,  etc.)  : 
Dermatitis,  Purunculosis,  Cellulitis,  Carbuncle,  Erysipelas,  Peri- 
tonitis,  Empyema,   Meningitis,   Synovitis,  Phlebitis,  Cystitis, 
Osteomyelitis,  etc. 


By  special  germs : 
Malignant  oedema. 
Anthrax. 
Glanders. 


Fig.  10. 


Actinomycosis.  Syphilis. 

Tuberculosis  (lupus).  Tetanus. 

Leprosy.  Eabies. 

2a.  Special  germs  attacking  mucous  membranes  (without  previous  lesion) : 
Gonorrhoea  (Gonococcus).  Diphtheria  (B.  diphtherias). 

Pathological  Changes. — Hyperaemia. — When  one  of  the  causes 
mentioned  above  acts  upon  the  tissues,  the  first  alteration  seen  is  an  increasing- 
supply  of  blood  to  the  part,  the  arterial  circulation  being  increased  both  by 
greater  rapidity  of  the  current  through  the  vessels  and  by  dilatation  of  all 
the  small  branches  and  capillaries.  This 
can  be  illustrated  by  the  experiment  of 
dividing  the  main  artery  which  supplies 
each  ear  of  a  rabbit  and  immersing  the 
tip  of  one  ear  in  very  hot  water,  when  it 
will  be  observed  that  the  flow  of  blood 
from  the  cut  end  of  the  artery  upon  that 
side  will  be  greater  than  that  fi-om  the 
other.  Since  the  vessel  is  thus  caused  to 
dilate  at  a  distance  from  the  irritated 
part,  the  latter  must  have  an  actual  in- 
crease in  its  supply  of  blood.  When  the 
inflammation  grows  more  intense,  the  cir- 
culation of  the  capillaries  becomes  slower 
and  the  corpuscles  collect  until  they  clog 
the  vessels.  The  normal  current  of  the 
blood  in  small  vessels  as  seen  under  the 
microscojie  shows  a  thick  central  stream 
of  corpuscles  with  a  transparent  border 
of  lymiah  between  it  and  the  vessel  wall 
containing  only  a  few  white  corpuscles.  (Fig.  10.)  As  the  stream  diminishes 
in  rapidity  the  number  of  white  cells  in  this  clear  space  increases,  the  third 
corpuscles  of  the  blood  (blood  plaques)  api^ear  also,  and  finally,  when  the 
current  is  reduced  to  stagnation,  the  clear  sj)ace  disappears,  being  entirely 


Normal  circulation  in  a  frog :  red  disks  in 
centre  of  stream,  leucocytes  on  the  bordere. 
(Agnew.) 


16 


PATHOLOGY   OF  INFLAMMATION. 


filled  witli  cells,  chiefly  with  leucocytes,  although  even  the  red  corpuscles 
then  find  their  way  into  it.  (Figs.  11  and  12.)  This  tendency  of  the  white 
cells  to  separate  from  the  others,  even  when  the  current  is  still  rapid,  is 
partly  due  to  their  viscosity  and  j)ower  of  amoeboid  movement,  but  is  in  the 
main  a  purely  mechanical  effect  of  the  slower  current.  It  has  been  proved 
(Schlarewsky)  that,  when  particles  of  different  density  are  suspended  in  a 


Fig.  11. 


Fig   12. 


Frog's  mesentery,  normal.  FrOo     iiit  l  lUn    mil 

Figs.  11  and  12.— o,  small  vein ;  bb,  dd,  nerve-flbres ;  c,  capillary ,  ee,  connective  ti'sue  (m  Fig  12  filled  with 
migrating  leucocytes) .    (Agnew.) 

liquid  which  is  circulating  through  a  system  of  narrow  tubes  with  a  very 
rapid  current,  there  is  a  clear  space  next  to  the  wall  of  the  tubes,  where  the 
friction  necessarily  reduces  the  speed  of  the  fluid,  which  is  free  from  parti- 
cles, and  as  the  current  is  slowed  down  some  of  the  particles  of  the  least 
density  begin  to  appear  in  this  clear  space,  their  number  increasing  as  the 
current  becomes  slower,  until  even  the  heavy  particles  also  collect  here  when 
it  is  very  slow.  It  is  known  that  among  the  cellular  elements  of  the  blood 
the  leucocytes  have  the  least  specific  gravity  or  density,  and  the  third  cor- 
puscles rank  next,  while  the  red  blood-disks  are  the  heaviest,  and,  as  we 
have  seen,  these  bodies  appear  in  the  clear  serum  near  the  vessel  wall  in  that 
order,  according  to  the  daw  just  described. 

Complete  stasis,  or  stoppage,  of  the  circulation  is  seen  only  when  the 
inflammation  is  exceedingly  intense.  If  the  stasis  continues  it  causes  the 
death  of  the  part,  as  occurs  in  some  forms  of  inflammation,  in  which  the 
flrst  clinical  sign  of  disturbance  is  the  appearance  of  necrotic  areas,  and  in 
which  there  is  little  or  no  accompanying  congestion.  Usually  stasis  does  not 
develop,  and  the  current  merely  becomes  slower  than  normal.  This  retarded 
circulation  is  followed  by  the  phenomena  of  emigration. 


EMIGRATION  OF  WHITE  CORPUSCLES. 


17 


Fig.  13. 


Leucocytes  in  motion. 
(Agnew.) 


Fluid  Exudate. — The  slow  current  is  associated  with  an  increased  in- 
travascular pressure,  and  the  latter  produces  an  exudation  of  the  serum  of 
the  blood,  which  passes  out  of  the  vessels  and  collects  in  the  It^mphatic 
spaces  in  the  cellular  tissues  and  elsewhere,  and  also  exudes  from  the  sur- 
face of  mucoiis  or  synovial  membranes,  or  forms  vesicles  or  blisters  in  the 
skin  by  detaching  the  superficial  epithelial  layers. 

Emigration. — Emigration  of  the  white  blood- corpuscles  consists  in  the 
passage  of  the  cells  directly  through  the  vessel  wall.  It  is  most  fi'equently 
seen  in  the  capillaries,  although  it  may  also  take  place 
in  the  small  veins.  The  white  corpuscles,  or  leuco- 
cytes, have  the  property  of  amoeboid  movement  (Fig. 
13),  stretching  out  long,  narrow  processes  of  their  pro- 
toplasm (called  pseudoijodia),  which  may  be  attached 
to  any  object,  and  draw  the  rest  of  the  protoplasmic 
body  after  them.  In  this  way  the  leucocytes  are  able 
to  pass  through  interstices  between  cells  or  along  nar- 
row channels  in  the  tissues.  When  the  blood-current  becomes  sufficiently 
slow  to  enable  them  to  cling  to  the  walls  of  the  vessels,  the  amceboid  move- 
ments can  be  observed.  Sometimes  the  cells  lose  their  hold  and  are  swept 
on  again,  but  in  other  cases  a  minute  bud  of  protoplasm  will  appear  on  the 
outer  side  of  the  wall  of  the  vessel,  opposite  to  the  spot  where  the  leucocyte 
is  clinging,  and  as  this  grows  larger  a  narrow  neck  of  protoplasm  can  be 
traced  through  the  wall  directly  to  the 
leucocyte,  and  it  will  presently  be  seen 
that  the  mass  of  the  leucocyte  becomes 
proportionately  smaller  as  the  external 
bud  of  protoplasm  grows  larger.  (Fig. 
14.)  The  nuclei  of  the  cell  appear  out- 
side, and  only  a  small  mass  of  proto- 
plasm then  remains  within  the  vessel, 
until  finally  the  entire  leucocyte  is  in 
the  tissue  outside  of  the  %'essel  and  is 
free  to  wander  in  any  direction.  The 
mechanical  part  of  this  process  is  not 
yet  understood.  It  is  claimed  by  some 
that  small  openings,  called  stomata,  ex- 
ist in  the  walls  of  the  vessels  between 
the  endothelial  cells  which  line  them. 
These  openings  are  ordinarily  invisible, 
but  it  is  said  that  they  enlarge  when  the  vessels  are  dilated  by  the  inflam- 
matory reaction,  and  that  the  leucocytes  escape  through  them.  Others 
(Metchnikolf )  assert  that  the  endothelial  cells  themselves  possess  the  power 
of  amceboid  movement,  and  draw  apart  so  as  to  allow  the  leucocytes  to  pass 
between  them.  The  vital  part  of  the  process  is,  however,  fully  demonstrated, 
and  the  old  theory  that  the  emigration  is  simply  the  result  of  the  increased 
pressure  of  the  blood  in  the  vessels  has  been  abandoned  as  an  explanation  of 
the  emigration  in  the  earlier  stages  of  the  inflammation.  There  can  be  no 
doubt  that  the  emio-ration  is  due  to  the  amoeboid  movement  of  the  cells,  and 


Emigration  of  leucocytes, 
rection  of  blood-current. 


The  arrow  shows  di- 
(F.  C.  Wood,  M.D.) 


18  CHEMOTAXIS. 

the  discovery  of  the  phenomenon  to  which  is  given  the  name  of  chemotaxis 
aifords  a  suflBLcient  explanation. 

Chemotaxis. — Chemotaxis  is  the  influence  of  attraction  or  repulsion 
exerted  upon  amoeboid  cells  by  certain  substances.  In  some  cases  this 
attraction  appears  to  be  purely  mechanical,  but  it  is  probably  a  chemical 
effect  of  some  kind  in  most,  if  not  all,  instances.  Thus,  certain  low  vege- 
table organisms  known  as  the  myxomycetes  assume  at  one  stage  of  their 
existence  the  form  of  a  mass  of  protoplasm  with  several  nuclei,  called  a 
Plasmodium,  which  resembles  on  a  huge  scale  what  pathologists  know  under 
the  name  of  giant-cells.  If  this  Plasmodium  is  brought  near  an  infusion  of 
decayed  leaves  it  extends  its  pseudopodia  in  that  direction,  dips  them  into 
the  fluid,  and  finally  passes  entirely  into  it.  If,  on  the  other  hand,  a  solution 
of  quinine  be  brought  near  it,  or  be  added  to  this  infusion  of  leaves,  the 
pseudopodia  are  retracted  at  once,  others  are  thrown  out  on  the  opposite  side, 
and  the  organism  moves  away  from  the  solution.  This  apparent  distinction 
between  food  and  poison  is  undoubtedly  merely  a  chemico-biological  influ- 
ence upon  the  organism,  and  there  is  no  reason  to  doubt  that  similar  influ- 
ences would. act  upon  the  amoeboid  cells  of  the  body.-  The  process  of  in- 
flammation in  some  way  attracts  the  cells  and  causes  the  leucocytes  to  leave 
the  vessels  and  to  find  their  way  by  the  shortest  route  to  the  seat  of  inflam- 
mation. This  is  especially  well  seen  in  the  cornea,  in  which  there  are  no 
vessels,  for  if  inflammation  be  excited  in  that  structure,  the  emigration  of 
leucocytes  from  the  blood-vessels  on  its  edge  is  so  abundant  that  within  a 
very  short  time  the  inflammatory  focus  is  full  of  these  cells. 

Diapedesis. — When  the  circulation  becomes  very  slow  and  the  pressure 
very  high,  there  is  a  tendency  for  the  third  corpuscles,  and  even  the  red 
corpuscles,  to  leave  the  vessels.  This  is  a  purely  passive  process,  and  is 
observed  only  when  the  changes  in  the  vessel  wall  are  extreme.  Both  of 
these  varieties  of  cells  die,  and  are  destroyed  in  the  exudate,  the  former 
furnishing  the  fibrin  which  is  so  abundant  in  some  forms  of  inflammation. 
This  escape  of  the  red  corpuscles  is  known  as  diapedesis,  and  is  sometimes 
so  extensive  as  to  amount  to  capillary  hemorrhage. 

Cellular  Exudate. — Pus. — The  leucocytes  direct  their  course  through 
the  tissues  to  the  chief  point  of  irritation  by  reason  of  chemotaxis,  and  sur- 
round any  dead  tissue,  any  point  of  bacterial  growth,  or  any  foreign  body 
which  may  be  the  cause.  There  are  always  some  free  cells,  known  as  lym- 
phocytes or  wandering  cells,  moving  about  in  the  lymph  spaces,  and  these 
collect  in  the  inflamed  part.  If  the  inflammation  has  lasted  for  some  time, 
evidences  of  growth  and  midtiplication  are  seen  in  the  fixed  cells  of  the 
surrounding  tissues,  and  their  offspring  also  add  somewhat  to  the  mass  of 
cells.  Many  good  observers  agree  (Grawitz,  Shakespeare)  that  under  the 
stimulus  of  inflammation  many  cells  appear  in  the  tissues  which  must  have 
been  present  previously,  although  invisible  under  ordinary  circumstances, 
existing  in  a  "slumbering"  state  in  which  they  are  indistinguishable  from 
the  flbres  of  the  connective  tissue.  These  are  the  three  sources  from  which 
the  cells  of  the  exudate  originate, — the  emigrating  leucocytes,  the  multiply- 
ing fixed  cells,  and  the  slumbering  cells.  The  free  cells  crowding  towards 
the  inflamed  point  usually  die,  and  if  these  dead  cells  are  very  abundant 


PHAGOCYTOSIS. 


19 


they  form  witli  tlie  serous  exudate  the  fluid  called  pus.  When  pus  is  pro- 
duced the  inflammation  is  said  to  be  suppurative.  The  pus  cells,  however, 
are  almost  entirely  made  up  of  the  leucocytes,  of  which  three  forms  are 
known.  These  three  fornis  are  :  first,  a  small  round  cell  with  a  nucleus  so 
large  as  to  occupy  the  entire  cell ;  secondly,  a  similar  round  cell  of  much 
greater  diameter,  with  a  single  nucleus  not  so  large  in  proportion ;  and, 
thirdly,  a  round  cell  as  large  as  that  last  described,  but  with  several  nuclei 
all  united  by  a  narrow  band  of  protoplasm.  This  third  cell  is  much  the 
most  numerous  both  in  the  blood  and  in  the  exudate,  forming  in  the  latter 
over  three-quarters  of  all  the  cells  present. 

Phagocytosis. — The  object  and  effect  of  the  emigration  of  leucocytes  in 
inflammation  are  still  subjects  of  dispute.  The  leucocytes  surround  any 
foreign  body,  and  if  the  particles  are  small  enough  to  be  taken  up  the 
cells  incorporate  them  in  themselves, — in  fact,  they  may  be  said  to  swallow 
them.  This  taking  up  of  particles  by  the  wandering  cells  is  called  phagocy- 
tosis (Fig.  15),  a  process  which  some  observers  look  upon  as  more  or  less 

Fig.  15. 


U45 


O' 


a 


f  ^--dl^w^" 


Pigment  has 
ceased  moving. 


\    >      \ 

210 
Outline  lost. 


Phagocytosis.    Destruction  of  a  Plasmodium  malarije  by  a  leucocyte  in  human  blood.    The  figures  indicate 
the  time  of  observation,  the  whole  process  lasting  1  hour  and  25  minutes.     (F.  C.  Wood,  M.D.) 

accidental,  while  others  consider  that  it  is  intentional,  seeing  in  it  the 
essential  part  of  inflammation.  Metcbnikoff  thinks  that  the  object  of  the 
emigration  is  to  furnish  a  large  number  of  cells  which  will  take  up  any 
foreign  substance,  such  as  bacteria  or  sloughing  tissues,  or  the  dead  cells  of 
the  organism  which  may  have  been  killed  by  injury  or  subsequent  inflam- 
mation. If  the  particles  are  small  enough  to  be  taken  up  by  one  cell,  the 
latter  may  carry  them  away  to  the  blood-vessels  or  lymphatics,  or  to  some 


20  LEUCOCYTOSIS. 

free  surface  where  cell  and  contents  will  be  thrown  off,  or  it  msij  digest  the 
material  it  has  collected  and  continue  to  live. 

He  claims  to  have  seen  living  bacteria  taken  up  by  such  cells,  with  the 
result  that  in  some  cases  the  bacteria  multiply  in  the  cell  and  cause  its  death, 
while  in  others  the  bacteria  are  digested  and  destroyed.  This  he  terms  a 
war  of  cells,  and  looks  upon  inflammation  as  simply  a  nutritive  process  by 
which  the  tissues  furnish  the  cells  to  drive  out  or  neutralize  the  invaders. 
His  theories  command  respect,  but  many  able  investigators  still  refuse  im- 
qualified  endorsement  of  them.  Even  if  we  cannot  accept  the  doctrine  of 
phagocytosis,  there  can  be  no  doubt  that  the  accumulation  of  wandering 
cells  is  useful  in  limiting  the  inflammatory  action  by  filling  up  the  lymjjh- 
spaces  and  blocking  the  lymjahatics,  and  thus  mechanically  preventing  any 
spread  of  the  cause  of  the  irritation. 

Leucocytosis. — Direct  infection  of  the  blood  by  bacterial  cultures 
causes  in  animals  an  immediate  rediictiou  in  the  number  of  leucocytes  in 
the  circulation,  soon  to  be  followed  by  an  increase.  When  an  inflammatory 
focus  exists  anywhere  in  the  body  it  is  also  the  rule  to  find  an  increase 
in  the  number  of  leucocytes  in  the  circulating  blood,  and  to  this  condition 
is  given  the  name  leucocytosis.  The  additional  cells  come  from  the  spleen, 
the  blood- marrow,  and  the  lymphatic  glands  where  they  are  stored.  Active 
proliferation  at  once  begins  in  the  blood-marrow  which  produces  these  cells. 
In  certain  forms  of  inflammation  the  leucocytosis  is  very  marked,  in  others 
it  is  slight,  and  in  some  it  may  be  absent.  It  is  sup^iosed  that  the  toxines 
produced  by  the  infectious  agents  causing  the  inflammation  act  upon  the 
leucocytes  by  chemotaxis  and  draw  them  out  of  their  storage-places.  It  is 
possible  that  the  differences  in  the  qualities  of  the  toxine  may  account  for 
the  great  difference  in  the  degree  of  leucocytosis  observed  in  different  cases. 
When  the  quantity  or  virulence  of  the  toxines  is  very  great,  as  in  over- 
whelming sepsis,  leucocytosis  may  be  absent.  Leucocytosis  may  exist  in 
other  than  inflammatory  conditions.     (See  page  25.) 

Gaseous  Septic  Infections. — An  unusual  complication  of  inflammation 
is  the  formation  of  gas  in  the  tissues.  This  must  not  be  confounded  with 
the  escape  of  gas  or  air  into  the  cellular  spaces  from  some  of  the  air- contain- 
ing cavities  of  the  body,  for  it  is  a  true  production  of  gas  originating  from 
bacterial  growth.  When  gas  develops  in  the  closed  cavity  of  an  abscess  it 
does  not  necessarily  Imjjly  that  the  micro-orgaiiisms  concerned  are  unusu- 
ally virulent  or  dangerous  to  life,  for  it  is  more  particularly  the  putrefactive 
microbes  which  produce  these  gases.  But  when  it  is  found  in  the  cellular 
tissues  as  a  diffuse  emphysema,  sometimes  crackling  under  the  fingers  in 
spots  far  distant  from  the  original  source  of  infection,  or  advancing  rapidly 
up  a  limb,  even  without  any  congestion  of  the  overlying  skin,  it  is  a  sign 
of  the  most  serious  import,  and  it  is  seldom  that  the  patient  can  be  saved, 
even  by  an  amputation  done  at  a  point  far  removed  from  the  nearest  sign 
of  emphysema.  Some  of  these  cases  are  instances  of  malignant  oedema, 
but  not  all,  for  there  are  other  forms  of  septicaemia  which  are  accomjjanied 
by  the  production  of  gas.     (See  Chapter  YII. ) 

We  have  observed  a  general  gaseous  septicfcmia  apijearing  in  a  patient 
less  than  twenty-four  hours  after  an  internal  urethrotomy  done  with  all  the 


SUPPURATION.  21 

ordinaxy  antiseptic  precautions,  the  patient  having  a  high  temperatm-e  but 
no  local  symiitoms,  feeling  bright  and  well,  and  complaining  only  of  a  little 
sore  throat,  although  crepitation  was  distinct  in  the  subcutaneous  tissues  of 
the  ankle,  and  death  followed  forty-eight  hours  after  the  operation.  The 
cause  of  the  infection  could  not  be  ascertained.  Autopsy  revealed  no 
unusual  appearance  of  the  urethra,  but  gas  was  diffused  through  all  the 
vessels  of  the  body.  Death  is  said  to  occur  in  some  of  these  cases  merely 
from  the  mechanical  effect  of  the  presence  of  the  gas  in  the  blood-vessels, 
just  as  when  air  enters  a  vein  during  an  operation,  but  it  is  more  often  due 
to  septictemia. 

Terminations. — Inflammation  may  result  in  resolution,  supjiuration, 
sloughing,  or  in  the  establishment  of  a  chronic  state. 

Resolution  is  the  termination  of  an  inflammation  by  the  gradual  retro- 
gression of  all  the  changes  which  have  occurred.  The  pain  subsides,  the 
circulation  becomes  more  normal,  and  finally  the  exudation  is  absorbed  or 
makes  its  way  to  the  free  surfaces  of  the  body,  disappearing  in  the  latter 
case  as  serous  or  purulent  fluid.  The  fluid  exudation  re-enters  the  circula- 
tion by  the  lymph-vessels  or  blood-vessels,  and  the  new  wandering  cells 
either  die  and  become  disintegrated  or,  possibly,  enter  the  lymph -channels 
and  the  circulation  intact.  It  is  denied  by  the  best  observers  that  the 
wandering  cells  ever  become  changed  into  the  fixed  connective-tissue  cells 
of  the  part.  Resolution  may  take  place  before  any  serious  damage  has  been 
produced,  or  it  may  not  occur  until  the  tissues  have  partly  suffered  from 
suppuration  or  sloughing^  Any  loss  of  substance  caused  by  inflammation 
is  restored  by  processes  similar  to  those  of  the  repair  of  wounds. 

Suppuration. — Pus  consists  of  a  serum  containing  little  or  no  fibrin 
and  large  numbers  of  cells  resembling  the  multimrclear  leucocytes  described 
above.  These  cells  are  for  the  most  part  dead  or  dying,  and  represent  the 
waste  thrown  off  from  the  tissues  as  a  result  of  the  inflammatory  action.  A 
pui-ulent  inflammation  or  suppurative  process  is  one  which  results  in  the 
production  of  pus.  When  suppuration  occurs,  the  cellular  exudate  or  pus 
maj^  make  its  way  to  a  free  surface,  such  as  a  mucous  membrane,  or  may 
form  an  abscess  or  may  be  diffused  in  the  spaces  of  the  cellular  tissues.  Pus 
may  be  thrown  off  by  a  mucous  membrane  without  any  actual  breach  of  con- 
tinuity, the  individual  pus-cells  being  discharged  singly,  like  the  natural 
secretion  or  excretion  of  the  part. 

Abscess. — An  abscess  is  a  cavity  which  is  formed  in  the  tissues  and  con- 
tains pus.  The  pus  accumulates  in  the  spaces  of  the  tissues,  and  the  natural 
boundaries  between  these  spaces  are  destroyed  so  that  they  are  merged  into 
one.  A  collection  of  pus  in  one  of  the  recognized  anatomical  cavities  of 
the  body  is  known  as  a  purulent  effusion  or  empyema.  The  outer  limit  or 
wall  of  an  abscess  consists  of  the  tissue  in  which  it  happens  to  be  situated, 
thickly  infiltrated  with  cells,  the  layers  nearest  the  abscess- cavity  being- 
formed  of  the  cells  alone,  while  in  the  outer  layers  the  cells  are  seen  to  be  less 
closely  xjlaced,  and  the  structure  of  the  original  tissue  becomes  more  evident 
as  one  passes  outward,  until  normal  tissues  are  reached,  there  being  no  dis- 
tinct outer  limit  to  the  abscess  wall.  Owing  to  the  fact  that  the  inner  sur- 
face of  the  abscess  often  looks  like  mucous  membrane,  it  was  formerly  often 


22  SLOUGHING. 


spoken  of  as  a  pyogenic  membrane,  a  term  which  has  novr  deservedly  passed 
out  of  use,  for  this  lining  is  in  no  sense  a  membrane,  nor  does  it  produce  the 
pus.  An  abscess  grows  by  the  softening  and  loosening  of  infiltrated  tissues 
about  it,  under  the  peculiar  solvent  properties  of  the  pus,  the  infiltration 
spreading  on  the  outer  limits,  while  the  most  infiltrated  tissues  on  the  side 
towards  the  cavity  are  constantly  breaking  down.  When  an  abscess  has 
existed  for  a  long  time  it  may  be  encapsulated  by  an  irregular  layer  of 
connective  tissue  formed  around  it,  but  this  capsule  is  not  permanent,  for 
it  constantly  tends  to  break  down  on  the  side  towards  the  abscess  cavity. 

Puriilent  Infiltration.— Diffuse  infilti-atiou  of  the  tissues  with  pus  is 
the  most  dangerous  form  of  suppm-ation.  In  this  variety  of  inflammation 
the  exudate  is  brought  into  contact  with  the  greatest  possible  extent  of  ab- 
sorbent vessels,  for  as  the  surfiice  of  a  sponge  is  greater  than  that  of  a  bag 
which  would  just  contain  it,  so  the  surface  of  these  intercellular  spaces  is 
much  greater  than  that  of  au  abscess- cavity  filled  by  the  same  amount  of 
pus.  In  this  form  also  the  bands  of  cellular  tissue  lying  between  and  form- 
ing the  boundaries  of  these  spaces  have  their  nutrition  and  circulation  im- 
paii-ed,  and  frequently  slough,  but,  as  they  lie  under  unaltered  skin  and  still 
remain  partly  in  connection  with  the  surrounding  tissues  by  their  fibres, 
theii'  elimfnation  is  very  difficult.  The  entire  skin  of  the  part  is  fi-equently 
detached  from  the  fascia  by  the  sloughing  of  the  subcutaneous  tissues  before 
it  gives  way,  and  even  when  it  finally  yields  to  the  necrotic  process  the 
openings  formed  will  be  altogether  too  small  in  proportion  to  the  extent  of 
the  disease  beneath,  so  that  healing  is  still  further  delayed. 

Sloughing.— Inflammation  may  result  in  sloughing  or  death  of  the 
tissue.  Gangrene,  mortification,  necrosis,  or  sphacelus  is  a  death  of  the  tissues 
from  any  cause.  The  part  which  has  died  is  designated  as  a  slough,  although, 
sti-ictly  speaking,  this  term  should  be  limited  to  a  dead  portion  which  is 
already  partly  separated  from  the  living  tissues.  The  word  necrosis  is 
generally  Imited  to  the  bones,  and  the  slough  in  this  case  is  also  separately 
designated  as  a  sequestrum.  Any  violent  mechanical,  chemical,  thermic  or 
electric  injury  may  cause  death  of  the  tissue  directly  involved,  and  4n- 
grene  can  also  be  produced  by  any  cause  which  entirely  suspends  the  circu 
lation  of  a  part,  so  that  it  is  frequently  found  associated  with  inflammation 
either  as  an  accidental  complication  or  as  a  necessary  consequence  of  that 
process.  During  the  progress  of  inflammation  the  circulation  may  be  shut 
off  from  any  part  of  the  tissues  by  (1)  mechanical  compression  of  the  ves- 
sels by  the  inflammatory  exudate,  (2)  internal  obstruction  of  the  vessels  bv 
the  growth  of  bacteria  and  of  the  cells  in  their  walls,  or  (3)  coagulation  of 
the  blood  m  the  vessels  by  some  intense  fibrin-producing  effect  of  the  in- 
flammatory process.  It  is,  for  instance,  well  known  how  great  is  the  dan..er 
of  sloughing  when  suppurative  inflammation  attacks  the  tendons,  which  are 
poorly  supplied  with  blood,  and  often  enclosed  in  narrow,  unyielding  chan 
nels,  so  that  inflammatory  swelling  may  easUy  shut  off  their  blood-supp^y 
In  other  cases  thei^  is  a  combination  of  causes,  as  may  occur  in  diabetes  S 
at  the  close  of  exhausting  fevers  in  which  the  general  system  has  been 
greatly  reduced  and  the  vital  resistance  of  the  tissues  impS^d  so  that  an 
inflammation  which  would  be  of  little  moment  in  healthy  persons  may  tsult 


CHRONIC  INFLAMMATION.  23 

in  the  extensive  destruction  observed  in  diabetic  gangrene  of  the  limbs  or  in 
noma  of  the  face  and  genitals.  Finally,  there  is  that  class  of  cases  which 
are  known  as  hospital  gangrene,  emphysematous  gangrene,  or  malignant 
oedema.     (See  Chapter  VII.) 

"When  a  slough  or  sequestrum  has  formed,  the  separation  of  the  dead 
from  the  living  tissues  is  accomplished  chiefly  by  the  new  cells,  although  it 
is  uncertain  whether  these  new  cells  consist  of  the  wandering  cells  from  the 
vessels,  or  whether  the  cells  of  connective-tissue  origin  are  also  included. 
Some  claim  that  ouly  the  latter  are  concerned  in  this  as  well  as  other  efforts 
■  of  repair.  But  sloughs  often  separate  at  the  height  of  the  inflammatory 
process  before  any  repair  can  have  begun,  so  that  there  is  reason  to  supi^ose 
that  in  some  cases  at  least  the  separation  takes  iilaee  before  the  connective- 
tissue  cells  proliferate,  and  hence  must  be  due  to  the  action  of  the  lympho- 
cytes. However  this  may  be,  a  section  through  the  point  of  separation 
shows  on  the  one  side  dead  slough,  on  the  other  living  tissue  infiltrated  with 
cells  and  other  products  of  inflammation,  and  at  the  point  of  juncture  (or 
of  separation)  the  connecting  fibres  are  surrounded  by  compact  masses  of 
lymphocytes,  some  dead,  some  living,  many  containing  detritus  (granules, 
fatty  globules)  which  they  have  taken  up  from  the  slough.  The  fibres  are 
apparently  dissolved  by  the  fluids  and  consumed  by  the  phagocytosis  of  the 
cells.  When  the  inflammation  has  subsided,  grauulation-tissue  forms  on 
the  living  tissue  directed  towards  the  slough,  and  the  fibres  are  destroyed  in 
a  similar  way  by  its  vital  action.  This  process  is  most  readily  studied  in 
necrosis  of  bone,  and  will  be  further  dealt  with  under  that  head. 

Chronic  Inflammation.— The  third  termination  of  inflammation  is 
the  arrest  of  its  changes  in  resolution  or  suijpuration  at  any  stage,  and 
the  continuance  of  the  existing  symptoms  and  pathological  changes  in  this  • 
lessened  intensity  for  a  more  or  less  protracted  time, — in  other  words,  the 
develojjment  of  chronic  inflammation.  By  chronic  inflammation  we  under- 
stand a  long  continuance  of  some  or  all  of  the  changes  seen  in  acute  inflam- 
mation, but  in  less  intensity,  and  with  a  tendency  to  the  production  of  new 
tissue  by  i^roliferation  of  the  fixed  cells  of  the  part  affected.  This  thick- 
ening of  the  tissues  is  due  to  the  unusual  amount  of  nutrition  afforded  the 
cells  of  the  region.  As  a  sequel  of  acute  inflammation,  the  chronic  form  is 
due  to  a  diminished  intensity  of  the  original  irritation,  to  the  fact  that  the 
cells  have  become  accustomed  to  it.  or  to  changes  in  the  cells  produced  by 
the  long  battle  against  the  irritation,  the  cells  being  so  perverted  that  they 
cannot  at  once  return  to  their  natural  state.  But  chronic  inflammation 
is  sometimes  observed  to  rise  independently,  without  a  preliminary  acute 
stage,  as  the  result  of  certain  irritants  similar  to  those  which  excite  the 
acute  form,  but  not  so  intense,  or  acting  upon  tissues  which  are  better  able 
to  resist,  and  responding  only  by  the  lower  grade  of  reaction. 

The  pathological  changes  in  chronic  inflammation  vary  with  the  origi- 
nal cause,  and  with  the  tissues  affected,  more  than  do  those  of  the  acute  form. 
There  is  an  increased  vascularity,  chiefly  noted  in  the  venous  capillaries, 
and  an  unusual  richness  of  cells  in  the  tissues.  All  the  tissues  are  thick- 
ened,— the  connective-tissue  stroma,  the  walls  of  the  blood-  and  lymph- 
vessels,  the  endothelium,  the  epithelium,  the  periosteum,  etc.     Ossification 


24  CHRONIC  INFLAMMATION. 

may  extend  into  tlie  soft  tissues,  and  normal  bone  may  soften  and  disappear 
under  the  influence  of  tlie  proliferation  of  cells.  In  the  latter  changes  the 
effect  appears  paradoxical,  but  in  both  cases  it  is  due  to  the  abnormal  cell- 
life,  for  the  quiescent  bone-cells  tend  to  return  to  the  embryonal  active  state 
and  to  absorb  the  bone-salts  about  them,  while  the  quiescent  connective- 
tissue  and  j)eriosteal  cells  are  roused  to  unusual  activity  and  produce  new 
bone  at  the  edges  of  the  inflammatory  area,  where  the  irritation  is  less  intense 
and  does  not  prevent  deposition  of  bone.  These  changes  in  the  tissues  are 
evidentlj^  largely  conservative.  The  abundant  cell-production  and  thicken- 
ing of  the  tissues  tend  to  neutralize  the  irritant,  and  to  close  all  avenues  of 
entrance  to  the  rest  of  the  system  by  thickening  the  walls  of  the  absorbent 
vessels  and  blocking  them  with  the  new  cells.  Among  the  characteristic 
changes  in  the  cells  in  chronic  inflammation  is  the  appearance  of  the  giant- 
cells.  The  origin  and  function  of  these  bodies,  consisting  of  large,  irregular 
masses  of  protoplasm  with  several  distinct  nuclei,  is  as  yet  uncertain.  Cer- 
tain it  is,  however,  that  they  are  found  in  the  neighborhood  of  foreign  mate- 
rial which  the  tissues  are  trying  to  eliminate  or  encapsule.  Some  hold  that 
they  consist  of  numerous  small  cells  which  have  lost  their  vitality  and  be- 
come fused  together,  deducing  their  origin  from  the  wandering  leucocytes 
which  have  been  attracted  by  chemotaxis  to  the  foreign  body  and  are  dying. 
Metchnikoff  claims  to  have  seen  such  giant-cells  about  the  foreign  bodies 
occasionally  observed  in  the  lower  infusorial  animals,  which  are  formed  only 
of  an  external  and  internal  layer  of  cells  (ectoderm  and  entoderm),  with  an 
intermediate  mass  of  protoplasm  containing  amoeboid  cells  corresj)ondiug  to 
our  leucocytes,  but  without  blood-vessels  of  any  kind.  He  supposes  that 
they  have  formed  from  these  amoeboid  cells,  and  advances  the  theory  that, 
•as  the  foreign  body  was  too  large  for  one  of  them  to  take  it  iip  into  itself, 
the  cells  became  fused  in  order  to  furnish  enough  protoj)lasm  to  surround 
the  foreign  bodj^,  but  the  nuclei  remained  distinct.  He  denies  that  the 
giant-cell  represents  lowered  vitality,  and  assumes  that  it  is  an  instance  of 
active  fusion  of  the  cells  for  the  better  performance  of  their  function  of 
phagocytosis.  In  certain  sarcomatous  tumors  giant-cells  are  common,  and 
appear  to  possess  the  power  of  absorbing  or  cansing  the  absorjition  of  bone 
with  which  they  are  brought  in  contact,  and  this  may  be  considered  a  clue 
to  their  functions. 

The  local  and  general  symptoms  of  chronic  inflammation  depend  so  en- 
tirely upon  its  situation  that  they  can  hardly  be  described  here.  We  mei-ely 
mention  the  fact  that  in  long-continued  suppuration  of  the  bones  or  other 
parts  an  amyloid  or  waxy  degeneration  is  apt  to  take  j)lace  in  the  liver, 
kidney,  and  spleen,  probably  due  to  the  circulation  of  bacterial  toxines  in 
the  blood.  While  generally  fatal,  instances  of  recovery  from  this  condition 
have  been  observed  in  children.  It  is  recognized  by  enlargement  of  the 
affected  organs,  and  by  albuminuria  when  the  kidney  is  involved. 


CHAPTER    III. 

SYMPTOMS  AND  TREATMENT  OF  INFLAMMATION. 
By  B.  Faequhar  Curtis,  M.D. 

Symptoms. — Prom  antiquity  tlie  local  symptoms  of  inflammation  have 
been  enumerated  as  rubor,  dolor,  calor,  et  tumor,  and  to  these  the  moderns 
have  added  only  one,  largely  a  consequence  of  the  others,  functio  Iwsa — 
impaired  function.  The  redness  is  due  to  the  congestion.  The  ][)ain  is  due 
to  the  pressure  exerted  upon  the  sensory  nerves  by  the  surrounding  swell- 
ing, as  is  well  shown  by  the  intensification  of  the  distress  as  every  beat  of 
the  heart  forces  more  blood  into  the  space  already  overfilled.  In  some  cases, 
however,  it  may  be  caused  by  the  direct  action  of  the  inflammatory  agent 
on  the  nerves.  The  lieat  is  caused  by  the  increased  supply  of  warm  arterial 
blood,  for  it  has  been  abiindantly  proved  that  the  local  temperatnre  never 
rises  above  the  heat  of  the  circulating  blood.  The  swelling  is  due  to  dilated 
vessels,  to  the  effusion  of  lymph  and  cells,  and  to  the  presence  of  pus.  The 
impaired  function  is  chiefly  caused  by  the  pain,  which  is  often  increased  by 
any  attemjat  to  use  the  part,  and  by  the  swelling,  which  jprevents  its  free 
movement,  though  the  loss  of  function  may  also  be  dependent  upon  the 
direct  action  of  the  inflammatory  cause  upon  the  nerves. 

The  constitutional  symptoms  of  inflammation  are  an  elevation  of  tem- 
perature, with  or  without  a  chill,  and  the  general  disturbance  due  to  this 
condition,  leucocytosis,  and  disturbances  of  certain  organs,  such  as  the  ner- 
vous centres,  which  are  poisoned  by  the  toxic  substances  produced  in  the 
inflamed  parts,  and  the  liver,  kidney,  and  intestine,  which  endeavor  to 
eliminate  the  poison  from  the  system. 

Leucocytosis. — An  increase  of  the  i^olynuclear  leucocytes  in  the  circu- 
lating blood  over  the  normal  amount  of  seven  thousand  five  hundred  to  the 
cubic  centimetre  is  called  leucocytosis,  and  this  is  a  common  symptom  of 
inflammation,  although  it  may  be  due  to  other  causes.  This  increase  occurs 
physiologically  to  the  amount  of  ten  or  twelve  thousand  during  the  diges- 
tion of  proteid  fopds,  and  the  same  amount  or  more  is  frequently  observed 
during  the  latter  months  of  pregnancy.  The  leucocytosis  of  inflammation 
is  caused  by  chemotaxis  (see  page  18),  and  runs  from  fifteen  thousand 
to  fifty  thousand,  although  seldom  over  thirty  thousand.  "  The  amount  is 
independent  of  the  extent  of  the  focus,  and  may  be  as  great  with  a  minute 
panaritium  as  with  a  large  abscess.  It  is  found  in  suppurative  and  gan- 
grenous inflammations,  in  pneumonia,  in  acute  articular  rheumatism,  scarlet 
fever,  actinomycosis,  glanders,  and  many  similar  conditions.  If  a  sudden 
overwhelming  septictemia  accompanies  the  beginning  of  an  inflammation,  as 
in  peritonitis  caused  by  intestinal  perforation,  leucocytosis  may  fail  to 
develop,  and  it  may  be  absent  when  an  abscess  exists  but  is  well  encapsu- 

25 


26  LEUCOCYTOSIS. 

lated.  It  is  also  occasionally  absent  in  inflammatory  conditions  in  which  it 
would  be  expected,  for  reasons  which  are  as  yet  unknown,  so  that  it  is  not 
an  absolutely  reliable  symptom.  Leucocytosis  is  present  also  in  a  number 
of  conditions  without  inflammation.  Any  serious  hemorrhage  may  cause  a 
relative  increase  in  the  leucocytes  for  a  time,  their  number  returning  to  the 
normal  proportion  when  the  antemia  becomes  less  acute.  The  increase  is 
observed  when  the  blood  flows  into  one  of  the  cavities  of  the  body,  as  well 
as  when  it  escapes  externally,  being  marked  in  ruptured  ectopic  gestation, 
in  which  we  have  observed  a  count  of  twenty-six  thousand  five  hundred. 
The  intravenous  infusion  of  normal  salt  solution  will  also  cause  a  leucocy- 
tosis. The  administration  of  certain  drugs,  such  as  salicylic  acid,  causes  a 
leucocytosis,  and  it  is  the  rule  after  the  ansesthetic  inhalation  of  ether.  We 
have  observed  it  to  occur  after  operations  undertaken  with  intraspinal  cocaine 
anaesthesia,  although  it  is  not  so  i-apid  as  with  ether  ansesthesia,  the  count 
with  the  latter  being  doubled  in  a  few  minutes.  Cases  of  sarcoma  often  show 
a  leucocytosis,  and  it  is  said  also  to  occur  in  carcinoma  in  the  late  stages, 
although  its  ]3resence  in  the  latter  is  denied  by  some  unless  there  is  ulceration. 

From  these  facts  it  is  evident  that  while  leucocytosis  is  a  symptom  which 
may  be  very  useful  in  diagnosis,  it  must  be  interpreted  with  care,  just  as  we 
have  learned  that  even  the  temperature  of  a  patient  cannot  always  be  accepted 
as  a  reliable  symptom.  Before  we  assume  that  the  leucocytosis  indicates  a 
suppurative  inflammation,  we  must  exclude  other  possible  causes  for  the  in- 
crease, such  as  ijneumonia,  or  a  previous  ether  anaesthesia,  or  hemorrhage. 
Leucocytosis  is  most  useful  in  the  diagnosis  between  conditions  which  re- 
semble each  other  in  other  respects,  but  differ  in  their  effect  upon  the  leuco- 
cytes. Thus,  leucocytosis  is  present  in  su^jpurative  or  gangrenous  appendicitis 
and  in  peritonitis  (unless  overwhelming  sepsis  has  developed),  but  is  absent 
in  intestinal  obstruction  and  in  typhoid  fever.  It  is  absent  in  malarial 
fevers,  and  present  in  pyaemia.  It  is  present  in  actinomycosis  and  glanders, 
absent  in  tuberculosis.  In  typhoid  fever  the  leucocytes  are  abnormally 
scanty,  but  if  perforation  takes  place  they  increase,  although  they  may  not 
reach  the  normal  even  then.  (See  Peritonitis.)  When  the  leucocyte  count 
is  not  definite,  successive  examinations  made  at  intervals  of  an  hour  or  more 
will  show  whether  there  is  a  tendency  towards  an  increase  or  decrease. 

Treatment. — The  general  indications  to  be  observed  in  the  treatment 
of  inflammation  are,  (1)  to  combat  the  active  and  passive  congestion  of  the 
parts,  (2)  to  relieve  tension,  (3)  to  give  free  issue  to  the  products  of  inflam- 
mation, (4)  to  promote  the  early  separation  of  sloughs,  and  (5)  to  assist 
elimination  of  toxines  by  the  skin,  bowels,  and  kidneys.  K"o  specific  has  yet 
been  discovered  to  act  directly  against  the  bacteria  which  cause  cellulitis  and 
allied  inflammatory  processes,  unless  the  claims  of  the  new  serum  therapy  be 
established.  The  most  that  the  surgeon  can  do  at  present  is  to  assist  the  tis- 
sues in  their  attempt  to  neutralize  and  limit  the  action  of  the  invading  germs. 

Elevation. — The  active  congestion  can  be  relieved  in  the  first  place  by 
placing  the  inflamed  part  on  a  higher  level  than  the  rest  of  the  body  and  by 
securing  as  complete  immobilization  as  possible.  In  some  peculiar  cases  local 
bloodletting  by  scarification  is  useful,  but  general  bleeding  should  never  be 
employed,  for  the  patient  wUl  need  all  his  vitality  to  resist  septic  infection. 


TREATMENT  OF  INFLAMMATION.  27 

Heat  and  Cold. — Very  cold  or  very  hot  applications  to  the  seat  of  in- 
jiammatiou  will  relieve  the  pain,  lessen  the  congestion,  soften  the  parts  so 
as  to  rednce  the  tension,  and  thus  assist  the  tissues  in  their  struggle  against 
the  invading  germs.  It  is  probably  of  little  moment  whether  heat  or  cold 
be  employed,  so  long  as  the  applications  be  made  continuously,  for  an  alter- 
nation of  heat  and  cold  is  a  stimulant  to  the  circulation,  whereas  the  con- 
tinuous application  of  either  is  a  sedative.  Extremes  of  heat  and  cold  have 
the  power  of  contracting  the  caliber  of  the  blood-vessels,  but  the  action  of 
heat  is  apparently  more  lasting  and  less  apt  to  be  followed  by  a  reaction  from 
subsequent  paresis  of  the  vascular  walls,  and  hot  applications  are,  as  a  rule, 
more  agreeable  to  the  patient  than  cold.  Every  surgeon  has  his  own  pref- 
erences, and  personally  we  have  observed  the  best  effects  from  hot  poultices 
in  such  conditions  as  cellulitis,  whereas  in  peritonitis  and  meningitis  the 
use  of  the  ice-bag  and  cold  coil  has  given  us  the  best  results,  possibly  be- 
cause in  these  diseases  the  general  elevation  of  temperature  is  a  dangerous 
condition  in  itself,  and  this  fever  is  directly  reduced  by  the  ai^plication 
intended  to  affect  the  local-  lesion.  A  poultice  should  not  be  api^lied  to  an 
open  wound  or  ulcer,  because  it  quickly  becomes  foul  with  the  discharge, 
and  it  should  always  be  sterilized  by  boiling  before  being  used. 

Wet  Antiseptic  Dressings. — With  the  demonstration  of  the  bacterial 
origin  of  inflammatory  affections  the  use  of  various  antiseptic  substances  as 
external  applications  to  the  inflamed  parts  became  universal,  and,  in  spite 
of  the  early  proof  of  the  fact  that  none  of  these  substances  could  be  made 
to  iDcnetrate  the  skin  in  suflicient  quantity  to  affect  the  growth  of  micro- 
organisms beneath  it  without  poisoning  the  individual  by  constitutional 
absorption,  the  practice  is  still  prevalent.  It  has  been  proved  that  in  order 
to  destroy  or  even  seriously  hinder  the  growth  of  germs  a  considerable 
quantity  of  any  of  the  antiseptic  substances  as  yet  known  must  be  brought 
in  contact  with  them,  and  it  is  self-evident  that  any  substance  which  passes 
inward  through  the  skin  and  other  vascular  tissues  must  be  taken  up  by  the 
blood  in  the  vessels  and  carried  away,  so  that  it  would  reach  any  other  part 
of  the  body  as  quickly  as  it  could  reach  the  parts  just  beneath  the  skin  to 
which  the  application  is  made.  We  have  as  yet  no  antiseptic  agent  which 
can  affect  the  growth  of  germs  and  yet  will  not  injure  the  patient,  so  that 
such  absorption  as  this  would  be  of  very  serious  moment.  These  facts  prove 
the  absurdity  of  applying  dressings  wet  with  carbolic  acid  or  corrosive  sub- 
limate solutions  to  the  unbroken  skin  over  inflamed  deep  parts.  Any  bene- 
fit which  has  been  observed  to  follow  their  use  has  undoubtedly  been  due  to 
the  effect  of  the  moisture  and  warmth  or  cold  (according  to  the  temijerature 
of  the  dressings)  thus  obtained,  while  local  sloughing  and  general  constitu- 
tional poisoning  are.  a  common  result  of  such  applications.  In  some  cases 
an  attempt  has  been  made  to  cause  absorption  of  the  antiseptic  by  scarifying 
the  surface,  but  with  doubtful  effect.  A  light  gauze  dressing  applied  cold 
and  kept  constantly  wet  with  any  evaporating  solution  will  greatly  relieve 
the  congestion,  and  so  assist  the  inflamed  tissiies  in  their  contest  with  the 
ii-ritating  material.  A  thick  wet  dressing  made  with  a  hot  solution 
and  well  protected  against  evaporation  so  that  it  will  retain  its  heat  will 
produce  the  same  eifect,  acting  like  a  poultice,  although  less  powerfully. 


28  TREATMENT  OF  INFLAMJLiTIOX. 

When  there  are  discharging  wounds  or  raw  surfaces,  one  of  the  methods 
just  described  should  be  employed,  for  poultices  are  then  inadmissible,  and 
the  weak  antiseptic  solutions  will  prevent  additional  infection  of  the  dis- 
charge. Astringent  solutions  applied  either  cold  or  hot  have  an  excellent 
effect  upon  iniiammatory  processes,  and  the  most  generally  useful  of  these  is 
the  solution  of  acetate  of  aluminum.  The  best  formula  for  this  is  Von 
Burow's :  R  Aluminis,  3vi  (24  grammes);  plumbi  acetatis,  Sixss  (38 
grammes)  ;  aquse,  Oii  (1000  grammes).  M.  S. — Filter  after  standing  twenty- 
four  hours.  This  solution  is  strongly  astringent,  somewhat  antiseptic  (25 
parts  to  1000  preventing  development  of  bacteria),  not  poisonous,  and  so 
little  irritating  that  it  can  even  be  used  about  the  face  without  danger  of 
conjunctivitis. 

Injections  of  Antiseptics. — To  overcome  the  difficulties  of  bringing  the 
antiseptic  substances  In  contact  with  the  micro-organisms  through  the  un- 
broken skin,  it  has  been  suggested  that  they  should  be  injected  by  the  hypo- 
dermic syringe  directly  into  the  inflamed  area.  In  some  cases  an  immediate 
limitation  of  the  inflammation  has  thus  been  secured,  but  the  method  is 
painful  and  there  is  danger  of  constitutional  poisoning.  The  best  results 
have  been  obtained  in  very  superficial  inilammatious,  such  as  erysipelas, 
and  in  specific  chronic  inflammations,  such  as  tuberculosis.  We  refer  to  the 
special  sections  for  details. 

Mechanical  Astringents. — Attempts  to  modify  the  circulation  and  to 
prevent  the  spread  of  inflammation  have  been  made  by  compression  of  the 
tissues  just  beyond  the  inflamed  area  by  the  painting  of  bands  of  contractile 
■  collodion  on  the  skin  or  simply  by  tight  strapping  with  adhesive  plaster. 
This  will  be  described  under  erysipelas,  in  which  the  best  effects  are 
obtained. 

Permanent  Irrigation  and.  Baths. — When  there  are  abscesses,  suppu- 
rating joints,  or  other  cavities,  or  sinuses  with  a  tendency  to  a  retention  of 
pus,  permanent  irrigation  is  one  of  the  best  methods  of  treatment.  In  some 
cases  permanent  baths  have  been  successfully  employed,  the  part  being  sus- 
pended by  bandages  in  a  small  bath-tub  beneath  the  level  of  the  fluid.  The 
latter  method  answers  for  large  superficial  lesions,  but  the  irrigation  is  better 
for  cavities.     (See  Chapter  XIII.) 

Incision. — While  the  means  already  described  enable  us  to  combat  the 
congestion  and  therefore  relieve  tension  to  some  extent,  the  relief  is  only 
partial.  If  resolution  of  the  inflammation  does  not  speedily  occur,  tension 
must  be  relieved  by  dividing  dense  tissues  which  surround  the  inflammatory 
focus,  or  by  giving  exit  to  the  inflammatory  exudate.  It  is  sometimes  neces- 
sary to  incise  the  inflammatory  focus  very  early,  before  pus  appears,  in  order 
to  ijrevent  the  sloughing  which  will  follow  if  the  intense  pressure  which  is 
strangulating  the  parts  and  entirely  shutting  off  their  blood-supply  is  not 
relieved  at  once.  Early  incision  may  also  be  necessary  to  obtain  relief  of 
tension  which  is  causing  the  absorption  of  dangerous  amounts  of  toxines 
from  the  inflammatory  focus,  or  the  inflammation  may  be  so  situated  that 
immediate  interference  is  necessary  in  order  to  exclude  all  possibility  of  sub- 
sequent invasion  of  important  organs,  as  in  facial  carbuncle,  which  may  in- 
fect the  veins  and  then  extend  back  through  the  orbital  vein  to  the  cerebral 


TREATMENT   OF  INFLAMMATION.  29 

sinuses.    As  a  rule,  however,  incisions  are  not  required  until  pus  has  formed, 
and  the  surgeon  mvist  be  guided  by  the  symi^toms. 

Indications  for  Incision. — Pain  is  an  excellent  sign  of  tension,  and  if 
it  is  found  to  continue  or  even  to  increase  in  spite  of  the  thorough  and  in- 
telligent use  of  ice-bags  or  poultices  for  twenty-foiir  hours,  especially  if  the 
pain  is  sufficient  to  prevent  sleep,  an  incision  is  urgently  needed.  In  some 
cases,  however,  dangerous  inflammation  may  exist  without  much  pain. 

Induration. — If  a  brawny  induration  of  the  subcutaneous  tissue  exists,  its 
edge  being  xirominent  under  the  skin  almost  as  if  the  cellular  tissue  were 
injected  with  wax,  and  esj)ecially  if  it  is  extending,  immediate  incision  is 
necessary,  for  such  inflammations  seldom  resolve  or  form  well -localized  ab- . 
scesses,  but  are  apt  to  cause  extensive  sloughing,  and  any  delay  will  result 
in  greater  destruction  of  tissue. 

Fever  and  Rigors. — The  elevation  of  temperature  will  generally  be 
proportionate  to  the  amount  of  tension  in  the  inflamed  part  and  to  the  kind 
of  toxine  which  is  absorbed,  and  both  demand  relief  by  the  knife  as  soon 
as  they  become  at  all  marked.  With  the  febrile  movement  there  will  be  a 
chill  in  some  cases,  and  when  chills  appear  after  a  period  of  fever  they  gen- 
erally indicate  that  pus  exists.  In  pyaemia  a  chill  sometimes  marks  the 
beginning  of  every  fresh  abscess.  But  it  should  be  especially  noted  that 
these  chills  are  merely  the  reaction  of  the  body  to  certain  bacterial  poisons, 
and  are  by  no  means  a  pathognomonic  sign  of  the  presence  of  pus. 

Physical  Signs. — The  physical  signs  of  the  presence  of  pus  in  the  tissues 
are  the  evidences  of  elastic  distention  and  fluctuation.  Fluctuation  is  the  sen- 
sation communicated  by  the  wave  of  fluid  playing  in  a  closed  cavity  or  sac, 
and  it  is  produced  by  holding  one  hand  or  finger  lightly  but  steadily  in  con- 
tact with  the  surface  of  the  suspected  swelling,  while  with  another  a  quick 
impact  is  made  upon  the  swelling  at  a  point  as  far  distant  as  possible.  A 
sensation  similar  to  this  can  be  obtained  from  any  of  the  large  muscles  of  the 
body  if  the  test  is  made  at  right  angles  with  the  long  axis  of  the  muscular 
fibre ;  hence  an  examination  for  fluctuation  in  a  swelling  situated  under  a 
muscular  layer  should  always  be  made  parallel  with  the  length  of  the  fibres 
of  the  latter.  The  symptom  sometimes  cannot  be  detected  in  abscesses, 
because  the  walls  are  so  dense  that  the  fluid  wave  cannot  be  felt  through 
them,  or  because  the  cavity  is  not  completely  distended  with  the  fluid.  In 
the  latter  case  pressure  upon  the  sides  of  the  cavity  will  collect  the  fluid  in 
the  part  immediately  under  the  fingers  and  bring  out  the  sign.  Any  fluid 
may  cause  fluctuation.  An  aneurism  or  a  soft,  rapidly  growing  sarcoma 
has  frequently  been  taken  for  an  abscess,  and  in  any  doubtful  case  the 
incision  should  not  be  made  until  examination  shows  the  absence  of  thrill 
and  the  exploring  syringe  has  demonstrated  the  presence  of  pus. 

When  pus  is  detected  in  an  acute  inflammation  it  should  be  discharged 
by  incision  at  once.  If  an  incision  is  postponed,  the  cavity  of  the  abscess 
will  increase,  surrounding  tissues  will  be  further  destroyed,  vessels  may  be 
opened  as  their  walls  are  softened  by  the  solvent  action  of  the  i)us,  and 
hemorrhage  take  place ;  or  vessels  may  be  blocked  and  gangrene  may  re- 
sult ;  not  to  mention  the  danger  that  the  abscess  may  burst  through  its  wall 
and  invade  the  peritoneal  or  the  pleural  cavity,  or  one  of  the  hollow  organs. 


30  TREATMENT  OF  INFLAMMATION. 

such  as  the  bladder  or  the  bronchi.  This  bursting  of  the  abscess  may  have 
both  infectious  and  mechanical  results,  either  pneumonia  or  suffocation  being 
the  consequence,  for  example,  when  the  pus  enters  the  bronchi.  There  is, 
moreover,  a  constant  absorption  of  toxines,  which  can  be  arrested  only  by 
discharge  of  the  pus,  and  no  one  can  tell  at  what  moment  a  fatal  septicaemia 
or  pyjBmia  may  be  set  up. 

Making  the  Incision. — In  a  well- limited  abscess  a  single  incision  is  usu- 
ally sufficient,  being  placed,  if  possible,  at  the  most  dependent  portion,  so 
that  the  discharge  will  naturally  flow  from  the  cavity  by  the  most  direct  route. 
If  the  cavity  is  rather  large,  another  incision  may  be  made  above  to  allow 
irrigation.  This  method  of  making  two  incisions  is  called  through  drainage. 
Such  simple  abscesses  will  generally  heal  readily  under  a  plain  dressing 
without  irrigation,  a  small  tube  or  wick  of  gauze  being  placed  in  the  in- 
cision until  the  cavity  contracts.  In  some  regions  it  is  wise  to  limit  the 
interference  as  much  as  possible,  so  as  to  avoid  the  production  of  disfiguring 
scars,  but  a  small  incision  is  apt  to  be  followed  by  prolonged  suppuration. 
Free  incision  and  completely  filling  the  cavity  of  the  abscess  with  gauze 
insure  the  most  rapid  and  complete  healing,  and  should  be  the  method  of 
choice  in  the  general  treatment  of  abscess.  "When  septa  are  found  dividing 
an  abscess-cavity,  they  should  be  broken  down,  for  they  will  interfere  with 
proper  drainage,  and  all  sloughs  should  be  removed  unless  there  is  danger 
of  hemorrhage. 

In  making  incisions  to  relieve  tension,  when  the  life  of  the  parts,  if  not 
the  life  of  the  patient,  is  in  danger,  the  incisions  should  be  carried  beyond 
the  edge  of  the  induration  into  healthy  tissue,  and  the  very  centre  of  the 
inflammatory  focus  must  be  laid  bare.  In  cases  of  extensive  cellulitis,  it 
will  be  necessary  to  make  incisions  of  great  length,  or  a  large  number  of 
moderate  incisions,  and  if  the  focus  is  in  the  medullary  cavity  of  a  bone,  it 
must  be  opened  up.  The  size  and  depth  of  the  wounds  are  of  secondary 
importance.  In  some  inflammatory  processes  of  limited  extent  but  great 
virulence  (as  in  anthrax)  the  entire  focus  may  be  excised  like  a  tumor,  the 
knife  being  kept  outside  of  the  diseased  tissue  on  all  sides,  or  the  infected 
part  may  be  completely  destroyed  by  the  cautery. 

After-Treatment. — Some  sm-geons  irrigate  every  suppurating  cavity  as 
soon  as  opened  ;  others  prefer  to  let  nature  clean  the  cavity,  fearing  that 
irrigation  may  wash  out  clots  and  result  in  serious  hemorrhage,  and  jjack 
the  cavity  with  iodoform  gauze  or  sterilized  gauze  for  the  first  twenty-four 
hours.  At  the  second  dressing  the  cavity  may  be  irrigated  with  simple 
sterilized  water  or  with  boric  acid  solution,  or  with  weak  antiseptic  solutions, 
such  as  1  to  5000  bichloride  of  mercury  or  1  to  100  carbolic  acid.  If  the 
cavity  is  not  laid  widely  open  and  packed,  a  tube  or  a  tent  of  gauze  is  to  be 
kept  in  for  drainage  until  it  has  fully  contracted,  and  a  compressive  dressing 
applied  in  order  to  approximate  its  walls.  The  dressing  is  to  be  changed  as 
often  as  it  is  soaked  through  with  the  discharge,  or  whenever  pain  and  fever 
indicate  any  retention  of  discharge  in  the  cavity.  Although  it  is  possible 
to  obtain  good  results  by  dressing  abscesses  with  simple  sterilized  gauze, 
we  prefer  some  mild  antiseptic  (1  to  3000  or  5000  bichloride  of  mercury 
solution)  in  the  gauze,  because  of  the  tendency  of  the  pus  to  decomposition. 


CHAPTER    IV. 

sapriemia,  septicjemia,  py^imia. 
By  B.  Fabquhar  Cuktis,  M.D. 

Under  the  general  term  septicfemia  we  include  certain  conditions  wliich 
are  not  to  be  considered  as  independent  diseases,  but  as  advanced  states  or 
sequelfB  of  a  local  bacterial  invasion.  Se^pticmmia  may  be  defined  as  a  morbid 
condition  of  the  system  caused  by  the  presence  of  bacteria  or  their  toxic 
products  in  the  blood.  Practically,  we  limit  the  term  septicfemia  to  the 
effects  of  those  bacteria  which  cause  the  acute  surgical  infectious  diseases, 
although  there  is  no  pathological  difference  between  the  condition  of  general 
infection  seen  in  typhoid  fever  and  that  of  erysipelas,  the  constitutional 
symptoms  in  both  cases  being  due  to  entrance  into  the  circulation  of  germs 
or  the  toxic  products  of  germs  growing  in  the  local  lesions  of  the  skin  in  the 
latter  case,  and  of  the  intestine  in  the  former. 

Sapraemia. — We  distinguish  between  the  poisoning  of  the  system  due 
to  the  absorption  of  the  toxic  products  of  the  germs  of  decay  and  those  of 
disease,  calling  the  first  saprsemia,  the  second  septicaemia,  because  of  the 
important  clinical  difference  between  the  two.  As  the  ordinary  saprophytes 
cannot  exist  in  living  tissues  or  in  the  blood,  the  only  manner  in  which  they 
can  affect  the  body  is  by  the  introduction  of  their  toxic  products  into  the 
circulation,  x^roducing  saprsemia.  If  these  bacteria  are  implanted  in  dead 
matter  in  the  body  upon  which  they  can  grow,  such  as  a  clot  of  blood  or 
necrotic  tissue,  decomposition  sets  in,  ptomaines  are  produced,  and  gas  is 
often  generated.  If  no  ]3yogenio  or  other  special  bacteria  are  implanted 
with  the  saprophytes,  there  is  no  inflammation,  but  the  surrounding  tissues 
absorb  these  chemical  substances,  and  the  whole  body  is  poisoned  by  their 
presence  in  the  blood. 

Symptoms. — There  will  be  an  elevation  of  temperature,  with  chilly 
sensations,  although  a  true  chill  may  not  occur,  a  flushed  skin,  rapid  pulse, 
dry,  coated  tongue,  loaded  urine,  and  constipation,  followed  by  diarrhoea. 
This  intoxication  is  rare  in  its  pure  form,  but  may  develop  from  a  putrid 
placenta  or  clots  retained  in  the  uterus  after  labor,  or  from  a  large  imper- 
fectly drained  abscess,  the  prompt  recovery  of  the  patient  after  removal  of 
the  cause  of  intoxication  proving  that  pyogenic  or  pathogenic  bacteria  ai-e 
absent  or  so  scanty  as  to  be  of  no  moment.  An  intoxication  of  this  kind  is 
never  found  until  two  or  three  days,  or  even  longer,  after  the  bacterial  infec- 
tion. It  begins  gradually,  for  the  putrefactive  germs  must  grow  to  a  cer- 
tain extent  before  they  can  produce  enough  ptomaines  to  poison  the  system. 
A  complete  removal  of  the  decomijosing  material,  moreover,  cuts  the  process 
short,  just  as  evacuation  of  the  stomach  will  cause  the  symptoms  of  mineral 
poisoning  to  cease  as  soon  as  the  poison  which  has  already  been  absorbed 
and  entered  the  system  is  eliminated.     These  two  facts  enable  us  to  make 

31 


32  SEPTICEMIA. 

the  diagnosis  of  saprsemia.  It  should  be  noted  that  gas  production  and  foul 
odors  are  not  always  found  in  decomposition. 

Treatment.- — The  treatment  consists  in  (1)  removing  the  decomposing 
blood,  pus,  slough,  or  other  material,  as  far  as  possible  ;  (2)  disinfecting  what 
cannot  be  removed  and  the  surrounding  parts ;  (3)  assisting  elimination  of 
the  poison  by  the  bowels,  the  kidneys,  and  the  skin  ;  and  (4)  administering 
nourishing,  easily  digested  food,  and  stimulants. 

Septicaemia. — Septicaemia  must  be  divided  into  at  least  two  varieties, 
one  due  to  the  bacteria  themselves,  which  may  be  called  progressive  septicw- 
mia ;  the  other  due  to  their  products,  to  which  may  be  given  the  name  of 
septic  intoxication,  or  toxcemia.  There  is  no  one  germ  which  is  responsible  for 
all  varieties  of  septicaemia,  for  apparently  any  of  the  pathogenic  varieties 
is  capable  of  producing  the  condition. 

Septic  Intoxication. — In  septic  intoxication,  or  toxaemia,  the  patient 
shows  symptoms  due  to  the  absorption  by  the  blood  of  the  ptomaines  and 
toxines  produced  by  some  focus  of  growth  of  the  bacteria  in  the  tissues. 
Fever  is  almost  always  present,  with  its  various  effects,  but  the  symptoms 
are  not  merely  those  of  the  febrile  state,  for  many  of  them  are  the  direct 
results  of  the  toxines  acting  upon  the  diffei'ent  nerve-centres  and  other 
organs.  The  indifference  and  somnolence,  the  delirium  or  coma,  and  the 
great  prostration  are  mainly  caused  by  the  poisons.  The  nausea,  vomiting, 
and  diarrhoea,  as  well  as  the  polyuria,  suppression  of  urine,  or  albuminuria 
often  seen,  are  due  to  the  efforts  which  the  system  is  making  to  eliminate 
the  toxines,  and  to  the  irritant  effect  of  those  substances.  Sweating  also 
occurs,  although  not  so  constantly  as  in  pyaemia,  and  indicates  a  similar 
attemjjt  at  elimination,  while  an  evanescent  erythema  or  urticaria  shows  the 
irritation  excited  in  the  skin  by  the  poison. 

Treatment. — If  the  original  focus  can  be  thoroughly  disinfected,  the 
symptoms  of  septic  intoxication  will  disappear  very  rapidly.  If  this  can- 
not be  accomplished,  and  the  local  growth  of  bacteria  continues,  the  patient 
will  succumb  to  the  depressing  effects  of  the  toxines,  and  this  result  may 
take  place  in  a  few  days  in  cases  of  ordinary  severity.  The  general  treat- 
ment will  be  the  same  as  that  of  j)rogressive  septicaemia. 

Progressive  Septicsemia. — This  is  the  worst  form  of  sepsis,  and  one 
which  can  be  resisted  only  by  preventing  its  occurrence,  for  when  the  bacteria 
have  once  entered  the  blood,  few  persons  are  able  to  withstand  the  attack, 
and  the  issue  is  almost  always  fatal.  In  such  cases,  in  addition  to  the  origi- 
nal focus  of  disease  there  is  the  danger  that  the  germs  may  multiply  indefi- 
nitely in  the  blood  and  found  colonies  in  other  parts  of  the  body.  For- 
tunately, if  the  bacteria  are  not  too  numerous,  the  blood  can  destroy  them, 
or  at  least  limit  their  growth.  In  spite  of  the  enormous  quantity  of  germs 
circulating  in  the  blood,  it  must  not  be  supposed  that  they  can  be  found  in 
any  drop  which  may  be  examined,  for  exxaerience  has  shown  that  their  actual 
demonstration  in  the  blood  is  a  matter  of  the  greatest  difficulty,  and  is 
usually  impossible  even  when  thej'  are  so  abundant  that  minute  quantities 
of  the  blood  will  produce  infection  in  animals.  The  usual  channel  by  which 
the  bacteria  enter  the  circulation  is  through  some  vein  which  is  involved  in 
■the  inflammation.     The  bacteria  penetrate  its  walls,  and  either  enter  the 


SEPTICvEMIA.  33 

blood  dii-ectlj^  or  cause  a  thrombus  aud  enter  the  clot,  small  pieces  of  M'hich 
are  detached  and  carried  off  into  the  circulation.  It  is  supx)osed  by  some 
that  bacteria  may  also  indirectly  reach  the  blood  by  means  of  the  lyjnphatics. 
Some  forms  of  bacteria  are  able  to  live  in  the  blood,  multiplying  there  in 
such  quantities  as  to  block  the  small  vessels  (a  condition  called  infarction) 
and  they  may  thus  cause  gangrene  mechanically. 

Symptoms. — The  symptoms  of  this  disease  are  the  same  as  those  of 
septic  intoxication,  with  the  addition  of  others  due  to  the  mechanical  effects 
of  the  bacteria  in  the  blood-vessels  and  to  the  progressive  development  of 
new  foci  of  disease.  The  general  symptoms  are  more  Intense,  because  the 
tosines  are  produced  in  the  blood  itself,  where  they  can  exert  their  full 
effect,  instead  of  being  absorbed  from  some  place  of  production  outside  of 
the  vessels.  The  toxines  increase  in  proportion  to  the  multiplication  of  the 
bacteria,  and  the  symijtoms  become  progressively  worse.  Fresh  symptoms 
may  be  added  from  time  to  time  as  other  parts  of  the  body  are  attacked, 
depending  ui)on  the  organ  affected.  One  of  the  most  constant  of  these -is 
enlargement  of  the  spleen  and  the  lymphatic  glands.  The  secondary  effects 
of  i^rogressive  septicaemia  may  be  suppurative  or  non-suppurative  inflam- 
mations. The  suppurating  lesions  we  shall  consider  bj'  themselves  under  the 
head  of  Pycemia.  The  non-suppurating  inflammations  attack  the  veins,  the 
endocardium,  the  kidney,  the  mucous  membrane  of  the  intestine,  the  me- 
ninges, the  pleura,  aud  other  j)arts. 

Treatment. — This  is  the  field  of  serum-therapy,  of  antitosines,  and  we 
look  to  the  future  to  provide  us  with  some  such  agents  which  can  be  intro- 
duced into  the  body,  by  hyijoderniic  injection  or  otherwise,  and  will  be 
capable  of  destroying  the  germs  or  enabling  the  tissues  and  blood  to  destroy 
or  neutralize  them  without  injury  to  the  patient.  Some  success  has  been 
achieved  in  this  direction  in  the  case  of  rabies,  tetanus,  diphtheria,  and  even 
pyogenic  septicsemia,  but  the  subject  is  still  too  undeveloped  for  profitable 
discussion  of  its  results.  As  yet  the  treatment  of  this  condition  is  practically 
limited  to  disinfecting  the  original  focus  and  any  secondary  one,  so  far  as 
this  can  be  accomplished,  and  to  supporting  the  strength  of  the  patient  in 
the  hope  that  the  amount  of  infection  of  the  blood  does  not  exceed  his 
powers  of  resistance.  Easily  digested,  nourishing  food,  such  as  milk  and 
extracts  of  beef,  must  be  given  in  suitable  quantities  and  as  often  as  the 
digestion  is  able  to  dispose  of  them,  aided  by  peptonizing  agents  and  bitters. 
Stimulants  must  be  administered  in  large  amounts, — strychnine,  digitalin, 
coffee,  whiskey,  brandy,  wines,  aud  liqueurs.  The  skin,  bowels,  and  kid- 
neys must  be  kept  active.  The  introduction  of  normal  saline  solution  into 
a  vein,  beneath  the  skin,  or  as  an  enema,  greatly  assists  these  functions  and 
stimulates  the  heart  as  well.  If  there  is  diarrhoea,  it  is  not  to  be  completely 
suppressed,  for  it  aids  in  the  elimination  of  the  toxines,  but  it  should  be 
held  in  check  with  oisium  sufficiently  to  allow  of  proper  absorption  of  the 
food.  Where  the  vomiting  is  marked  and  uncontrollable,  the  stomach 
should  be  washed  out  and  rectal  feeding  may  be  necessary.  Drugs  are  of 
little  value,  but  sparing  use  may  be  made  of  morijhine  and  quinine  as  heart 
and  nerve  tonics,  and,  if  the  stomach  is  not  disturbed,  iron  may  be  emi^loyed 
in  the  form  of  the  tincture  of  the  chloride.     Some  of  the  septic  toxines  act 


34  PYEMIA. 

similaiijr  to  stryclinine  and  others  act  like  atropine,  and  it  is  ijossible  that 
one  of  these  drugs  may  be  useful  to  counteract  effects  similar  to  those  pro- 
duced bjr  the  other.  There  can  be  no  question  that  the  free  use  of  pure 
oxygen  by  inhalation  is  one  of  the  best  means  for  combating  the  depression 
of  septicemia. 

Pyaemia. — That  variety  of  progressive  septicaemia  known  as  pysemia 
deserves  separate  consideration.  Pysemia  is  characterized  by  multiple  sup- 
purative inflammations  occurring  throughout  the  body,  which  are  due  to  the 
presence  of  pyogenic  bacteria  circulating  in  the  blood,  either  free  in  the 
blood-serum  or  contained  in  pus-cells  or  thrombi.  These  suppurative 
inflammations  may  occur  in  the  synovial  and  serous  membranes,  or  may 
produce  abscesses.  They  are  called  metastatic  inflammations  because  they 
develop  at  a  distance  from  the  original  focus.  Like  all  forms  of  septicemia, 
pyaemia  can  appear  only  as  the  sequel  of  some  local  inflammatory  process. 
According  to  the  former  idea  of  its  etiology  the  pus-cells  actually  entered 
the  blood-vessels,  as,  for  instance,  when  an  abscess  lay  in  contact  with  a 
vein  and  the  wall  of  the  latter  was  perforated  by  ulceration  or  sloughing, 
allowing  the  pus  to  enter  it,  an  occurrence  which  has  been  observed,  but 
which  must  be  very  rare.  It  is  only  necessary,  however,  for  the  pj'ogenic 
bacteria  to  gain  access  to  the  circulation  by  directly  penetrating  the  walls  of 
a  vein,  or  by  infecting  a  clot  which  has  formed  within  it,  in  order  to  pro- 
duce metastatic  supx)uration. 

Thrombosis  and  Embolism. — The  blood  normally  remains  fluid  in  the 
vessels  on  account  of  the  peculiar  influence  of  the  endothelial  lining,  and 
does  not  coagulate  even  if  it  be  imprisoned  and  station- 
ary in  a  part  of  a  vessel  included  between  two  ligatures. 
But  if  the  endothelial  surface  be  roughened  by  mechan- 
ical means,  such  as  scratching  by  a  needle,  or  by  in- 
flammation, fibrin  will  be  deposited  and  a  clot  formed, 
which  is  known  as  a  thrombus.  A  thrombus  will  form 
wherever  bacteria  fasten  themselves  upon  the  wall  of 
the  vessel,  whether  thej^  are  brought  to  the  spot  by  the 
circulating  blood  or  penetrate  the  vessel  from  without. 
These  thrombi  not  only  interfere  with  the  circulation, 
but  form  an  element  of  serious  danger,  as  they  are  apt 
to  extend,  and  may  reach  and  project  into  another 
branch  of  the  vessel  which  is  still  pervious  (Fig.  16), 


Fig 


Thrombosis,  with  clot 
projecting  into  the  main 
trimk,  so  that  the  current 

shown  by  arrow  would  tend    aud  then  the  blood-current  may  detach  small  fragments 
to  wash  off  a  fragment.    (^^^^^^   emboli)  and   Carry  them  into  the   circulation. 

(Agnew.)  ^  ^  ■'  1  n    -u 

Embolism  is  the  blocking  of  any  arterial  vessel  by  a 
clot  brought  to  it  by  the  circulation.  If  the  artery  obstructed  has  no  anas- 
tomotic branches  with  a  neighboring  artery  beyond,  death  of  all  the  tissues 
dependent  upon  it  must  follow,  and  even  if  there  is  sufacient  anastomosis  to 
prevent  gangrene,  the  tissue  may  be  so  poorly  nourished  that  infection  takes 
place  very  readily.  If  the  embolus  contain  pyogenic  germs,  even  when 
the  circulation  is  not  impaired,  metastatic  abscesses  will  develop.  Such 
abscesses  may  occur  anywhere. 

Metastatic  suppurative  inflammation  is  common  in  the  joints  aud  the 


PY.EMIA. 


35 


serous  membranes,  producing  synovitis,  endocarditis,  iileuritis,  or  meningitis, 
for  instance,  with  their  usual  results.  This  secondary  inflammation  appears  to 
be  due  to  the  lodging  of  bacteria  or  minute  emboli  in  the  capillaries.  In  rare 
cases  only  a  serous  inflammation  is  produced,  a  result  which  is  to  be  ascribed 
to  the  fact  that  the  germs  are  not  virulent,  or  that  but  few  germs  are  present. 
Symptoms.— The  symptoms  of  pyaemia  are  ushered  in  by  a  severe  chill, 
followed  or  accompanied  by  a  sudden  marked  rise  of  temperature  to  103°  or 
105°  F.  (39.5°  or  40.5°  C),  or  even  more,  which  lasts  a  few  hom-s  and  passes 

Fig.  17. 


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off  with  violent  sweating.  The  paroxysm  is  repeated,  and  the  intervals  may 
be  so  regular  as  to  resemble  malarial  fever  closely.  But  the  distinctive 
feature  of  pysemia  is  the  great  irregularity  with  which  the  febrile  attacks 
occur,  the  interval  varying  from  a  few  hours  to  several  days.  (Fig.  17.) 
Although  the  usual  type  presents  very  severe  symptoms,  there  are  cases  in 
which  there  is  only  a  little  chilly  sensation  and  a  slight  rise  of  temperature, 
so  trifling  as  not  to  prevent  the  patient  from  attending  to  his  ordinary  busi- 
ness. The  formation  of  new  sui^purative  foci  is  generally  marked  with  a 
chill  and  febrile  movement,  but  it  is  not  to  be  assumed  that  every  such  attack 
signiiies  the  invasion  of  a  new  teriitorj'',  for  the  mere  presence  of  the  poison- 


36  PYiEMIA. 

ous  materials  circulating  in  the  blood  is  sufficient  to  account  for  it.  The 
febrile  movement  njay  be  accompanied  by  nausea,  delirium  or  somnolence, 
flushed  face,  and  diminished  high-colored  urine.  An  examination  of  the 
blood  will  reveal  a  marked  leucocytosis. 

The  formation  of  the  abscesses,  or  the  beginning  of  inflammation  in  a 
fresh  place,  is  not  always  accompanied  by  pain  ;  in  fact,  j)ain  is  rather  rare 
in  j)ya}mia.  The  surgeon  should  make  a  daily  routine  examination  of  the 
entire  body,  for  he  will  often  be  astonished  by  discovering  new  abscesses, 
inflammation  of  additional  joints,  or  a  fresh  endocarditis  or  pleuritis,  which 
have  developed  within  twenty-four  hours  without  any  subjective  symptoms. 
The  subcutaneous  abscesses  and  the  synovitis  of  superficial  joints  will  present 
much  less  tenderness,  tension,  and  redness  of  the  surrounding  skin  than  are 
usual  in  such  inflammations. 

As  the  disea.se  progresses,  great  prostration  ensues,  diarrhoea  sets  in,  the 
delirium  or  somnolence  passes  into  a  low  typhoid  mental  state,  and  the 
patient  dies  from  exhaustion.  This  fatal  result  usually  takes  place  within 
two  weeks,  but  it  may  be  postponed  for  months.  As  a  rule,  the  chronic 
cases  are  more  likely  ultimately  to  recover.  The  milder  cases,  however, 
may  suddenly  sink  into  a  hopeless  condition,  and  even  the  desperate  cases 
will  in  rare  instances  slowly  improve,  and  recovery  may  take  place,  with  a 
convalescence  protracted  through  months.  Besides  the  well-marked  cases 
there  are  others  of  a  doubtful  character  and  very  chronic  course,  in  which 
the  original  seat  of  infection  may  be  some  unrecognized  or  neglected  inflam- 
matory condition  in  the  urethra  or  in  the  nose,  for  example,  the  only  symp- 
toms being  the  apiDearance  from  time  to  time  of  indolent  abscesses,  such  as 
have  been  described,  with  very  slight  febrile  disturbance,  which  is  apt  to  be 
ascribed  to  chronic  malarial  poisoning.  We  have  seen  such  a  case  run  a 
course  of  two  years,  with  subcutaneous  abscesses  and  synovitis  of  the  knee- 
joint,  the  final  outcome  being  unknown  to  us,  in  which  the  primary  infection 
was  probably  in  the  urethra,  but  no  gonococci  cou.ld  ever  be  found  in  the 
pus  of  the  secondary  lesions.  The  prognosis  in  pytemia  is  best  when  the 
abscesses  are  limited  to  the  cellular  tissues,  not  so  good  when  a  joint  has 
been  involved,  and  very  bad  if  abscesses  occur  in  any  of  the  viscera. 

Treatment. — The  treatment  of  pyaemia  is  the  usual  supporting  one  to 
be  employed  in  septic  affections,  and  all  suppurating  foci  must  be  opened 
and  thoroughly  drained  as  soon  as  detected.  Every  branch  of  the  irregular 
cavities  must  be  discovered  and  drained  at  the  most  deiseudent  part,  and  the 
sinuses  must  be  carefully  examined  daily  in  order  that  no  pocketing  take 
place,  for  they  have  a  peculiar  tendency  to  burrow  in  every  direction. 

When  a  supiDurative  phlebitis  exists,  the  vein  should  be  ligated  above 
the  inflamed  area,  if  it  is  accessible,  in  order  to  prevent  direct  extension  of 
the  phlebitis  or  the  occurrence  of  embolism  (Chapter  XX.).  If  there  is  a 
suppurative  lymphadenitis,  the  infected  glands  should  be  completely  re- 
moved, whenever  the  general  condition  of  the  patient  will  permit. 

In  both  seiaticEemia  and  pysemia  intravenous  injections  of  salt  solution 
(Chapter  XIII. )  have  been  found  to  stimulate  the  heart  and  assist  the  elimi- 
nation of  the  toxines  by  the  skin  and  kidneys.  High  enemata  of  warm  saline 
solution  will  have  a  similar  effect. 


CHAPTEE    V. 

ULCER,   SINUS,   FISTULA. 
By  B.  Faequhar  Curtis,  M.D. 

In  connection  -with  inflammation,  especially  with  the  chronic  form,  we 
must  consider  three  allied  conditions,  ulcer,  sinus,  and  fistula,  which  are 
among  its  results,  but  are  best  considered  separately. 

Ulcer. — An  ulcer  may  be  defined  as  a  loss  of  continuity  upon  one  of  the 
free  surfaces  of  the  body  which  shows  no  tendency  to  heed.  Ulceratiou  is  the 
process  of  molecular  gangrene  of  a  superficial  part  which  results  in  the 
production  of  an  ulcer,  and  this  term  should  not  be  applied  to  indicate  the 
mere  presence  of  an  ulcer,  as  is  frequently  done  in  speaking  of  ulceration 
of  the  throat  or  rectum.  The  process  by  which  an  abscess  extends  is  often 
called  ulceratiou,  as  there  appears  to  be  no  pathological  difference  between 
this  process  and  the  formation  of  an  ulcer.  Ulcers  must  be  distinguished 
clinically  from  fresh  or  granulating  wounds,  for  as  soon  as  an  ulcer  is  actu- 
ally healing  it  ceases,  strictly  speaking,  to  be  an  ulcer. 

Etiology. — Ulcers  are  the  result  of  local  causes,  such  as  injury,  infec- 
tion (pyogenic,  tubercular,  syphilitic,  etc.),  interference  with  the  circulation 
by  varicose  veins,  the  breaking  down  of  neoplasms,  pressure  from  within 
by  the  growth  of  benign  tumors,  or  embolism.  The  great  majority  are  also 
partly  dependent  upon  constitutional  conditions  causing  a  lowered  vitality, 
such  as  acute  or  chronic  diseases  (typhoid  fever,  syphilis)  or  mineral  poi- 
soning. The  constitutional  condition  is  generally  the  predisposing,  and  tlie 
local  lesion  the  exciting,  cause  of  the  ulcer.  Sometimes  no  definite  cause  is 
discoverable,  and  such  ulcers  must  still  be  termed  simple  ulcers.  Chronic 
ulcers  of  the  skin  are  three  times  more  common  in  men  than  in  women,  and 
the  aged  are  not  more  liable  to  them  than  persons  in  middle  life.  The  most 
frequent  site  for  these  ulcers  is  on  the  leg,  owing  to  the  greater  liability  of 
that  part  to  impaired  circulation  and  to  injury.  They  are  often  associated 
with  varicose  veins,  but  the  large  number  of  individuals  with  such  veins 
who  never  have  ulcers  shows  that  there  is  no  absolutely  necessary  causal 
relationship.  Varicose  veins  do  not  cause  ulcers  unless  the  vascular  changes 
have  involved  the  minute  venous  radicles  in  the  skin.  Tubercidous  and 
syphilitic  ulcers  are  described  elsewhere.     (Fig.  18.) 

A  simple  ulcer  presents  a  base  covered  with  more  oi-  less  healthy  granu- 
lations, nearly  level  with  the  surrounding  skin,  a  rather  regular  circular 
or  oval  outline,  with  few  if  any  inflammatory  signs  about  it,  and  a  scanty 
serous  or  sero-piu-ulent  discharge.  When  the  ulcer  becomes  chronic  or 
indolent,  the  granulations  become  paler  and  smaller,  the  edges  thickened 
and  iiidurated,  and  the  discharge  thinner  and  more  abundant.     When  still 

37 


38 


ULCEES. 


further  deteriorated  tlie  base  of  the  nicer  is  without  granulations,  but  is 
covered  with  a  thin,  white,  necrotic  layer,  which  on  removal  discloses  a 
white  or  pale-pink  surface  as  smooth  as  mucous  membrane.  In  some  cases 
the  surface  looks  quite  raw,  as  if  it  were  a  fresh  injury,  so  that  skin,  con- 
nective tissue,  and  muscular  fibres  can  be  distinguished  at  the  bottom  if 
muscle  happens  to  lie  beneath  the  ulcer.  The  base  lies  below  the  level  of 
the  surroundiug  skin,  and  is  sometimes  deeply  excavated.  The  edges  are 
thick,  sloping  gradually  or  rising  abruptly  from  the  base,  and  very  hard, 
the  induration  also  extending  beneath  the  base  of  the  ulcer.  The  discharge 
is  very  thin,  and  may  be  profuse  or  scanty,  usually  the  latter.  The  sur- 
rounding skin  is  not  inflamed,  and  the  whole  picture  is  one  of  lack  of  vital- 
ity. If  such  an  ulcer  becomes  inflamed,  dermatitis  and  cellulitis  will  ap- 
pear around  it,  the  base  will  become  reddened,  and  the  discharge  purulent ; 
but  granulations  seldom  appear  even  then.  Sometimes  the  thickened  edges 
become  uneven  and  warty,  and  epitheliomatous  degeueration  sets  in,  the 

induration    spreads    into    the    sur- 
FiG.  18.  rounding  skin,  and  friable,  granula- 

tion-like prominences,  which  bleed 
readily,  appear  in  the  base  of  the 
ulcer,  with  a  foul  discharge. 

Fig.  19. 


Syphilitic  ulcer  of  the  leg. 


Varicose  ulcer  of  the  1 


Varicose  ulcers  frequently  arise  from  minute  points  of  phlebitis  in  the 
small  varicose  veins  of  the  skin,  resulting  in  the  formation  of  an  abscess 
and  sloughing  of  the  cuticle  over  it,  the  ulcer  enlarging  by  molecular 
necrosis  of  the  edges  or  by  the  coalescence  of  several  such  periphlebitic 
abscesses.  (Fig.  19.)  Such  ulcers  are  apt  to  have  rather  irregular  under- 
mined edges.  Any  injury  to  a  limb  with  varicose  veins  is  apt  to  result  in 
an  ulcer  unless  extreme  care  be  taken  during  the  healing,  and  such  ulcers 
resemble  simple  or  chronic  ulcers  elsewhere  except  for  the  deep  blue  color 
often  seen  in  the  granulations.  Hemorrhage  fi"om  varicose  ulcers  is  not 
infrequent,  and  may  be  alarming  and  even  fatal. 


TREATMEiS^T   OF  ULCERS.  39 

Phagedaena  is  the  name  given  to  a  rapid  form  of  ulceration  most 
frequently  seen  in  connection  with  venereal  nlcers  or  hospital  gangrene, 
which  is  irndoubtedly  due  to  some  form  of  bacterial  infection,  although  its 
l^recise  cause  is  not  known.  The  ulcer  spreads  with  great  rapidity,  with  or 
without  the  production  of  large  sloughs,  so  that  in  a  few  hours  the  extension 
is  very  marked,  the  skin  and  the  tissues  at  the  base  of  the  ulcer  appearing 
to  melt  away  under  its  influence.  This  form  of  ulceration  is,  fortunately, 
of  very  rare  occurrence. 

Treatment. — The  treatment  of  ulcers  must  be  directed  to  subduing 
any  inflammation  which  may  be  present,  removing  all  causes  of  sepsis,  im- 
proving the  circulation,  jiromoting  absorption  of  the  induration,  stimulating 
granulations,  encouraging  cicatrization,  and,  finally,  to  covering  the  defect 
in  the  skin  by  transplantation  or  grafting,  if  necessary.  Many  of  these  in- 
dications can  be  met  by  some  single  method  of  treatment,  but  none  should 
be  neglected,  for  the  surgeon  will  need  to  make  every  possible  effort  In  order 
to  cure  these  intractable  lesions. 

Inflammation  is  reduced  by  the  same  measures  as  dermatitis  or  cellulitis 
elsewhere.  The  parts  are  rendered  aseptic  by  thorough  washing  and  sterili- 
zation with  chemicals  as  usual,  and  nothing  is  so  essential  to  success  in  treat- 
ment as  the  complete  maintenance  of  aseptic  conditions.  The  circulation  is 
Improved  by  rest  in  bed,  elevation  of  the  part,  and  the  i)ressure  of  bandages 
when  there  is  venous  congestion.  Sometimes  the  elastic  pressure  of  a  pure 
rubber  bandage  properly  applied  and  worn  while  the  patient  is  up  is  all  that 
is  necessary  to  obtain  a  cure.  These  rubber  bandages  are  generally  known 
as  Martin's.  The  ulcer  should  be  dressed  lightly  with  some  simple  solution 
or  powder  and  a  few  thicknesses  of  gauze  under  the  bandage.  Elastic 
stockings  (ointments  attack  the  rubber)  are  soon  ruined  by  the  discharge 
or  the  applications  employed,  but  are  excellent  as  a  prophylactic  .  or  to 
prevent  a  relapse  of  ulcer  of  the  leg. 

In  some  cases  the  establishment  of  asepsis  and  the  compression  and  pro- 
tection of  a  good  dressing  and  bandage  are  all  that  is  necessary,  and  for  such 
cases  we  can  recommend  the  application  of  a  piece  of  sterilized  rubber  tissue, 
cut  to  the  shape  of  the  ulcer,  but  a  little  larger,  covered  by  a  dry,  sterile 
dressing  of  gauze,  with  a  very  thick  layer  of  sterilized^  cotton  and  a  firm 
starched  bandage  outside.  This  dressing  can  be  left  in  ijlace  for  a  week. 
In  some  cases  there  is  a  tendency  for  the  granulations  to  rise  above  the  level 
of  the  skin,  and  then  firm  strapping  of  the  leg  with  strips  of  adhesive  plas- 
ter is  required.  The  strapping  also  draws  together  the  edges  of  the  ulcer 
and  thus  assists  it  to  heal.  If  there  is  much  discharge  a  dressing  must  be 
applied  over  the  strapi^ing. 

Local  Applications. — In  other  cases  it  is  necessary  to  stimulate  the 
granulations  by  very  light  applications  of  nitrate  of  silver  (gr.  v  to  x  in  f  =  i), 
balsam  of  Peru,  alum,  permanganate  of  potasih  (gr.  v  to  x  in  f  .fi),  nitrate  of 
mercury,  sulphate  of  copper  or  zinc  (same  strength),  or  powdered  quinine, 
salicylic  acid,  antipyrin,  orthoform,  or  aristol,  or  a  ten  to  twenty-five  per 
cent,  ointment  of  ichthyol.  Ointments  of  oxide  of  zinc  or  boric  acid  are 
merely  protectives,  and  suited  to  cases  in  which  the  granulations  are  tairly 
healthy.     For  small  iilcers  of  the  same  character,  powdered  subnitrate  of 


40  TEEATMEiS'T  OF  ULCERS. 

bismuth  or  calomel  is  useful,  forming  a  protective  scab  ■svith  the  secretions. 
For  sloughing  ulcers,  especially  of  syphilitic  origin,  iodoform  applied 
abundantly  as  a  powder  is  unexcelled ;  but  in  some  cases  it  excites  a 
dermatitis,  so  the  surrounding  skin  should  be  protected  with  some  simple 
ointment.  Iodoform  is  excellent,  too,  in  the  treatment  of  tuberculous 
ulcers,  and  balsam  of  Peru  is  also  somewhat  of  a  specifio  in  these 
cases. 

In  order  to  obtain  a  cure  in  chronic  ulcers  it  is  necessary  to  cause  absorp- 
tion of  the  indurated  tissues  of  the  base  and  edges.  Moist  warm  dressings, 
ma.ssage  (through  some  gauze  laid  over  the  part),  and  incisions  are  the  best 
methods  of  treatment.  Poultices  are  unnecessary  and  unclean,  and  a  heavy 
gauze  dressing  wrung  out  of  any  very  hot,  mild,  sterile  fluid  will  produce 
the  same  effect  as  a  poultice  if  kept  covered  with  a  very  thick  layer  of 
cotton  and  some  impervious  material  like  oil-silk  or  rubber  tissue.  Hot 
and  cold  douches  aud  massage  are  extremely  useful ;  but  it  is  necessary  to 
make  the  parts  absolutely  sterile  and  free  from  inflammation  before  massage 
is  attemj)ted,  for  septicemia  might  follow  any  manipulation  in  septic  con- 
ditions. The  pressure  of  a  tin  plate  or  piece  of  sheet  lead  cut  exactly  of  the 
shape  of  the  ulcer,  but  a  little  larger,  with  its  edges  bent  up  a  little  so  as 
not  to  cut,  and  secured  in  place  with  rubber  plaster  under  an  aseptic  di-ess- 
ing,  has  an  excellent  effect  in  reducing  the  thickened  margins  of  an  old 
ulcer.  A  double  series  of  incisions,  crossing  like  the  "cross-hatching"  lines 
of  the  engravers,  hastens  the  absorption  of  the  induration  in  chronic  ulcers, 
the  effect  being  to  relieve  the  tension  on  the  parts  due  to  the  contraction  of 
the  cicatricial  tissue,  so  that  the  A'essels  can  distend  and  new  vessels  can 
enter.  The  new  granulations  which  spring  up  in  the  incisions  will  soften 
the  cicatricial  tissue  on  each  side,  and  also  provide  the  way  for  new  vessels 
to  travel  into  the  centre  of  the  indurated  area.  The  parts  must  be  com- 
l^letely  sterilized,  the  surface  of  the  ulcer  being  lightly  cm-etted  in  order 
to  insure  this,  before  the  incisions  are  made.  The  cross-hatching  incisions 
should  be  so  placed  that  the  distance  between  them  will  equal  the  thickness 
of  the  indui-ated  layer  (varying  from  one-quarter  to  one-half  inch),  and 
they  must  be  carried  entirely  through  the  cicatricial  tissue  at  the  base 
and  beyond  the  edges  of  the  ulcer.  When  the  ulcer  is  situated  over  a  bone, 
the  knife  must  be  carried  firmly  down  to  the  latter.  We  have  successfully 
treated  ulcers  extending  half-way  up  the  leg  and  around  its  entire  circum- 
ference by  this  method. 

To  promote  cicatrization  a  very  slight  touch  with  nitrate  of  silver,  just 
enough  to  faintly  cloud  the  granulations  next  to  the  edge  of  the  epidermis, 
will  assist  the  epithelium  to  spread  over  them.  Ichthyol  favors  the  epithe- 
lial growth.  Sometimes  the  latter  remains  deficient  in  spite  of  all  our  at- 
tempts, or  the  ulcer  may  be  so  large  that  there  is  no  hope  of  its  being  cov- 
ered by  natural  growth,  and  then  some  form  of  shin-grafting,  as  described  in 
Chapter  XVII.,  becomes  necessary.  If  extensive  grafting  is  done,  the  patient 
should  be  confined  to  bed  for  some  weeks  after  healing,  imtil  the  new  skin 
has  become  thoroughly  well  organized,  for  it  will  break  down  as  soon  as  the 
upright  position  is  resumed.  Even  after  that  time  a  bandage  should  be 
employed  for  mouths  to  avoid  a  relapse. 


SINUS  jVND  fistula.  41 

Perforating  Ulcer  of  the  Foot  and  Hand. — A  deep  fuunel-sliaped 
ulcer,  sometimes  so  narrow  as  to  resemble  a  sinus,  is  not  infreqiientlj-  ob- 
served upon  tlie  sole  of  the  foot  in  patients  with  locomotor  ataxia,  and 
occasionally  in  other  conditions,  such  as  diabetes.  It  usually  begins  in  a 
callous  spot  or  corn  where  the  skin  is  exposed  to  ijressure,  especially  at  the 
head  of  the  first  metatarsal  bone.  The  callous  spot  turns  white  with  a  small 
areola  of  congested  blood-vessels,  then  dark,  infiltrated  with  blood,  and 
becomes  gangrenous.  When  the  slough  falls  it  leaves  a  deep  ulcer,  funnel- 
shaped,  about  one-half  an  inch  in  diameter  at  the  surface,  narrowing  to  a 
sinus,  which  may  penetrate  the  bone  or  communicate  with  a  joint.  In  the 
latter  case  the  bone  or  joint  will  suppurate,  but  usually  there  is  little  or  no 
inflammatory  reaction.  The  ulcer  is  covered  with  feeble  granulations,  has 
a  scanty  discharge,  and  is  surrounded  with  a  ring  of  callous  skin,  more  or 
less  undermined,  the  edges  of  which  look  as  if  punched  out.  There  is  little 
or  no  pain.  The  process  often  begins  with  some  trivial  infection,  such  as 
might  follow  paring  a  corn.  In  many  cases  distinct  evidence  of  trophic 
disturbance  and  areas  of  limited  anaesthesia  are  to  be  found  on  the  skin  of 
the  foot  and  leg.  Similar  ulcers  are  seen  upon  the  hands,  but  very  rarely. 
While  some  of  these  cases  are  of  unknown  origin,  the  true  perforating  ulcer 
of  the  foot  is  undoubtedly  a  trophic  lesion,  due  to  some  central  affection 
like  locomotor  ataxia,  or  to  a  peripheral  neuritis.  Local  applications  and 
such  measures  as  curetting  and  excision  are  very  rarely  of  benefit.  If  a 
toe  is  involved  amputation  will  give  relief  The  French  surgeons  report 
recently  a  large  number  of  cases  successfully  treated  by  stretching  the 
nerve  supplying  the  part  of  the  foot  where  the  lesion  is  situated,  usually 
the  internal  or  external  plantar.  The  nerve  should  be  exposed  at  the 
ankle  or  higher. 

Sinus  and  Fistula. — A  sinus  ov  fistula  is  a  narrow  tract  through  the 
tissues,  lined  with  granulations  or  epithelium.  The  term  fistula  is  generally 
limited  to  openings  connected  with  organs  lined  by  mucous  membranes,  and 
these  openings  will  be  described  in  connection  with  the  latter.  A  sinus  is 
usually  the  result  of  an  abscess,  and  may  be  formed^  by  the  passage-way 
which  has  served  to  discharge  the  abscess,  in  which  case  the  latter  will  be 
found  at  its  end,  or  more  frequently  it  represents  the  shrunken  remains 
of  the  abscess-cavity  itself  The  granulations  which  line  the  sinus  rest 
upon  a  layer  of  cicatricial  connective  tissue,  sometimes  of  considerable 
thickness. 

Treatment. — In  order  to  obtain  a  cure  it  is  generally  necessaiy  to  re- 
move, or  at  least  divide,  this  cicatricial  tissue,  by  a  cut  running  the  entire 
length  of  the  sinus  on  one  side,  on  the  same  principle  as  the  incision  of 
indurated  callous  ulcers.  The  exciting  cause  of  the  sinus,  whether  it  be 
an  uudrained  abscess- cavity,  or  a  foreign  body  or  sequestrum  contained  in 
the  tissues,  must  be  remedied  or  removed  before  a  cure  can  be  effected. 
Then  the  sinus  may  be  treated  by  simply  packing  it  thoroughly  with  gauze 
or  by  keeping  it  distended  with  a  drainage-tube,  these  simple  means  usually 
sufficing  when  the  cause  has  been  removed.  If  this  attempt  fails,  scraping 
or  cauterization  of  the  walls  of  a  sinus  will  destroy  its  lining  of  granulations, 
and  the  contraction  of  the  cicatricial  tissue  may  bring  about  a  cure  ;  but  it 


42  SINUS  AND  FISTULA. 

will  generally  be  necessary  to  remove  the  connective-tissne  wall  as  well, 
or  to  divide  it  along  one  side.  Sinuses  are  sometimes  kept  open  by 
tlie  constant  motion  of  tlie  muscles  and  other  soft  i^arts  through  which 
they  run.  They  should  then  be  ti-eated  by  dividing  these  parts  (as  in 
fistula  in  ano,  Chapter  XXXIS.)  or  by  making  pressure  over  the  sinus 
and  restraining  the  motions  of  the  adjacent  muscles  by  an  appropriate 
dressing  and  bandage.  The  latter  method  has  been  especially  recommended 
for  chronic  sinuses  originating  in  abscesses  of  the  breast.  Sinuses  some- 
times become  infected  with  tuberculosis,  and  are  then  very  obstinate,  and 
they  have  even  been  known  to  undergo  changes  in  their  walls  resulting 
in  the  formation  of  malignant  tumors.  The  worst  forms  of  sinus  are  those 
connected  with  disease  of  the  spinal  or  pelvic  bones,  which  may  be  over 
a  foot  in  length,  and  in  which  the  original  cause  may  lie  at  too  great  a 
depth  to  be  recognized  and  tieated. 


CHAPTEE    VI. 

INFLAMMATION  OF   SPECIAL  TISSUES. 
By  B.  Faeqtjhae  Curtis,  M.D. 

The  variations  of  the  processes  of  inflammation  in  the  different  tissues 
(vessels,  bones,  glandular  organs,  etc.)  and  their  treatment  will  be  con- 
sidered in  the  separate  chapters  devoted  to  them,  but  it  will  be  convenient 
to  discuss  here  the  inflammations  of  the  mucous  membranes,  and  of  the 
serous  and  synovial  membranes,  and  dermatitis,  cellulitis,  furuncle,  and 
carbuncle. 

Mucous  Membranes. — We  describe  three  kinds  of  inflammation  of 
the  mucous  membranes,  — catarrhal,  suppurative,  and  fibrinous. 

Simple  or  Catarrhal  Inflammation.— This  form  exhibits  hyperjemia, 
with  some  exudation  of  serum,  desquamation  of  the  cells,  and  increased  or 
diminished  secretion  by  the  mucous  glands.  This  condition  reveals  itself 
by  slight  redness  and  swelling  and  by  the  changes  in  the  secretion.  It  may 
terminate  in  resolution  or  go  on  to  suppurative  inflammation. 

Suppurative  Inflammation. — In  this  form  the  exudation  contains  emi- 
grated cells,  and  is  puriilent.  In  the  superficial  variety  the  pus-cells  find 
their  way  to  the  surface,-  making  the  secretion  cloudy,  and  even  distinctly 
purulent.  The  pus  may  collect  in  the  substance  of  the  mucous  membrane 
and  produce  mijiute  abscesses,  or  cause  superficial  sloughing  and  ulceration. 
The  clinical  appearances  coincide  with  these  iiathological  changes.  The 
ulcerative  process  may  extend  into  the  submucous  tissue  and  result  in  sui)- 
puration  there,  with  more  or  less  complete  destruction  of  the  overlying 
mucous  membrane. 

Fibrinous  Inflammation. — This  variety  results  in  the  formation  of 
layers  of  exudation,  known  as  false  membranes,  upon  the  surface  of  the 
mucous  membrane.  These  false  membranes  are  made  up  of  fibrin,  in  fibres 
and  granules,  and  some  free  cells,  either  emigrated  leucocytes  or  mucous 
epithelia,  some  normal,  others  having  undergone  fibrinous  degeneration, 
and  occasionally  red  blood-corpuscles  also.  It  was  formerly  customary  to 
distinguish  between  a  so-called  croupous  and  a  diphtheritic  false  membrane, 
but  modern  pathologists  assert  that  the  inflammation  which  produces  croup- 
ous membrane  in  the  larynx  and  trachea  is  the  same  variety  that  produces 
diphtheritic  membrane  in  the  j)harynx.  The  term  diphtheria  is  now  usually 
limited  to  the  inflammation  caused  by  the  bacillus  of  Loeffler  (Fig.  9,  Plate 
I.),  and  the  demonstration  of  its  presence  should  be  the  determining  point 
in  the  diagnosis  of  diphtheritic  inflammations.  A  fibrinous  inflammation, 
resulting  in  the  production  of  a  false  membrane,  may  arise  from  other  causes, 
but  the  inflammation  should  not  in  that  case  be  called  diphtheritic.  In 
wounds  fibrinous  infiammation  with  the  production  of  false  membranes  may 
be  caused  bv  the  B.  diphtherite  and  other  bacteria. 

43 


44  IXFLAJBIATION   OF  SEROUS  AND  SYNOVIAL  MEMBEANES. 

Chronic  Inflammation. — The  chronic  form  will  show  the  changes  al- 
ready described,  with  thickening  or  ulceration  of  the  parts.  In  some  cases 
this  results  in  atrophy  of  the  entire  mucous  membrane,  in  others  in  an 
hypertrophy  of  the  adenoid  tissues  which  are  so  abundant  in  the  mucous 
membranes,  especially  in  the  j)harynx  aud  the  intestine. 

Inflammation  of  Serous  and  Synovial  Membranes. — When 
the  serous  aud  synovial  membranes  are  attacked  by  inflammation  the  stage 
of  congestion  is  accompanied  with  exudation  of  serum  and  fibrin  from  the 
surface,  aud  the  endothelial  cells  become  swollen  and  detached  in  large  num- 
bers.    The  serous  exudation  may  be  sufficient  to  fill  the  entire  cavity  involved. 

Fibrinous  Inflammation. — This  is  a  variety  without  fluid  exudate,  in 
which  the  surface  of  the  membrane  loses  its  polish,  becoming  dry  and  red, 
and  adhesions  readity  form  wherever  the  surfaces  are  in  contact. 

Suppurative  Inflammation. — Pus  is  produced  iu  these  membranes  by 
emigration,  and  also  by  the  detached  endothelial  cells.  If  fibrin  is  present, 
false  membranes  form  on  the  surface,  and  the  membrane  ai^ijears  to  be  greatly 
thickened.  At  a  later  stage  the  proliferating  cells  invade  these  layers  of 
fibrin,  and  they  become  organized  into  connective  tissue,  and  new  vess^els 
develop  in  them.  Their  tendency,  however,  is  to  disappear  after  a  time, 
and  the  membrane  returns  to  its  original  condition,  unless  the  inflammation 
has  been  very  intense,  in  which  case  the  new  connective  tissue  becomes  perma- 
nent. In  the  serous  cavities  of  the  pleura  and  peritoneum  this  new  tissue  is 
of  great  importance,  for  the  smooth  serous  surface  is  destroyed  by  the  false 
membranes,  and  when  two  inflamed  surfaces  lie  in  aiiposition  adhesions 
form  which  may  be  of  great  detriment  to  the  organs  so  connected.  In  some 
respects,  however,  these  adhesions  are  undoubtedly  beneficent,  as  they  limit 
the  suppurative  exudations  and  surround  foreign  material  of  any  kind,  and 
thus  prevent  extension  of  the  inflammation  to  the  entire  cavity. 

Chronic  Inflammation. — Chronic  inflammation  of  these  membranes 
is  marked  bj'  general  thickening  of  all  the  layers,  the  formation  of  dense 
connective  tissue  in  the  fibrinous  membranes,  strong  adhesions,  and  some- 
times complete  obliteration  of  the  cavities,  their  endothelial  lining  entu-ely 
disappearing.  The  clinical  aud  other  facts  of  surgical  importance  will 
be  considered  more  fully  under  diseases  of  the  various  membranes,  such 
as  the  peritoneum,  pleura,  ax'achnoid,  tunica  vaginalis,  and  the  synovial 
membranes. 

Dermatitis. — Dermatitis  is  an  inflammation  of  the  skin  from  any 
cause.  It  may  be  acute  or  chronic,  and  exists  in  all  grades,  from  mere  con- 
gestion of  the  surface  to  vesiculation,  pustulation,  general  supiDuration,  and 
sloughing.  Fibrinous  false  membranes  may  be  formed.  Dermatitis  is  usu- 
ally seen  in  surgical  cases  as  the  result  of  irritating  dressings  or  discharges, 
or  is  produced  intentionally  for  counterirritation.  In  all  sm-gical  measures, 
particularly  in  these  days  of  vigorous  antisepsis,  it  is  well  to  emphasize  the 
necessity  for  avoiding  the  production  of  dermatitis,  for  the  condition  will  be 
a  serious  drawback  to  the  comfort  of  the  patient,  and  it  may  jeopardize  the 
aseptic  course  of  the  wound  by  the  serous, discharge  fi-om  the  skin.  Derma- 
titis generally  ends  in  recovery,  sometimes  being  followed  by  desquamation 
of  the  epidermis ;  but  occasionally  an  obstinate  eczema  is  set  up. 


FURUNCLE  AND  CARBUNCLE.  45 

Treatment. — The  milder  forms  are  to  be  treated  by  wet  dressiugs  of 
mild  solutious  or  ijlain  sterilized  water,  or  by  ointments  of  boric  acid  oi- 
zinc  oxide,  or  by  simxily  po^Ydering  the  skin  with  bismuth,  chalk,  Ij^co- 
podium,  calomel,  or  zinc  oxide.  The  api^lication  of  ointments  or  powder 
will  protect  the  skin  from  irritation  by  wound  discharges,  faeces,  or  uriue, 
and  prevent  dermatitis.  The  same  precaution  may  be  employed  on  the 
surrounding  skin  when  it  is  necessary  to  apply  very  strong  antiseptics. 

The  dermatitis  due  to  the  poison  ivy  (Ehus  toxicodendron)  is  worthy  of 
note,  as  it  might  possiblj^  be  coufoirnded  with  erysipelas,  although  the  char- 
acteristic location  of  the  eruption,  beginning  between  the  fingers,  the  trifling 
constitutional  reaction,  and  the  intense  itching  make  the  diagnosis  easy  in 
well-marked  cases.  The  eruption  is  at  first  a  mere  erythema,  but  vesicles 
soon  appear,  accompanied  by  considerable  subcutaneous  and  cutaneous 
oedema,  enough  in  some  cases  to  close  the  eyes  and  distort  the  genitals. 
The  disease  is  self- limited,  running  its  course  in  a  week,  although  sometimes 
prolonged  by  relapses.  It  should  be  treated  on  the  same  principles  as  an 
acute  eczema,  which,  indeed,  occasionally  follows  it.  SuliDhate  of  zinc,  gr. 
ii,  water,  S  i,  may  be  used  as  a  wet  application  ;  or  extr.  grindelia  robusta, 
fsi  to  fiiv,  water,  Oi.  An  ointment  of  carbolic  acid  (gr.  x-sx  to  si)  or 
icMhyol  (ten  per  cent.)  will  soothe  the  itching.  We  \i&\e  had  excellent 
results  from  the  latter,  api^lied  to  the  face  on  a  mask. 

Furuncle. — Carbuncle. — A  very  superficial  pyogenic  infection  of  the 
skin  produces  merely  an  acne  pustule.  A  hoil  or  furuncle  is  a  pyogenic  in- 
fection of  the  sebaceous  glands  or  hair-follicles,  or  in  rare  cases  of  the  sweat- 
glands,  involving  the  surrounding  connective  tissue,  aud  causing  a  circular 
slough,  which  is  extruded  through  a  small  opening  in  the  skin  at  the  centre 
of  the  inflamed  area.  It  is  usually  limited  to  a  spot  about  an  inch  in  diam- 
eter. A  carbuncle  is  a  similar  lesion,  in  which  there  is  i^robably  more  thau 
one  point  of  infection  from  which  the  inflammation  spreads.  It  causes 
rather  extensive  sloughing  of  the  cellular  tissue,  the  skin  being  perforated 
by  several  of  the  circular  openings  and  presenting  an  appearance  like  a 
coarse  sieve,  or  as  if  it  had  received  a  charge  of  bird-shot.  Warren  asserts 
that  a  carbuncle  may  begin  by  the  infection  of  a  single  hair-follicle,  work- 
ing its  way  downward  into  the  cellular  tissue  along  the  column  of  fat  which 
runs  from  the  latter  through  the  thick  derma  to  every  follicle.  He  thinks 
that  the  peculiar  multilocular  appearance  of  the  lesion  is  due  to  the  very 
dense  fibrous  tissue  which  divides  the  cellular  tissue  into  irregular  spaces 
in  those  parts  of  the  body  in  which  carbuncle  most  frequentlj^  occurs, — the 
back  and  the  nape  of  the  neck.  (Fig.  20)  A  carbuncle  may  begin  as  a 
papule  or  vesicle,  but  usually  resembles  an  unusually  large  furuncle  in 
its  first  stage.  Or  it  may  originate  from  a  pustule  or  furuncle.  The 
induration  and  dusky  redness  of  the  skin  spread  usually  over  an  area 
two  or  three  inches  in  diameter,  but  may  be  four  times  that  width  or 
more.  The  tissues  are  at  first  densely  hard  and  brawny,  subsequently 
becoming  boggy  when  the  cellular  tissue  has  sloughed.  The  skiu  is  ojdem- 
atous  and  hard,  and  circular  openings  result  from  sloughing  in  different 
parts  of  the  infected  area.  Through  these  small  openings  the  sloughing 
tissue  must  be  eliminated   by  slow  degrees   unless  assisted  by  incisions. 


46  FURUNCLE  AND  CARBUNCLE. 

The  ijrocess  rarely  penetrates  the  deep  fascia  even  in  very  large  carbun- 
cles. Both  of  these  forms  of  inflammation  are  found  in  any  part  of  the 
skin,  but  most  commonly  about  the  back  of  the  neck  and  the  shoulders. 
They  occur  in  aged  persons  or  those  who  are  exhausted  by  poverty  or  over- 
work, and  they  are  often  accompanied  by  the  presence  of  sugar  in  the  urine. 
The  immediate  cause  is  infection  from  without,  by  scratching  with  the  finger- 
nails, or  through  wearing  soiled  clothing. 


Section  at  the  edge  of  small  caibuncle  of  neck,  hliu\\iug  two  suppurating  foci:  a,  skin  perforated  at 
two  points,  otherwise  but  slighth  inflamed  m  its  upper  layers  ,  b,  deeper  layers  of  corimn  and  subcutaneous 
fat  infiltrated  with  round  cells  and  intensely  inflamed.    (F.  C.  AVood,  M.D.) 

Treatment. — Furuncles  are  apt  to  form  in  a  successive  series,  and  their 
appearance  can  be  prevented  by  attention  to  the  secretion  of  the  sebaceous 
glands.  This  should  be  promoted  by  thorough  cleansing  of  the  skin  with 
soap  and  hot  water,  followed  by  inunctions,  and  we  have  found  a  ten-per- 
cent, boric  acid  vaseline  ointment  very  efficacious.  A  furuncle  or  boil  is  to 
be  treated  by  a  free  incision,  which  may  be  made  crucial  if  the  central  slough 
be  large,  and  which  should  pass  entii-ely  through  the  slough  if  the  incision 
is  made  before  the  latter  is  detached.  It  is  best  to  delay  incision  until  the 
slough  has  softened  and  partly  separated,  treating  the  boil  by  hot  wet  dress- 
ings, unless  the  pain  is  very  great  or  the  inflammation  threatens  to  spread. 
It  is  claimed  that  the  growth  of  a  carbuncle  can  be  arrested  by  circumscribing 
it  with  strips  of  plaster  di-awn  very  tightly  across  the  skin  around  the  edges. 
Some  assert  that  injections  of  carbolic  acid  made  into  the  sm-rouuding  parts 
at  the  edge  of  the  induration  will  check  the  process  ;  but  the  disease  is  often 
self-limited,  running  a  course  of  a  week  or  ten  days,  and  these  statements 
are,  therefore,  uncertain.  Our  best  results  have  been  obtained  by  excision 
or  by  thorough  curetting.  Excision  is  of  necessity  limited  to  carbuncles  not 
over  two  or  three  inches  in  diameter  occurring  in  robust  patients.  The  knife 
must  be  carried  into  the  sound  tissues  beyond  the  edges  and  beneath  the  bot- 
tom of  the  inflammatory  focus,  and  after  waiting  a  few  days  to  be  sure  of 
an  aseptic  wound  without  sloughing,  the  granulating  area  can  be  covered 
with  skin-grafts.  Healing  can  thus  be  secured  in  two  or  three  weeks.  When 
excision  is  not  feasible  the  carbuncle  can  be  thoroughly  curetted,  the  curette 
being  passed  into  small  incisions  running  through  the  openings  in  the  skin. 


CELLULITIS.  47 

aud  the  slough  remo^'ecL  The  undermined  skin  should  be  cut  away.  By 
keeping  up  pressure  on  the  part  already  treated  while  scrajpiug  out  the  re- 
mainder, the  loss  of  blood  can  be  limited,  and  a  firm  dressing  will  stop  all 
oozing.  The  most  supporting  constitutional  treatment  is  to  be  employed  to 
overcome  the  weakening  effect  of  the  septic  element  in  the  disease. 

Cellulitis. — Inflammation  of  the  connective  tissue,  or  cellulitis,  has  been 
fully  described  in  the  preceding  sections,  for  it  is  from  this  most  common 
form  of  inflammation  that  the  general  jjicture  has  been  sketched.  It  is  in- 
variably caused  in  surgical  practice  by  bacterial  infection,  and  almost  in- 
variably results  in  the  production  of  pus.  The  infection  takes  place  through 
a  wound,  and  more  often  through  a  minute  puncture  than  an  extensive 
wound,  probably  because  in  the  latter  the  tissues  are  freely  divided,  the  dis- 
charges escape  at  once,  and  any  infection  which  is  present  shows  itself  only 
in  the  suppuration  of  the  wound  surfaces,  not  gaining  headway  enough  to 
invade  the  surrounding  tissues.  In  wounds  which  are  narrow  and  deep,  on 
the  other  hand,  the  micro-organisms  develop  abundantly  in  the  deeper  parts 
where  effused  blood  is  retained,  and  manufacture  the  toxines  which  impair 
the  vitality  of  the  surrounding  tissue,  so  that  the  bacteria  are  enabled  to 
attack  the  latter  with  success. 

Syraptoms. — An  infected  wound,  which  may  have  been  so  slight  as  to 
be  unnoticed  when  it  was  inflicted,  becomes  painful  a  few  hours  later,  an 
area  of  redness  develops  around  it,  and  the  part  swells  and  becomes  tender 
to  i^ressure.  These  symptoms  spread  for  some  distance  from  the  injured 
point,  showing  more  tendency  to  extend  in  the  direction  of  the  returning 
blood-  and  lymj)h-vessels  than  distally.  If  the  infection  has  begun  in  very 
deep  structures,  siich  as  the  tendon  sheaths  or  the  periosteum  of  the  finger, 
there  may  be  no  indications  of  the  commencing  inflammation,  except  pain 
aud  tenderness  on  pressure.  The  infection  attacks  the  lymphatics,  aud  is 
carried  upward  along  them  to  the  nearest  glands.  In  some  cases  the  lym- 
phatic vessels  themselves  are  inflamed,  aud  their  course  can  be  traced  on  the 
skin  by  the  red  lines  or  indurated  cords  resulting  from  that  inflammation. 
In  other  cases  the  irritant  leaves  no  sign  as  it  glasses  through  the  vessels,  but 
the  nearest  lymph-node  becomes  swollen  and  tender.  In  some  cases  there 
will  be  no  tendency  of  the  original  inflammation  to  extend  beyond  its  origi- 
nal site,  although  it  may  be  intense  enough  to  produce  an  abscess  or  even 
extensive  sloughing  at  that  point.  In  others  it  will  begin  to  advance  before 
the  local  inflammation  seems  to  have  reached  the  stage  of  sui^puration,  aud 
within  a  few  hours  a  cellulitis  which  began  in  some  minute  wound  of  a  fin- 
ger may  involve  the  entire  arm.  In  these  rapidly  spreading  cases  the  sub- 
cutaneous tissues  are  very  dense  and  brawny,  feeling  as  if  injected  with 
wax,  the  overlying  skin  is  red  and  oedematous,  and  sometimes  of  a  bluish 
hue,  owing  to  the  great  obstruction  which  exists  in  the  circulation,  aud  the 
line  of  advance  is  usually  well  marked.  In  this  type  of  cellulitis  there  is 
little  tendency  to  produce  pus  at  once,  but  the  inflammation  is  so  intense 
that  sloughing  often  follows. 

Treatment. — The  treatment  of  ordinary  cellulitis  has  been  sufficiently 
described  on  pages  26  to  30.  In  the  rapidly  spreading  variety  immediate 
incisions  are  needed,  and  these  should  not  only  be  made  at  intervals  over  the 


48  CELLULITIS. 

entire  area  involved,  but  some  of  them  sliould  cross  tlie  advancing  edge  of  the 
inflammation  and  extend  into  the  sound  tissues  for  an  inch  or  more  in  advance 
of  the  wave  of  inflammation.  Often  these  incisions  across  the  advancing 
margin  will  at  once  cut  short  the  further  extension  of  the  inflammation. 
Incisions  for  this  type  of  cellulitis,  when  it  involves  a  considerable  area  or 
an  entire  extremity,  must  be  made  aboiit  two  or  three  inches  in  length,  and 
not  over  two  inches  apart,  being  arranged  in  irregular  rows,  and  they  must 
be  carried  down  to  the  deep  fascia.  The  main  veins  of  the  limbs  should  be 
avoided,  and  all  incisions  should  be  directed  parallel  to  the  long  axis  of  the 
limb.  The  hemorrhage  is  naturally  free,  but  unless  the  patient  is  feeble  it 
should  be  allowed  to  continue,  for  it  relieves  the  congestion.  It  can  readily 
be  controlled  with  gauze  i)acking  and  a  firm  bandage  if  it  should  seem  to  be 
too  profuse.  The  part  is  then  to  be  covered  with  wet  dressings.  Permanent 
irrigation  of  all  the  cavities  will  be  useful. 


CHAPTER    VII. 

SPECIAL  FORMS  OF  INFECTION. 
By  B.  Paeqxjhak  Cuetis,  M.D. 

Erysipelas. — Definition.^- Although  it  is  now  generally  ackuowledged 
that  there  is  no  essential  difference  between  the  coccus  of  Pehleisen,  at  one 
time  held  to  be  the  specific  germ  of  erysipelas,  and  the  stre])iococcus  i^yogenes, 
the  affection  known  as  erysipelas  is  so  different  clinically  from  the  ordinary 
infection  produced  by  the  streptococcus  that  we  must  still  describe  it  sepa- 
rately. Erysipelas  is  a  circumscribed  capillary  lymphangitis  of  the  skin 
and  mucous  membranes,  marked  by  oedema  and  a  dusky  flush,  which  is 
strictly  limited  by  a  sharp  edge.  It  begins  in  any  part  of  the  body,  and 
advauces  at  one  edge  while  it  often  subsides  at  another,  thus  wandering 
over  the  surface.  The  constitutional  symptoms  in  the  milder  forms  are 
scarcely  perceptible,  but  in  the  severer  cases  they  present  the  profoundest 
septic  intoxication.  There  are  two  clinical  varieties,  phlegmonous  erysipe- 
las and  facial  erysipelas,  and  we  prefer  to  describe  with  them  the  "erysipe- 
latoid  lymphangitis"  of  Eosenbach. 

Phlegmonous  Erysipelas. — In  this  form,  which  is  most  frequently 
found  upon  the  extremities  in  connection  with  ulcers  or  cellulitis,  but  may 
also  appear  on  the  trunk  or  head,  the  skin  of  the  part  becomes  faintly 
reddened,  then  oedematous,  the  rosy  hue  giving  way  to  a  dusky-red  flush, 
the  skin  being  apparently  increased  to  two  or  three  times  its  ordinary  thick- 
ness, and  becoming  dense  and  brawny.  The  edge  of  the  affected  area  is 
sharply  distinguished  from  the  healthy  skin  by  the  color  and  the  oedema. 
The  disease  progresses  in  a  solid  mass,  and,  although  the  edge  may  be  very 
irregular,  outljdng  spots  are  very  rarely  seen.  After  a  time  the  skin  first 
attacked  begins  to  grow  pale  again  and  the  oedema  disappears,  the  only  trace 
of  the  inflammation  left  behind  being  the  desquamation  of  the  epithelium 
and  the  falling  of  any  hair  growing  upon  the  part.  Often,  however,  the 
inflammation  of  the  skin  is  accompanied  by  a  cellulitis,  which  results  in  the 
formation  of  extensive  sloughs  and  abscesses,  although  the  skin  itself  seldom 
sloughs  even  when  this  complication  is  added.  The  patient  complains  of 
heat,  weight,  or  intense  burning  pain  in  the  part,  but  in  some  cases  there  is 
no  pain.  The  disease  is  ushered  in  by  a  chill,  which  may  be  very  severe, 
followed  by  a  sudden  and  great  rise  of  temperature,  often  reaching  105°  to 
106°  F.  (40°  to  41°  C).  The  inflammation  may  progress  steadily  or  by  sud- 
den leaps,  every  extension  being  marked  in  the  latter  case  by  chills  and 
another  rise  of  temj)erature.  The  fever  is  of  the  septic  type,  with  sudden 
elevations  and  depressions,  the  former  sometimes  not  being  accompanied  by 
any  visible  spread  of  the  inflammation.  In  these  severe  cases  the  patient 
soon  becomes  delirious  or  somnolent,  the  latter  indicating  perhaps  the 
se\'erer  form  of  the  septic  infection.  The  ui-iue  is  loaded  with  albumin,  and 
the  bacteria  are  found  in  it.     The  patient  may  fall  into  a  typhoid  delirium, 

4  "  49 


50  FACLiL  EEYSIPELAS. 

muttering,  picking  the  bedclotlies,  with  involuntarj^  morements  of  the 
bowels  and  the  bladder,  and  die  comatose.  But  even  patients  who  are  so  ill 
as  this  ma,j  recover.  In  milder  cases  the  temperature  does  not  rise  above 
100°  or  101°  F.  (38°  or  39°  C),  there  is  no  delirium,  and  the  inflammation  is 
readily  controlled  by  treatment.  The  disease  usually  runs  its  course  in  ten 
days  or  a  fortnight,  but  often  lasts  five  or  six  weeks  if  the  patient' s  strength 
holds  out.  Aside  from  the  cellulitis  and  nephritis,  there  are  few  complica- 
tions of  erysipelas,  but  when  cellulitis  is  present  metastatic  abscesses,  lym- 
phadenitis and  phlebitis,  septic  bronchitis,  *pneumonia  or  meningitis,  and 
even  pysemia,  may  follow.  In  simple  erysipelas  without  cellulitis  the  lymph- 
glands  are  not  generally  infected,  although  it  has  been  erroneously  claimed  by 
some  that  their  enlargement  is  a  pathognomonic  sign.  The  develoiDment  of 
internal  complications,  known  as  metastatic  inflammations,  may  be  accom- 
panied by  a  subsidence  of  the  external  symptoms.  In  cases  of  erysipelas  of  the 
scalp,  a  meningitis  or  septic  phlebitis  of  the  sinuses  of  the  brain  may  result 
from  direct  extension  of  the  inflammation  inward  along  the  veins  of  the  dip- 
loe  which  communicate  with  the  internal  vessels.  The  local  sequelfe  of  ery- 
sipelas are  a  chronic  oedema  due  to  blocking  of  the  lymphatic  vessels,  which 
may  result  in  elephantiasis ;  and  an  impaired  vitality  of  the  skiu,  with  a 
tendency  to  eczema  or  ulceration.  The  cellulitis  may  result  in  extensive 
cicatricial  contraction.  The  mortality  of  erysipelas  has  been  estimated  at 
from  one  to  five  per  cent.,  although  it  reached  forty  per  cent,  in  some  epi- 
demics of  former  times. 

Facial  Erysipelas. — The  so-called  facial  erysipelas  differs  from  that 
just  described  only  in  severity.  The  truth  of  the  theory  that  erysipelas  must 
in  every  case  arise  from  the  inoculation  of  an  open  wound  has  now  been 
admitted  even  in  regard  to  the  facial  variety,  although  it  is  seldom  that  such  a 
point  of  entrance  can  be  demonstrated.  Tbis  is  not  strange  when  the  nu- 
merous concealed  cavities  (nose,  throat,  ear,  etc.)  in  lymphatic  connection 
with  the  face  are  taken  into  consideration,  for  a  breach  of  surface  might 
easily  exist  in  them  without  discovery.  Facial  erysipelas  is  distinguished 
by  the  benign  character  of  its  course  and  symptoms  in  most  cases  and  by  the 
frequency  with  which  some  individuals  are  subject  to  its  attacks.  The  color 
of  the  affected  skin  remains  a  rosy  pink,  the  oedema  is  slight,  often  barely 
sufficient  to  close  the  eyes  when  their  lids  are  affected,  the  temi^erature 
rarely  rises  over  100°  F.  (38°  C),  and  the  progress  of  the  disease  is  brief 
and  apparently  self-limited,  running  its  course  in  a  week  or  ten  days,  and 
often  confined  to  a  very  small  area.  Severer  attacks,  however,  are  not  in- 
frequent, and  some  cases  are  as  severe  locally  and  constitutionally  as  erysip- 
elas in  other  situations,  aud  especially  dangerous,  because  of  the  proximity 
to  the  brain,  and  the  greater  liability  of  sinus-phlebitis  or  meningitis.  Even 
the  mild  forms  of  the  disease  are  occasionally  A'ery  obstinate,  continuing  for 
weeks  and  even  months,  and  making  a  slow  progress  over  the  entire  head, 
neck,  and  chest.  Some  persons  may  have  several  attacks  in  a  year,  appar- 
ently brought  on  by  exposure  to  cold,  but  undoubtedly  marking  the  fresh 
infection  of  some  chronic  open  lesion  in  the  mouth,  ear,  or  air-iiassages, 
naturally  taking  place  whenever  the  vital  resistance  of  the  individual  is 
depressed  by  any  cause. 


EEYSIPELATOID  LYMPHANGITIS.  51 

Erysipelatoid  Lymphangitis  of  Rosenbach. — The  "erysipela- 
toid"  disease  described  by  Rosenbach  is  due  to  a  special  micro-organism, 
growing  like  the  cladothrix,  suijposed  to  be  a  mycelium-j)rodncing  fungus. 
The  disease  resembles  the  light  cases  of  facial  erysipelas  clinically,  although 
it  is  almost  invariably  found  upon  the  hands.  It  is  most  often  seen  in  persons 
engaged  in  handling  meat,  and  especially  iish,  in  the  market  or  kitchen,  and 
is  probably  associated  with  some  peculiar  form  of  early  decomj)Osition  in 
these  substances.  The  point  of  infection  can  generally  be  found  in  some 
slight  scratch  or  abrasion,  or  a  hang-nail.  Beginning  from  this  as  a  centre, 
the  infection  spreads  slowly  over  one  finger,  and  over  the  dorsum  or  palm  of 
the  hand  and  wrist,  but  seldom  extends  for  any  great  distance.  It  is  marked 
by  a  rosy  flush,  with  sharply  limited  edges,  although  there  is  little  or  no 
cedema.  It  heals  at  one  side  and  spreads  in  the  way  characteristic  of  erysip- 
elas, but  exceedingly  slowly.  There  is  usually  little  pain,  although  in  some 
cases  a  rather  severe  burning  sensation  is  felt  in  the  skin,  and  general  dis- 
turbance is  absent,  the  temperature  seldom  reaching  100°  F.  (38°  C).  The 
disease  seems  to  be  self-limited,  and  runs  its  com-se  in  from  ten  to  fifteen  days, 
gradually  fading  out,  first  in  the  oldest  parts,  finally  at  the  advancing  edge. 

Treatment. — Isolation. — The  first  essential  in  the  care  of  any  erysipe- 
latous inflammation  is  to  isolate  even  the  milder  cases  from  any  possibility 
of  infection  of  infants,  parturient  women,  and  persons  with  wounds  or 
ulcers.  Even  the  mildest  cases  of  facial  erysipelas,  occurring  in  individuals 
who  have  had  the  disease  so  often  as  to  consider  it  of  no  importance,  may 
be  capable  of  exciting  the  most  vigorous  septic  form  of  the  disease  in  others 
who  are  more  susceptible  to  the  poison.  In  these  mild  cases,  occui-ring  in 
families  in  which  there  are  no  such  especially  disposed  persons,  an  absolute 
quarantine  is  not  necessary  if  due  care  is  taken  to  avoid  actual  contact  with 
the  affected  individual,  to  keep  the  inflamed  part  well  covered,  to  disinfect 
the  hands  thoroughly  after  changing  the  dressings,  and  to  destroy  the  latter 
by  fire.  In  the  virulent  cases,  however,  no  ]precautions  can .  be  too  great, 
and  the  attendants  must  guard  their  own  hands  with  the  greatest  care  (by 
rubber  gloves)  in  order  to  avoid  infection  through  some  unnoticed  lesion. 
Any  one  having  a  wound  or  an  ulcer  should  abstain  from  actual  handling  of 
the  patient,  for  the  infection  is  one  of  the  inost  powerful  and  insidious  known. 

Local  Applications. — The  milder  cases,  especially  the  erysipelatoid  of 
Rosenbach,  appear  to  be  self-limited,  and  would  jDrobably  recover  without 
any  treatment — a  fact  which  makes  it  difficult  to  estimate  the  value  of  the 
various  methods  of  treatment  which  have  been  recommended.  There  ap- 
pears, however,  to  be  svrfiicieut  reason  to  believe  that  astringent  applica- 
tions, such  as  a  strong  solution  of  acetate  of  aluminum  or  a  twenty-five  per- 
cent, ointment  of  ichthyol,  will  check  the  spread  of  the  disease,  and  even 
hasten  its  resolution.  Strong  antiseptic  solutions,  such  as  1  to  20  carbolic 
acid  or  1  to  1000  bichloride  of  merciiry,  ai^pear  to  have  no  greater  power 
over  the  disease  to  offset  their  disadvantages  in  the  way  of  local  irritation 
and  the  danger  of  poisoning.  More  severe,  but  uncomplicated,  cases  are 
treated  upon  the  general  principles  of  reducing  inflammation  and  by  cer- 
tain special  efforts  to  reach  the  germs  developing  in  the  skin  or  to  limit 
their  spread.     The  parts  may  be  dressed  with  strong  antiseptic  solutions. 


52  TREATMENT  OF  ERYSIPELAS. 

applied  either  cold  or  very  hot,  and  the  surface  of  the  skin  has  been  scari- 
fied by  some  surgeons  in  order  to  obtain  increased  absorj)tion  of  the  germi- 
cide. It  cannot  be  said  that  the  results  of  this  treatment  are  very  much- 
better  than  those  obtained  with  milder  applications,  such  as  those  just  men- 
tioned. 

Limiting  Compression. — Some  success  is  said  to  have  been  achieved 
by  painting  the  skin  a  short  distance  from  the  advancing  edge  with  con- 
tractile collodion,  so  as  to  obtain  a  constriction  of  the  tissues  as  the  col- 
lodion dries  which  will  be  suflScient  to  shut  off  the  vessels  and  lymph  spaces 
of  the  skin,  and  so  hinder  mechanically  the  spread  of  the  disease.  Strips 
of  adhesive  plaster  have  also  been  employed  in  this  way.  It  is  obvious  that 
the  most  that  can  be  accomjjlished  by  such  measures  is  a  partial  closure  of 
the  avenues  of  infection. 

Scarification. — The  best  effects  of  the  scarification  and  germicide  appli- 
cations already  siiokeu  of  are  seen  when  the  treatment  is  limited  to  the 
advancing  edge  and  the  healthy  skin  just  beyond  it,  a  zone  of  scarification 
about  an  inch  in  breadth  being  made  on  the  healthy  skin  about  half  an 
inch  distant  from  the  nearest  sign  of  inflammation.  The  incisions  should 
be  about  one-sixth  of  an  inch  apart,  and  should  be  crossed  obliquely  by 
another  set,  making  a  diamond-pattern.  Applications  of  1  to  1000  bichlo- 
ride are  made  to  this  belt  and  to  the  advancing  edge.  The  necessity  for 
anesthesia  during  the  scarification  is  a  serious  drawback  to  the  method. 

Parenchymatous  Injections. — Some  surgeons  practise  injections  of 
1  to  20  carbolic  acid  or  1  to  1000  bichloride  of  mercury  solutions  into  the 
skin  just  beyond  the  advancing  edge,  small  quantities  being  injected  at  each 
point  and  a  complete  line  of  the  injection  being  drawn  across  the  front  of 
the  advancing  inflammatiou.  It  is  said  that  the  treatment  is  efficacious,  but 
it  is  very  painful,  and  it  is  necessary  to  use  dangerous  quantities  of  either 
drug,  in  most  cases,  on  account  of  the  extent  of  the  disease.  The  method 
would  seem  to  be  justifiable  only  in  cases  in  which  the  disease  is  limited 
in  extent,  but  threatens  to  be  very  virulent  in  character.  In  scarification 
and  injection  there  exists  some  danger  of  a  spread  of  the  disease  by  the 
instrument,  and  every  ijossible  precaution  must  be  employed  to  prevent  it. 

General  Treatment. — The  greatest  difficulty  to  be  met,  however,  is  the 
fact  that  in  the  severe  cases  there  is  such  prostration  that  the  patient  has 
not  sufficient  strength  to  bear  very  vigorous  measures  of  treatment,  and  the 
general  suj)i)ort  of  the  powers  of  resistance  seems  to  be  of  more  importance 
than  any  local  treatment  yet  devised.  Even  in  the  mild  facial  form  of  ery- 
sipelas the  patient  should  at  once  be  confined  to  his  room,  or  even  to  bed, 
in  order  to  secure  perfect  rest,  while  the  most  nourishing  and  easily  digestible 
food,  with  a  suitable  allowance  of  stimulants,  should  be  ordered  ;  the  diges- 
tion, and  especially  the  intestinal  evacuations,  should  be  regulated  and 
assisted,  and  such  tonics  prescribed  as  seem  best  suited  to  the  patient's  need. 
The  most  generally  useful  tonics  are  iron  and  quinine.  While  we  cannot 
endorse  the  so-called  specific  action  once  claimed  for  the  tincture  of  the  chlo- 
ride of  iron  given  in  large  doses,  there  can  be  no  question  that  relatively 
large  doses  (fifteen  to  thirty  minims),  given  every  three  hours,  have  in  some 
cases  a  stimulating  effect  which  may  possibly  be  due  to  the  stimulating  effect 


MALIGNANT  CEDEMA  AND  EMPHYSEMATOUS  GANGRENE.  53 

uj)ou  digestiou.  But  these  large  doses  soon  disorder  the  stomach  and  tend 
to  produce  constipation,  and  must  be  discontinued.  Quinine  is  a  raj)idly 
actiiig  and  i^owerful  stimulant,  and,  in  doses  of  from  three  to  ten  grains 
given  three  times  a  day,  supports  the  nerve-centres,  and  will  probably  re- 
duce the  temperature  somewhat,  although  its  supposed  power  to  check  ])us- 
formation  cannot  be  proved.  The  kidneys  are  to  be  carefully  watched,  and 
large  amounts  of  fluids  administered  in  order  to  produce  diuresis  and  en- 
courage them  to  throw  off  the  poison.  Intravenous  saline  infusion  or  con- 
tinuous hot  irrigation  of  the  rectum  will  aid  in  the  diuresis.  The  skin  may 
be  made  to  assist  the  kidneys  if  a  moderate  amount  of  sweating  is  encouraged 
by  a  daily  alcohol-bath  and  warm  covering.  If  cellulitus  develops,  it  is  to  be 
treated  In  the  usual  manner,  and  other  complications  may  require  attention. 
It  has  long  been  known  that  an  attack  of  erysipelas  has  a  curative  effect 
upon  certain  conditions.  Thus,  ulcers  take  on  a  healthy  action,  chronic 
inflammations  clear  up,  and  malignant  tumors  have  even  been  observed  to 
disappear,  after  such  an  attack.  Erysipelas  has,  therefore,  been  intention- 
ally inoculated  in  the  attempt  to  produce  these  effects,  and  occasionally  with 
success,  but  the  method  is  dang'erous  on  account  of  the  uncertain  and  uncon- 
trollable nature  of  the  disease,  and  has  been  abandoned  in  its  simpler  form. 
The  use  of  the  toxines  or  autitoxines  produced  by  the  germs  has,  how- 
ever, been  lately  introduced  for  the  treatment  of  malignant  tumors. 

MALIGNANT   CEDEMA  AND   EMPHYSEMATOUS   GANGRENE. 

Several  varieties  of  bacteria  produce  gas  when  growing  in  the  living 
tissues,  and  certain  of  these  varieties  cause  gangrene  also.  These  infections 
are  known  as  malignant  oedema,  emphysematous  gangrene,  gangrene  fou- 
droyante,  and  acute  traumatic  or  spreading  gangrene.  Malignant  oedema 
appears  in  the  lower  animals  as  a  well-marked  specific  disease,  but  in  man 
it  is  impossible  to  distinguish  clinically  between  these  infections. 

The  bacillus  of  malignant  oedema  (Pasteur,  Koch)  resembles  the  bacillus 
anthra.cis,  but  its  straight  rods  are  more  slender  (2  to  10  micromillimetres 
long  and  1  micromillimetre  thick).  It  produces  spores  in  the  body.  The 
rods  are  sometimes  found  in  motion,  having  flagella.  Usually  two  or  three 
are  joined  together,  forming  straight  or  curved  lines,  but  long  chains  are 
also  found.  The  germ  is  decolorized  by  Gram's  method.  It  will  not  grow 
unless  oxygen  is  excluded.  It  can  be  cultivated  in  agar-agar,  gelatin  (which 
it  liquefies),  or  coagulated  serum  of  the  blood  at  the  temperature  of  the 
body,  or  even  much  lower,  down  to  18°  C.  Its  growth  is  accompanied  by 
the  production  of  an  offensive  gas.  It  has  been  proved  experimentally  that 
one  attack  of  malignant  oedema  creates  immunity,  and  that  immunity  may 
be  conferred  by  injections  of  the  toxines. 

The  bacillus  aerogenes  capsulatus  (Welch)  is  about  5  micromillimetres 
long,  somewhat  resembling  that  of  anthrax,  but  with  slightly  rounded  ends, 
and  having  a  distinct  capsule.  It  is  decolorized  after  staining  by  Gram's 
method.  It  is  strictly  anaerobic.  It  grows  upon  agar,  in  bouillon,  and  on 
blood-serum,  producing  gas  in  all,  but  growing  spores  only  in  the  last-men- 
tioned medium. 

The  bacillus  oedematis  aerobicus  (Sanfelice,  Klein)  is  stout  with  rounded 


54  MALIGNANT  CEDEMA  AND  EMPHYSEMATOUS  GANGRENE. 

ends,  motile,  witliout  a  capsule,  and  resembles  the  colon  bacillus.  It  does 
not  decolorize  with  G-ram's  method:  It  is  a  facultative  aerobic  germ,  but 
grows  best  without  oxygen.  It  can  be  cultivated  on  the  usual  media,  with 
abundant  production  of  gas. 

The  bacillus  emphysematosus  (Praenkel)  is  stouter  than  the  bacillus  of 
anthrax,  non-motile,  not  encapsulated,  and  does  not  form  siiores.  It  decol- 
orizes by  the  Gram  method.  It  is  anaerobic,  and  produces  gas  in  growing 
upon  agar  and  glycerin,  but  not  on  gelatin. 

These  germs  are  found  in  the  earth,  and  in  faeces  of  man  and  auimals. 
They  appear  to  have  more  or  less  close  relations  with  the  colon  bacillus. 
All  but  one  of  them  are  anaerobic,  and  that  germ  grows  best  when  oxygen 
is  excluded,  and  the  infections  due  to  them  are  found  generally  in  such  in- 
juries as  compound  fractures,  in  which  deep,  narrow,  undraiued  wounds 
give  the  germs  the  oj)]3ortunity  to  grow  iirotected  from  the  air.  They  also 
appear  to  thrive  best  when  foreign  bodies  or  necrotic  tissue  are  present  in 
the  wounds. 

Symptoras. — The  clinical  picture  of  the  infections  produced  in  man 
by  all  these  germs  is  identical  so  far  as  our  present  knowledge  goes.  After 
a  severe  lacerated  and  contused  injury  of  this  nature,  a  dusky  bronze  hue 
appears  in  the  skin  near  the  wound  and  rapidly  extends,  so  that  in  a  few 
hours  it  may  involve  the  entire  extremity.  We  have  seen  it  begin  from  a 
lacerated  wound  in  the  popliteal  space  of  a  young  man  and  involve  the 
thigh  and  entire  trunk  in  twenty-four  hours.  Tlie  color  is  due  to  deep 
hemorrhagic  extravasations,  and  gradually  changes  into  the  darker  and 
mottled  discoloration  characteristic  of  gangrene.  The  part  becomes  hard, 
brawny,  and  cedematous,  and  subcutaneous  emi^hysematous  crackling  is 
felt,  showing  the  presence  of  gas  in  the  tissues,  which  sometimes  extends 
into  aj)parently  healthy  parts.  If  the  patient  survives  long  enough,  the 
usual  necrotic  changes  of  moist  gangrene  take  place.  Extreme  prosfcration 
accompanies  the  disease. 

If  the  infection  is  a  pure  one  there  are  none  of  the  ordinary  changes  of 
inflammation  such  as  redness  and  suppuration,  and  the  microscope  shows  a 
complete  absence  of  emigration  of  leucocytes  or  multiplication  of  cells. 
But  generally  the  infection  is  mixed  with  pyogenic  germs,  and  suppuration 
occurs  unless  the  process  spreads  so  rapidly  as  to  cause  fatal  sepsis  before 
pus  can  be  produced.  In  some  cases  the  gas  is  produced  in  such  quantities 
as  to  inflate  the  tissues  and  to  cut  off  the  circulation  by  its  pressure.  In 
such  cases,  the  tissues  become  swollen  and  hard  to  the  touch,  and  the  patient 
may  have  great  pain,  and  immediate  gangrene  occurs.  As  a  rule,  prostra- 
tion is  the  only  symptom.  The  patient  has  no  pain,  and  is  generally  apa- 
thetic. The  temperature  may  be  high,  but  in  many  cases  it  is  not  above 
normal. 

Treatment. — The  infection  being  anaerobic,  free  incisions  and  the  use 
of  hydrogen  dioxide  are  indicated.  The  incisions  also  relieve  tension  and 
thus  check  the  spread  of  the  infection  and  the  gangrene.  There  are  a  num- 
ber of  cases  on  record  in  which  recovery  was  brought  about  by  these  meas- 
ures, in  some  of  whicli  the  disease  had  reappeared  in  a  stump  after  amputa- 
tion for  the  same  lesion  lower  down.     In  spite  of  these  exceptional  cases 


ANTHRAX.  55 

immediate  amx^utation  should  be  done  whenever  it  is  possible  to  reach 
healthy  tissues  above,  and  it  may  be  done  even  when  some  infected  tissue 
must  be  left  in  the  stump.  Even  in  the  former  case  the  flaps  should  be  left 
open,  the  wound  being  packed  and  allowed  to  granulate  until  danger  of 
further  infection  has  passed. 

ANTHRAX. 

The  disease  properly  known  as  anthrax  was  formerly  called  malignant 
pustule,  malignant  carbuncle,  splenic  fever,  and  wool-sorter's  dis- 
ease (Fr.  Charbon  ;  Ger.  Milzbrand).  It  is  caused  by  the  bacillus  anthracis 
(Davaine,  Pasteur)  (Plate  II.,  Fig.  22),  which  is  one  of  the  lai-gest  of  the 
specific  iiathogenic  microbes,  and  was  one  of  the  earliest  to  be  detected. 
It  is  a  straight  rod,  from  5  to  10  or  even  50  micromillimetres  long  and  1 
micromillimetre  thick,  without  power  of  motion,  and  multiplying  in  living 
tissues  only  by  segmentation,  although  it  produces  spores  in  dead  culture 
media.  The  bacillus  is  killed  by  a  temperatui-e  of  132°  P.  (56°  C),  but 
the  spores  are  among  the  most  resistant  known.  It  is  easily  cultivated  in 
the  usual  media,  and  liquefies  gelatin,  producing  characteristic  colonies.  It 
is  sirpposed  by  some  to  grow  in  soil  or  manure  and  thence  make  its  way  into 
the  herbivora,  and  from  their  bodies,  either  living  or  dead,  other  animals 
and  man  may  take  the  disease.  Anthrax  is  much  more  common  in  the 
United  States  than  was  formerly  supposed.  Anthrax  may  be  acquired  by 
infection  through  the  outer  coverings  of  the  body,  or  through  the  respira- 
tory or  the  digestive  tract.  In  the  latter  cases  spores  penetrating  the 
mucous  membranes  produce  lesions  of  the  internal  organs,  which  are  de- 
scribed in  the  works  on  practice  of  medicine.  The  intact  epidermis  is  a 
complete  protection  against  the  germ,  and  it  can  enter  only  by  inoculation 
of  an  open  wound.  Man  is  most  likely  to  be  infected  by  hides,  by  the  hair 
or  wool  of  diseased  animals,  or  by  an  insect  bite  or  sting,  and  upon  exposed 
portions  of  the  body,  such  as  the  hands  and  face. 

Symptoms. — When  inoculation  of  the  skin  has  occurred,  two  distinct 
forms  of  inflammation  result,  the  localized  carbuncular  form  and  the  diffuse 
cedematous  form.  The  carbuncular  variety  begins  with  the  appearance  of 
a  minute  red  spot  at  the  point  of  inoculation,  which  soon  develoi^s  into  a 
vesicle  containing  clear  or  bloody  serum.  This  in  turn  dries  up,  leaving  a 
small  dark  purple  or  black  spot  in  the  skin  surrounded  by  a  zone  of  slight 
inflammation,  shown  by  a  rosy  tint  of  the  skin  and  the  formation  of  minute 
vesicles.  (Pig.  21.)  These  changes  take  place  in  from  twenty-four  to  forty- 
eight  hours,  but  may  develop  more  rapidly.  The  inflammatory  zone  spreads 
slowly  in  a  centrifugal  direction  into  the  healthy  skin,  while  towards  the 
centre  the  vesicles  dry  and  collapse,  and  the  rosy  pink  grows  gradually  darker 
to  a  deep  red,  soon  becoming  dusky,  and  finally  as  dai  k  as  the  centre.  The 
central  necrotic  spot  is  always  depressed  below  the  level  of  the  surrounding- 
skin,  and  it  usually  remains  dry  or  with  a  merely  serous  discharge,  as  the 
bacillus  is  not  pyogenic.  The  ordinary  signs  of  inflammation,  such  as 
pain,  swelling,  and  congestion,  are  absent,  the  process  being  that  of  an  acute 
necrosis  of  the  part  affected.  In  some  cases,  however,  there  will  be  some 
pain,  oedemai,  and  redness,  and  even  lymphangitis.     As  a  rule,  the  infected 


56 


ANTHRAX. 


Fig.  21. 


Anthrax  of  forearm.     (Dr.  E.  W.  Given.) 


spot  is  about  an  inch  in  diameter  or  less  when  it  is  bronglit  to  the  notice 
of  the  surgeon,  and  in  twenty-four  hours  it  will  double  in  extent.  Even 
when  there  is  no  pain  or  other  sensation  at  first,  pain  is  apt  to  begin  after 
forty-eight  hovirs,  when  a  local  oedema  appears,  which  is  sometimes  rather 
extensive.  The  bacillus  can  be  found  in  this  cedematous  tissue  as  well  as 
in  the  serum  of  the  vesicles.  At  this  time 
general  infection  is  evident  from  the  rising 
temperature,  due  to  the  absorption  of  the 
toxines.  Great  mental  anxiety  is  felt,  which 
subsides  into  a  somnolent  state,  and  the  pa- 
tient soon  succumbs  to  a  tyiiical  septicaemia, 
often  with  diarrhoea  and  occasionally  albu- 
minuria. The  temperature  is  rarely  high, 
and  the  worst  cases  often  show  the  least  ele- 
vation. If  recovery  takes  place,  the  tem- 
iserature  usually  returns  to  the  normal  ciuite 
abruptly  on  the  second  or  third  day.  Occa- 
sional instances  of  spontaneous  recovery  have 
been  noted,  the  inflammation  remaining  local 
and  the  adherent  slough  being  slowly  thrown 
off,  the  delay  dejjending  upon  the  fact  that 
sui^puration  never  occurs  in  a  pure  anthrax 
inflammation,  a  mixed  infection  with  pj^o- 
genic  germs  being  necessary  in  order  that 
pus  may  be  produced.  The  mortality  varies  greatly  with  the  situation  of 
the  primary  lesion,  for  one-fourth  of  the  cases  die  when  the  disease  attacks 
the  head  or  trunk,  only  one-eighth  when  it  is  on  the  uj)per  extremity,  and 
only  one  in  twenty  when  the  lower  extremity  is  involved. 

The  cedematous  form  is  even  more  dangerous,  instances  of  recovery 
being  very  rare,  even  with  vigorous  treatment,  and  almost  unknown  spon- 
taneously. In  this  form  there  is  a  sudden  appearance  of  a  tense  oedema, 
spreading  in  all  directions,  with  very  slight  discoloration  of  the  skin,  and 
without  the  sharj)  margin  which  is  so  characteristic  of  erysiijelas.  The  lack 
of  the  deep  bronze  color  may  serve  to  distinguish  it  from  malignant  oedema, 
but  sometimes  only  a  bacteriological  examination  can  decide  between  the  two. 
In  some  cases  local  patches  of  gangrene  appear  on  the  skin,  with  the  forma- 
tion of  blebs.  The  pain  is  not  always  severe,  and  at  first  the  constitutional 
reaction  is  slight,  but  the  temperature  soon  rises,  and  the  usual  signs  of 
septici3emia  develop,  with  rapid  and  great  prostratiou. 

Treatment. — Carbuncular  Form. — In  the  first  twenty-four  or  forty- 
eight  hours  after  the  api>earance  of  the  lesion  it  remains  strictly  local,  and  a 
general  infection  can  he  avoided  by  immediately  cutting  out  the  entire  area 
of  skin  affected,  with  a  liberal  allowance  of  the  healthy  skin  about  it.  The 
wound  will  then  heal  like  an  ordinary  wound,  and  the  patient  recover.  In 
the  cedematous  form  of  the  disease,  also,  excision  of  the  parts  first  affected 
with  cauterization  of  the  wound  will  sometimes  effect  a  cure,  if  the  disease 
is  not  too  extensive  ;  but,  as  a  rule,  operative  treatment  will  be  impossible. 
Injections  of  carbolic  acid  in  a  solution  of  water  and  glycerin  (1  to  10)  may 


PLATE  II. 
Pig.  22. 


/ 

/ 


^  :.  ^    o 


■.  0 

0 


Bacillus  anthracis  in  tlie  capillaries  of  tlie  liver.    (F.  C.  Wood,  M.D.) 


Fig.  25. 


Fig.  23.  _.  ^ 

'      \  V     ^    .\    ^  "^  )  \ 

^       ^  I 

Bacillus  mallei.    (F.  C.  Wood,  M.D.)  Bacillus  tuberculosis.    (F.  C.  Wood,  M.D.) 


GLANDERS.  57 

be  made  into  the  surroiiudiug  tissues  in  order  to  limit  tlie  growth,  of  the 
bacillus,  but  even  this  will  be  difficult  because  of  the  large  area  to  be  sur- 
rounded by  the  injection  and  the  consequent  danger  of  carbolic  poisoning. 
General  supporting  treatment  will  be  necessary.  The  infection  of  anthrax 
takes  place,  as  a  rule,  through  the  blood-vessels,  the  internal  capillaries 
being  finally  blocked  by  plugs  formed  of  the  rapidly  growing  germs  which 
thrive  in  the  blood.  Lymphangitis  and  adenitis  are  not  common  unless 
there  be  a  mixed  infection  with  pyogenic  germs  as  well,  but  in  some  cases 
the  glands  enlarge,  and  it  has  been  recommended  to  remove  them  when  the 
primary  lesion  is  excised.  Eecently  a  large  number  of  cases  have  been  re- 
ported from  Von  Bramann's  clinic,  many  of  them  of  the  severest  type  of  the 
disease,  all  of  which  recovered  practically  without  treatment,  the  part  in- 
fected being  simply  elevated  and  covered  with  blxie  ointment,  the  patient 
being  kej)t  in  bed  and  vigorously  stimulated.  Von  Bramann  was  led  to  this 
mode  of  treatment  by  the  observation  of  Miiller  that,  about  the  time  when 
the  surrounding  oedema  developed,  the  bacilli  in  the  primary  lesion  had 
entirely  lost  their  virulence  and  were  innocuous,  the  remaining  symjitoms 
being  due  only  to  their  toxines.  He  therefore  concluded  that  man  was 
refractory  to  the  anthrax  bacillus  and  that  with  a  little  assistance  his  tissues 
would  resist  the  germs. 

GLANDERS, 

Glanders,  also  known  as  farcy  or  equinia  (Pr.  Morve ;  Ger.  Eotz- 
krankheit),  is  an  infectious  disease  which  is  very  j)revalent  in  horses  and 
mules  and  rarely  observed  in  man,  being  contracted  from  these  animals. 
It  is  caused  by  the  bacillus  mallei  (Loeffier,  Schiltz)  (Plate  II.,  Fig.  23),  a 
rod-shaped  microbe,  somewhat  shorter  and  thicker  than  the  tubercle  bacillus 
(2  to  5  micro-millimetres  long  and  0.5  to  1.4  micromillimetre  thick),  motile, 
multiplying  by  segmentation — and,  according  to  some,  by  spores.  The 
bacillus  is  easily  killed  by  ten  minutes'  exposure  to  a  heat  of  131°  F.  (55° 
C.)  or  five  minutes  in  1  to  20  carbolic  acid  or  1  to  5000  corrosive  sublimate. 
It  grows  in  the  usual  media,  making  white  or  yellow  thread-like  colonies. 
It  is  a  true  parasite,  living  only  in  animals,  but  it  can  remain  alive  in  the 
dry  state  for  long  periods,  so  that  dried  secretions  may  be  dangerous, 
although  few  bacteria  are  usually  found  in  the  nasal  discharge. 

The  inflammation  excited  by  this  bacillus  results  in  the  formation  of 
characteristic  minute  nodules  by  an  accumulation  of  cells,  with  a  tendency 
to  necrosis  and  suppuration.  The  disease  spreads  by  the  blood-vessels  and 
also  by  the  lymphatics,  but  rarely  by  the  latter  in  man  unless  there  is  a 
simultaneous  infection  with  the  ordinary  pyogenic  germs.  Thrombosis  takes 
place  in  the  vessels  adjoining  the  nodule,  and  embolism,  followed  by  the 
development  of  metastatic  foci  in  distant  organs,  is  the  result.  In  man  the 
nasal  mucous  membrane,  the  skin,  and  the  lungs  are  most  frequently  af- 
fected, but  the  sexual  organs,  the  bones,  peritoneum,  and  other  parts  may 
be  attacked.  The  bacillus  may  be  found  in  the  circulating  blood  in  the 
acute  cases. 

Equine  Varieties. — In  the  horse  the  disease  appears  in  several  form.s. 
Acute  glanders  causes  a  necrotic  inflammation  of  the  mucous  membrane  of 
the  nose,    suppurative  cervical  adenitis,  and  rapid  septicemia.      Chronic 


58  GLA>rDEES. 

glanders.  ynXh  the  same  lesions  but  a  more  elironic  coui'se.  is  marked  by 
uleei-s  in  tlie  uose,  desti-oving  even  the  bones,  large  cervical  abscesses  fi-om 
the  inflamed  glands,  and  metastatic  foci  in  the  Inngs  or  other  internal  organs, 
and  also  in  the  muscles  and  joints.  Another  form  is  kno^mi  under  the  name 
of  farcy,  the  disease  begruning  in  the  same  ^ay,  but  with  the  addition  of 
metastatic  foci  in  the  skin,  which  may  break  down  and  form  extensive 
ragged  ulcers,  or  may  not  break  down  so  extensively,  but  a  general  enlai-ge- 
ment  of  the  lymph-nodes  may  take  place.  Acute  septiciiemia  may  develop 
even  in  the  chronic  form  and  cause  sudden  death. 

Symptoms. — The  usual  point  of  entrance  of  the  infection  is  the  nasal 
mncijus  membrane,  but  infection  may  occur  wherever  a  wound  or  abrasion 
is  inoculated;  and  it  has  been  experimentally  produced  by  rubbing  the  cul- 
tures on  the  skin,  thi'ough  the  haii--follicles.  In  man  the  disease  is  generally 
the  resrdt  of  contact  with  infected  animals,  although  it  may  be  passed  from 
man  to  man.  The  contagion  has  been  known  to  occur  during  sexual  inter- 
coui-se,  like  that  of  chancroids. 

The  symptoms  and  course  of  the  disease  depend  entirely  upon  the  seat 
of  infection.  If  the  nasal  mucous  membrane  is  primarily  involved,  and  in 
man  this  is  not  so  invariably  the  case  as  in  the  horse,  nodules  appear  and 
form  ulcers,  which  may  destroy  the  entire  nose,  as  well  as  the  hard  and  the 
soft  palate,  even  in  so  short  a  time  as  a  week.  If  the  infection  is  external, 
a  soft  nodule  forms  in  the  skin  and  cellular  tissue,  which  suppui-ates  and 
produces  a  ragged  ulcer  with  undermined  edges.  The  ulcer  may  remain 
localized  and  even  heal.  Metastasis  takes  place  through  secondary  involve- 
ment of  the  nearest  lymphatics,  or  more  frequently  through  embolism,  in 
consequence  of  which  secondary  foci  may  develop  in  any  organ  of  the  body. 
If  infection  takes  place  through  the  internal  organs  the  disease  may  closely 
resemble  acute  miliary  tuberculosis  or  tyjjhoid  fever  in  its  general  symp- 
toms, and  the  diagnosis  may  be  uncertain  until  an  external  focus  appears. 
When,  on  the  other  hand,  there  are  numerous  external  foci  without  any 
general  symptoms,  the  disease  is  frequently  mistaken  for  syphilis  or  local 
tuberculosis.  Wlien  secondary  pustules  appear  in  the  skin  they  often  re- 
semble those  of  small-pox,  and  in  other  casas  when  the  skin  is  involved  a 
patch  of  dusky  red  with  sharp  bordere  like  erysipelas  is  produced,  but  it 
does  not  migrate  like  erysipelas. 

The  constitutional  symptoms  also  vary :  in  some  a  condition  of  acnt« 
septicaemia  develops  at  once,  in  others  the  signs  of  a  general  infection  are 
absent,  even  although  the  glands  are  affected.  Death  may  ensue  in  a  few 
days  in  the  acute  cases,  while  in  the  chronic  form  recovery  may  take  place 
after  a  course  of  many  months.  The  chronic  cases  with  well-localized 
lesions  are  the  lea.st  dangerous,  but  acute  symptoms  have  been  known  to  de- 
velop suddenly  in  the  course  of  a  chronic  case.  The  diflftculty  of  diagnosis 
may  be  extreme.  The  bacteria  should  be  sought  for  in  the  contents  of  the 
pustules  and  in  the  blood,  and  inoculation  experiments  should  be  made  in 
animals. 

Treatraent. — The  only  treatment  possible  is  the  local  removal  of  in- 
fected tissue,  and  if  the  local  foci  are  not  too  extensive  they  should  be  ex- 
cisedL  or  incised  and  curetted  or  cauterized,  either  by  the  hot  iron  or  by 


ACTIX03fTCXtSIS.  59 

chemicals.  In  severe  cases,  however,  complete  eradication  of  the  disease  is 
impossible.  The  patient  must  be  qnarantined.  and  all  discharges  carefollv 
bnmed.  E3rperiments  have  been  made  with  a  sermn  containing  the  toxines 
(mallein;  which  is  xisefol  for  diagnostic  purposes,  lite  tuberculin  in  tubercu- 
losis, and  may  furnish  a  means  of  treatment  in  the  future. 

ACTIiSrOMTCOSlB. 

Actinomycosis,  or  •'Imapyjaw."  is  a  disease  produced  "bj  ih&  ray-fungm 
(streptothrix  actinomycotica)  which  forms  star-shaped  masses  of  mycelium, 
made  up  of  radiating  threads  with  bnll:»ous  extremities,  a  number  of  th^e 
being  generally  combined  to  make  a  mass  about  the  size  of  a  millet-seed,  of 
cheesy  consistency  and  usu- 
ally of  a  bright  yellow  color.  Tig.  24. 
(Fig.   24.)     It  gains  access  ,.^      \ 
through  some  open  wound  or                                        ^^    «^    / 
a  carious  tooth,  and  grows  -        _._ 
in  the  tissues,  which  react                                    -^  — 
towards  it  and  surround  it 
by  a   chronic  inflammatory                 "~^-v  ^^ 

granulation-tissue.    The  typ-  _^ ,,?    t-  i^- 

ical  nodule  contains  the  fan-  i^- 

gus  in  tlie  centre,  surrounded  " 


i^?-**;: 


-''  *%' 


by  a  mass  of  round  cells,  leu-  ' 

cocytes.  and  epithelioid  c-ells,     ^-  ^~  >  .  J^, 

often  containing  giant-c-ells.  ^  ~  - 

and  closely  resembling  tul>er-  ■''->~~-      -'  "^'-'--^  V 

CUIOUS  or  sarcomatous  tissue.  AeliB«iByecior3aT-feEgiL^    (Afterfeiae!.) 

This  mass  continues  to  grow 

by  the  formation  of  new  nodules  in  its  neighborhood  and  their  fusion  with 
the  original  one.  and  may  continue  for  some  time  as  a  firm  tumor  and  attain 
considerable  size.  It  soon  becomes  infected  with  pyogenic  germs,  and  breaks 
dowxL  forming  a  chronic  absc^s.  The  disease  spreads  by  direct  extension 
into  the  surix>unding  tissues,  destroying  even  the  bone,  but  not  invading  the 
lymphatics.  In  rare  cases  it  may  perforate  the  wall  of  a  vein  by  ulceration 
and  thus  produce  an  embolus,  which  will  be  c-arried  off  to  form  a  metastatie 
focus  in  some  distant  organ.  The  fongus  has  been  ctdtivated  artificially, 
but  with  great  difficulty.  It  has  been  found  growing  in  c-ariotis  teeth  in 
almost  pure  cultures  without  catising  any  symptoms  and  without  any  ten- 
dency to  spread.  On  the  other  hand,  a  carious  tooth  infected  with  it  has 
been  known  to  abrade  and  inoculate  the  tongue. 

"While  common  in  cattle,  actinomycosis  is  rather  a  rare  disease  in  man, 
but  Euhrah  has  collected  seventy -two  cases  observed  in  America.  The  ex- 
ternal habitat  of  the  fungus  is  not  known,  but  several  cases  are  on  record 
in  which  the  infection  was  directly  associated  with  the  presence  of  a  gi-ain 
or  a  beard  of  rye  in  the  tissues,  and  its  frequent  occurrence  in  cattle,  taken 
together  with  the  fact  that  the  great  majority  of  the  eases  originate  in  the 
alimentary  canal,  especially  the  mouth  and  jaws,  or  in  the  respiratory  tract, 
indicates  that  it  is  to  be  found  in  some  of  the  vegetable  foods.     In  some 


60  ACTINOMYCOSIS. 

cases  the  patients  had  been  in  the  habit  of  putting  raw  grain  or  stalks  in 
their  mouths.  In  others,  direct  infection  from  diseased  animals,  and  in  one 
case  infection  from  a  man,  has  been  proved. 

Symptoms. — In  man  the  progress  of  the  disease  is  best  seen  in  cases  of 
cutaneous  inoculation.  Here  a  hard  nodule  forms  in  the  skin  and  subcuta- 
neous tissue,  and  reaches  a  certain  size  without  j)ain  or  any  sign  of  inflam- 
mation except  congestion  of  the  skin.  The  nodule  often  forms  an  abscess, 
which  slowly  perforates  the  skin  and  discharges  from  a  small  opening  a 
rather  thin  white  pus  containing  some  of  the  characteristic  granular  masses, 
which  under  the  microscope  reveal  the  fungus.  These  abscesses  closely 
resemble  tubercular  cold  abscesses,  especially  in  their  tendency  to  bm-row 
in  the  direction  of  least  resistance  or  of  gravity,  and  in  the  formation  of 
long  fistulsB.  Euhrah  states  that  the  main  lesion  is  in  the  head  and  neck  in 
fifty-six  per  cent,  of  the  cases,  in  the  digestive  tract  in  twenty  per  cent. ,  and 
in  the  lungs  in  fifteen  per  cent. 

When  the  point  of  inoculation  i*  in  the  mouth  the  nodule  becomes  in- 
fected and  supijuration  sets  in  much  earlier,  and  with  the  suppuration  the 
growth  of  the  fungus  appears  to  be  accelerated,  so  that  large  tumors  are 
formed  about  the  jaws.  These  tumors  are  painful,  boggy,  and  the  skin 
covering  them  is  dark  red,  or  presents  the  typical  nodules,  abscesses,  and 
fistulse.  The  antrum  may  be  involved.  The  muscles  are  infiltrated,  and  the 
jaws  are  opened  with  diificulty.  If  the  infection  occurs  in  the  floor  of  the 
mouth  or  in  the  submaxillary  gland,  the  local  appearances  are  those  of  a 
tuberculous  submaxillary  adenitis,  or  of  a  brawny  infiltration  like  Ludwig's 
angina  but  with  a  chronic  course.  Infection  of  the  tongue  is  rare  in  man, 
and  the  lesion  closely  resembles  a  malignant  tumor  or  gumma.  The  lym- 
phatic glands  are  seldom  inflamed.  Metastasis  occurs  rarely,  but  has  been 
found  even  in  the  brain.  But  the  thoracic  and  abdominal  organs  are  gener- 
ally infected  directly  by  the  extension  of  a  nodule  which  forms  in  the  wall 
of  the  oesophagus  or  the  intestine  or  in  the  mucous  membrane  of  the  bronchi 
or  lungs  and  may  involve  any  of  the  neighboring  j)arts.  The  fungus  finds 
its  way  into  the  respiratory  passages  by  inhalation,  sometimes  being  carried 
down  by  a  foreign  body,  such  as  a  grain  or  an  infected  carious  tooth.  Pul- 
monary infection  results  in  a  specific  broncho-  or  pleuro-pneumonia,  with 
the  production  of  abscesses  which  may  discharge  externally  or  may  cause 
empyema.  There  is  local  pain  and  cough  with  expectoration  in  which 
the  characteristic  grains  and  the  fungus  can  be  detected.  Haemoptysis  is 
rare.  The  physical  signs  of  consolidation  or  of  an  abscess  cavity  are  found. 
Abdominal  infection  generally  results  in  abscess  of  the  liver  or  in  local 
peritonitis  with  abscess.  The  latter  is  especially  common  in  the  ileocsecal 
region.  The  infection  may  extend  directly  to  the  genito-urinary  organs, 
but  the  kidney  is  more  frequently  attacked  by  embolic  metastasis.  A 
chronic  inflammation  of  the  foot,  known  as  "Madura  foot,"  marked  by 
caries  and  multiple  sinuses,  caused  by  a  fungus  closely  resembling  that  of 
actinomycosis,  has  been  observed  in  India. 

The  general  symptoms  of  the  dise&,se  depend  upon  the  parts  involved, 
the  amount  of  suppuration  and  its  dm-ation.  A  moderate  leucocytosis  is 
the  rule,  and  fever,  resembling  that  of  tuberculosis,  is  generally  present. 


TUBERCULOSIS.  61 

Aiifemia  and  cachexia  may  develoi)  early  if  the  lesion  interferes  with  eating 
or  digestion.     The  clinical  picture  may  be  similar  to  pytemia. 

Diagnosis. — The  diagnosis  of  actinomycosis  is  very  difficult,  the  nodules 
before  breaking  doAvu  resembling  round-cell  sarcoma,  and  in  the  later  stages 
tuberculous  or  syphilitic  tissue,  even  under  the  microscope,  so  that  the 
recognition  of  the  fungus  may  be  absolutely  necessary  for  a  diagnosis.  Clin- 
ically it  may  be  distinguished  from  sarcoma  by  its  tendency  to  supi^uration, 
and  from  tuberculosis  and  syphilis  by  the  freedom  of  the  neighboring  glands 
from  infection.  The  lesions  of  actinomycosis  are  generally  painful  and 
tender  to  pressure.  Iodide  of  j)otassinni  affects  actinomycosis  as  well  as 
syphilis.  The  prognosis  depends  upon  the  site  of  the  infection  and  the  stage 
at  which  treatment  is  begun.  Left  to  itself  the  disease  appears  to  be  invari- 
ably fatal,  although  it  may  be  very  slow  in  its  i^rogress,  and  when  the  inter- 
nal organs  are  involved  thorough  surgical  treatment  is  impossible.  When 
it  is  possible  to  eradicate  it  completely  by  operation,  recovery. may  follow. 

Treatment. — When  the  focus  is  seen  before  it  has  broken  down,  it 
should  be  thoroughly  excised,  like  a  malignant  tumor.  If  an  abscess  has 
formed,  it  should  be  widely  opened,  and  its  walls  excised  if  possible  ;  if  not, 
it  must  be  treated  like  a  tuberculous  abscess,  with  thorough  curetting  and 
cauterization.  Injections  of  a  1  to  20  solution  of  carbolic  acid  may  be  made 
into  any  tissues  which  cannot  be  removed.  The  general  health  must  be 
improved  by  every  possible  means.  Iodide  of  potash  has  been  successfully 
employed  in  large  doses  in  man  and  animals,  and  should  always  be  admin- 
istered in  addition  to  the  surgical  ti'eatment. 

TUBERCULOSIS. 

Tuberculosis  is  an  infectious  disease  caused  by  a  specific  bacillus.  It 
is  marked  locally  by  circumscribed  inflammatory  nodules,  with  cheesy  de- 
generation of  the  centre  of  the  mass  and  the  production  of  peculiar  cells, 
and  has  a  tendency  to  invade  the  lymiihatic  channels,  and  secondarily  the 
blood,  resulting  in  similar  inflammations  of  distant  parts. 

Pathology. — Bacillus  Tuberculosis. — The  cause  of  the  disease  is 
the  bacillus  tuberculosis  (Plate  II..  Fig.  25),  discovered  by  Koch  in  1881,  a 
slender  bacillus,  sometimes  slightly  bent  or  curved,  2  to  6  micromillimetres 
long  and  2  micromillimetres  thick,  without  power  of  motion.  It  has  not 
been  found  elsewhere  than  in  living  animals,  and  appears  to  be  a  typical 
parasite.  It  can  be  cultivated  in  solidified  blood-serum,  or  in  a  mixture  of 
glycerin  and  gelatin,  at  a  temperature  of  98°  F.  (37°  C),  forming  white  or 
gray  opaque  colonies,  looking  like  thick,  round,  wrinkled  crusts  on  the  sur- 
face, not  lic|uefying  the  serum.  It  can  be  inoculated  in  the  animals  usually 
emiiloyed,  but  some  are  very  resistant,  as,  for  instance,  the  goat.  l^To  spores 
have  yet  been  demonstrated.  This  bacillus  can  grow  either  with  or  with- 
oiit  oxygen.  It  is  difficult  to  demonstrate,  but  stains  well  with  the  Ziehl 
carbolic-fuchsin  solution  or  by  Gram's  method.  The  tubercle  bacillus  is 
very  sensitive  to  changes  in  temperature  (even  108°  F.  (42°  C.)  arresting 
its  growth),  and  it  can  be  killed  by  any  of  the  ordinary  germicides,  and 
even  bj'  direct  sunlight. 

Inoculation. — The  usual  seat  of  its  inoculation  in  man  is  the  respiratory 


62  TUBERCULOSIS. 

or  intestinal  mucous  membrane,  althougli  it  may  invade  the  skin  if  there  is 
a  wound  or  an  ulcer,  and  it  may  also  begin  its  attack  in  the  genito-urinary 
organs.  A  period  of  incubation  of  three  weeks  is  said  to  intervene  after 
inoculation  of  the  skin  before  any  lesion  is  seen.  Wherever  its  point  of 
entrance,  its  tendency  is  to  invade  the  lymjahatic  vessels  and  glands  and 
from  them  spread  to  the  rest  of  the  body.  The  bacilli  find  their  way  into 
the  general  circulation,  and  if  large  numbers  enter  the  blood  they  may 
make  a  simultaneous  attack  upon  many  organs  in  the  form  known  as  acute 
miliary  tuberculosis.  If  the  bacilli  in  the  blood  are  not  numerous,  on  the 
other  hand,  they  may  die  out.  Any  organ  may  be  infected,  especially  if 
injury  or  other  cause  produce  a  disturbance  of  the  local  circulation,  and  so 
form  a  iDoint  of  lessened  resistance.  The  parts  liable  to  tuberculosis  which 
are  of  surgical  interest  are  the  superficial  mucous  membranes  (mouth, 
pharynx,  nose,  conjunctiva),  the  skin,  the  bones  and  joints,  the  lymphatic 
glands,  the  peritoneum,  the  kidneys,  bladder,  urethra,  testicles  and  pros- 
tate, and  the  female  genitals. 

External  Infection. — Tuberculous  Ulcer. — The  lesion  will  vary  with 
the  manner  of  its  origin,  whether  it  is  caused  by  inoculation  from  the  surface 
or  from  within  through  the  blood  or  lymphatic  vessels.  In  the  former  case 
an  external  wound  or  abrasion  appears  to  be  necessary.  An  open  wound 
forms  an  ulcer,  but  if  the  inoculation  be  at  the  bottom  of  a  puncture,  it  pro- 
duces a  nodule  which  breaks  down  into  an  abscess,  and  the  ulcer  is  produced 
by  sloughing  of  the  skin.  Inoculation  of  the  skin  may  take  place  in  wounds 
made  by  broken  vessels  used  by  phthisical  patients  for  expectoration,  by 
dressing  wounds  with  handkerchiefs  containing  their  sputa,  or  by  direct 
infection  of  wounds  from  the  mouth.  Whether  in  skin  or  in  mucous  mem- 
brane, the  ulcer  is  easily  distinguished.  The  base  is  covered  with  a  white, 
thin  slough  or  with  pale,  small  or  exuberant,  and  flaccid  granulations.  The 
edges  are  irregular  as  if  worm-eaten,  undermined,  bluish  pink  in  color,  and 
usually  surrounded  by  a  faint  inflammatory  areola.  The  discharge  is  serous, 
with  a  few  pus-cells.  In  the  mucous  membranes  the  color  of  the  base  is  apt 
to  be  rather  yellow  than  white.  There  is  never  any  trace  of  induration, 
although  there  may  be  a  soft  thickening  about  the  ulcer.  The  microscoxjic 
examination  of  such  a  lesion  discloses  a  general  round-cell  infiltration  with 
a  few  typical  tubercles  or  giant-cells,  ulceration  progressing  too  rapidly  to 
allow  of  these  characteristic  formations. 

Lymphatic  Infection. — The  Tubercle. — Very  different  is  the  lesion 
when  the  bacillus  has  penetrated  the  lymphatics  and  reached  the  nearest 
lymph-nodes.  The  infected  node  becomes  swollen  and  hyperaemic.  The 
cells  multiply  and  produce  rounded  cells,  from  two  to  six  times  the  size 
of  the  leucocytes,  with  indistinct  outlines,  a  pale,  granular  protoplasm, 
and  a  rather  small,  ovoid,  vesicular  nucleus,  causing  them  to  resemble 
epithelial  cells,  and  hence  they  are  named  epithelioid.  The  epithelioid 
cells  are  found  under  other  circumstances,  but  are  so  common  in  tubercle 
as  to  be  fairly  characteristic.  In  some  cases  of  true  tubercle,  however, 
they  are  absent.  Within  the  circle  of  epithelioid  cells  is  often  found  one 
or  several  giant-cells.  Outside  of  them  are  seen  very  numerous  small  round 
cells,  like  the  lymphocytes   commonly  found   in  lymphatic  glands,  form- 


TUBERCULOSIS.  63 

ing  the  outer  boundary  of  the  tuhercle,  as  the  entire  mass  is  called,  and 
infiltrating  the  neighboring  tissues.  (Fig.  26.)  These  cells  are  supposed 
to  come  from  emigration  of  white  blood-corpuscles,  as  in  any  ordinary  in- 
flammation. In  some  instances,  however,  no  epithelioid  cells  or  giant-cells 
are  formed,  and  the  tubercle  is  simply  made  up  of  the  round  cells,  and  is 
known  as  a  '■'■small  round-cell  tubercle.''''  The  epithelioid  cells  multiply,  two 
or  more  nuclei  being  frequently  seen  in  them,  and  it  is  supposed  that 
from  them  by  division  of  nuclei  without  division  of  cell-body  are  formed  the 

Fig  26 


f'c{  S-l 


,  1 


■^  / 


UyC. 


/i-V.^ 


Section  of  synovial  fold  from  a  tuberculous  kuee-jomt .  a,  free  surface  with  a,  laj  er  of  iibim  and  leucocytes ; 
6,  small  tubercle  with  leucocytes  and  epithelioid  cells ;  e,  large  tubercle ;  d,  giant-cells.  (F.  C.  Wood,  M.D.) 

giant-cells.  It  is  also  possible  that  the  giant-cells  may  be  formed  by  fusion 
of  several  cells  in  one,  or  even  by  the  multiiilication  and  fusion  of  the  endo- 
thelial cells  of  a  small  blood-  or  lymph-vessel,  the  characteristic  appearance 
being  produced  by  the  cross-section  of  such  an  occluded  vessel.  The  giant- 
cells  are  irregular  in  shape,  generally  more  or  less  elliptical  in  section,  with 
star-like  projections,  the  centre  formed  of  granular  protoplasm,  which  ap- 
pears to  be  already  degenerated,  surrounded  by  numerous  nuclei  near  the 
border  arranged  somewhat  radially.  Between  the  cells  is  a  more  or  less 
evident  reticulum,  supposed  to  be  the  remains  of  the  fibres  of  connective 
tissue,  which  holds  the  cells  firmly  in  ijlace  and  binds  the  entire  structure 
to  the  surrounding  tissues.  The  gross  appearance  of  such  a  tubercle  is 
that  of  a  gray,  pearly,  somewhat  translucent  nodule,  becoming  opaque  and 
white  as  it  grows  older,  without  blood-vessels,  firmly  attached  to  the  sur- 
rounding tissues,  and  quite  firm  or  even  hard  to  the  touch.  A  tubercle 
grows  by  addition  to  its  periphery  up  to  a  certain  size,  and  then  certain 
degenerations  occur,  undoubtedly  due  to  the  poison  of  the  bacilli,  for  such 
small  masses  would  not  undergo  these  changes  simply  from  a-  diminished 
blood-supply.  The  nodules  seen  by  the  unassisted  eye  are  made  up  of 
several  tubercles  fused  into  one,  the  degeneration  having  progressed  far- 
thest in  those  at  the  centre,  but  the  boundaries  between  them  can  gener- 
ally be  traced.     There  is  apt  to  be  some  production  of  fibrous  tissue  around 


64 


TUBERCULOSIS. 


tlie  tubercle,  which  may  finally  entirely  encaj)snlate  the  mass.  To  this 
new- formed  fibrous  tissue  are  to  be  ascribed  the  spindle-cells  often  seen  scat- 
tered through  the  tubercles.  The  bacilli  in  the  tubercles  of  man  usually 
lie  in  the  epithelioid  cells  or  giant-cells,  or  between  them,  but  they  are 
often  very  difficult  to  demonstrate,  as  they  do  not  stain  readily.  The  cells 
at  the  centre  of  the  tubercle  may  gradually  lose  their  moisture  and  form  a 
hard,  cheesy  mass,  or  even  calcify  by  deposit  of  lime  salts  in  the  caseous 
material.  In  other  cases,  a  thin,  milky  material  like  jjus  is  produced  at  the 
centre  of  the  tubercle,  and  by  constant  enlargement  and  the  conglomeration 
of  neighboring  tubercles  the  typical  cold  abscess  results.  If  such  an  abscess 
forms  in  a  lymj)h-node,  the  fibrous  capsule  of  the  latter  is  the  only  tissue 
able  to  resist  its  progress,  and  the  gland  becomes  converted  into  a  sac  of  this 
broken-down  material. 

Tuberculous  Infarction. — Somewhat  similar  is  the  process  when  the 
bacilli  reach  any  part  of  the  body  through  the  blood-vessels,  for  they  occlude 

a  small  cai)illary  as  if  by 

Fig.  27.  an  embolus,  and  thence 

_  ,-  -  .  ,^  "  7/  ,     ,  ,  :'■'.-.  ,  spread  into  the  tissues 

-  ;  -       .,     .  .  ■'  -j'  ,  '.   ,      ■     :j  suijplied  by  it,  forming 

'■..;.',,;'_;■,     '      •.  "■  ^ '      -J     .!  tubercles,  beginning  in 

'.'_'•.,.'•;■        .    .  '   :        "    .  ,         !__(,    the  walls  of  the  blood- 

■       .•.-,-'■'.:.■■.■;'>:     ^-  '.  '■■-■"         vessels,  the  entire  mass 

being  wedge  -  shaped, 
like  an  infarct.  The 
structure  of  each  tuber- 
cle is  similar  to  that 
iust  described.  This  is 
the  usual  process  in  the 
hones,  in  which  the  tu- 
berculous infiltration 
destroys  the  softer  i^arts, 
and  the  rest  of  the  bone 
remains  for  a  long  time 
as  a  soft  sequestrum, 
all  di- 
by    tubercu- 


:#,S 


/ 


Tubercular  osteomyelitis  of  head  of  tibia :  a,  tuberculous  abscess 
partly  filled  with  thick  pus  and  detritus ;  h,  fibrous  capsule  formed     penetrated 
around  abscess;  c,  trabeculae  of  bone;  d,  giant^cells  in  the  bone  mar-     i.ppfinnQ 
row ;  e,  fat-cells  in  the  marrow ;  /,  osteoclast  causing  absorption  of  bone. 
X  100  diameters.     (F.  C.  Wood,  M.D.)  loUS  graUulation-tiSSUe. 

(Fig.  27.)  Wherever 
the  tubercles  are  free  to  grow  they  produce  a  soft,  spongy  tissue  I'esembling 
granulation-tissue,  and  sometimes  known  as  tuberculous  granuloma,  and 
the  budding  processes  of  this  tissue  spread  into  the  surrounding  parts. 

When  serous  or  synovial  membranes  {peritoneum,  tunica  vaginalis,  pleura, 
the  joints)  are  involved,  tubercles  are  formed  in  the  same  manner,  but  the 
granulations  ai'e  of  a  very  faint  pink  color,  or  white  and  gelatinous-looking, 
owing  to  the  diminished  supply  of  blood  caused  by  the  dense  infiltration  of 
the  tissues  by  the  round  cells.  Tyx^ical  tubercles  are  found,  and  the  mem- 
branes appear  greatly  thickened,  owing  to  the  constant  deposition  of  new 
layers  of  fibrin  on  their  surfaces,  each  layer  in  its  turn  becoming  infiltrated 


TUBERCULOSIS.  65 

with  tubercles,  so  that  there  is  a  constant  formation  of  new  tissue  under 
the  stimulus  of  the  infection.  The  cartilages  of  the  joints  are  detached, 
and  look  worm-eaten,  from  the  encroachment  of  the  tuberculous  granula- 
tion-tissue, and  when  they  are  penetrated  the  growth  extends  into  the  bone. 
In  other  cases  the  disease  begins  in  the  bone  and  affects  the  joints  second- 
arily. In  the  peritoneal  and  pleural  cavities,  abscesses  may  be  formed, 
limited  by  adhesions.  Or  thick  layers  of  fibrin  may  be  deposited,  pro- 
ducing adhesions  and  obliterating  the  cavity.  Or,  finally,  large  quantities 
of  serum  may  be  exuded  by  the  inflamed  membrane,  and  but  little  fibrin. 
Similar  varieties  in  the  process  are  to  be  observed  in  the  synovial  mem- 
branes of  the  joints. 

Suppuration. — Whether  or  not  the  tubercle  bacillus  is  capable  of  ex- 
citing the  formation  of  pus  is  not  settled  as  yet,  but  the  weight  of  authority 
is  in  favor  of  this  theory.  Prudden,  however,  found  that  in  order  to  obtain 
true  phthisical  cavities  in  rabbits  afflicted  with  pulmonary  tuberculosis  it 
was  necessary  to  inject  the  streptococcus  into  the  trachea, — otherwise  no 
breaking  down  took  place. 

Tuberculous  abscesses  are  called  cold  abscesses,  because  they  are 
without  any  of  the  ordinary  signs  of  inflammation,  unless  pyogenic  infection 
has  occurred,  and  their  contents  are  iisually  sterile  or  merely  a  j)ure  culture 
of  the  tubercle  bacillus.  The  pus  or  puruloid  fluid  contained  in  these  ab- 
scesses is  thin,  white,  and  full  of  flakes  of  cheesy  matter.  Microscopically 
it  contains  fat-globules,  broken-down  cells,  cheesy  masses,  and  a  few  leuco- 
cytes. Some  suppose  that  a  double  infection  is  necessary  to  start  suppu- 
ration, but  that  when  pus  is  once  produced  its  formation  might  continue 
even  though  the  pyogenic  germs  died,  through  the  influence  of  their  toxines. 
Tuberculous  lesions  readily  become  infected  and  suppurate,  but,  even  when 
fully  exposed  to  the  air,  they  do  not  appeal'  to  be  subject  to  very  virulent 
infections, — erysipelas,  for  instance,  being  rather  rare  even  in  the  most 
neglected.  If  a  tuberculous  abscess,  however,  becomes  infected  and  is  not 
allowed  free  di-ainage,  a  sharp  rise  of  temperature  ensues.  Cold  abscesses 
are  lined  with  granulation  tissue,  the  so-called  pyogenic  membrane,  which  is 
merely  a  layer  of  tuberculous  tissue.  They  tend  to  spread  in  the  direction 
of  least  resistance,  usually  settling  through  the  cellular  spaces  in  accordance 
with  gravity,  softening  the  connective  tissue,  eroding  bones,  but  generally 
sparing  nerves  and  large  blood-vessels,  which  may  often  be  found  strung 
across  their  cavities,  the  surrounding  tissues  having  been  dissected  away. 
The  skin  over  these  abscesses  is  very  slowly  involved,  sometimes  remaining 
unaltered  for  years.  When  it  is  attacked  it  turns  purple,  sloughs  at  some 
point,  and,  when  the  contents  are  discharged,  a  typical  tuberculous  sinus  is 
formed.  Sometimes  these  abscesses  disappear  by  inspissation  and  absorption 
of  their  contents,  even  when  very  large. 

Symptoms. — The  symptoms  of  tuberculosis  are  considered  in  connec- 
tion with  the  various  organs  aifected. 

Treatment. — The  treatment  of  tuberculous  lesions  is  constitutional, 
germicidal,  or  mechanical.  The  tissues  resist  tuberculous  infection  in  vary- 
ing degrees,  and  in  some  parts  of  the  body,  and  in  some  individuals,  this 
resistance  is  very  great.     It  is  accomplished  by  the  formation  of  cicatricial 

5 


66  TREATMENT  OF  TUBEECULOSIS. 

tissue  around  tlie  tubercles,  shutting  off  their  blood-supply  by  compression 
aud  opposing  their  advance  by  its  fibrous  nature.  This  resistance  can  be 
greatly  increased  by  measures  directed  to  imi^roving  the  general  condition 
of  the  individual,  such  as  rest,  exercise,  fresh  air,  abundant  and  good  food, 
and  general  hygiene,  including  residence  in  a  suitable  climate.  Many  per- 
sons will  recover  without  any  other  treatment.  Cod-liver  oil,  various  tonics, 
and  sometimes  an  allowance  of  alcoholic  stimulants,  assist. 

Sclerogenic  Method. — Locally  the  formation  of  fibrous  tissue  may  be 
favored  by  injecting  a  ten  per  cent,  solution  of  chloride  of  zinc  into  the  tis- 
sue (Lannelongue),  a  method  which  appears  to  have  given  very  good  results 
in  the  hands  of  French  surgeons.  The  theory  upon  which  this  method  is 
advocated  is  that  the  tubercle  is  arrested  in  its  growth  by  the  production  of 
cicatricial  tissue  around  it.  The  punctate  use  of  the  thermo-cautery  has 
also  been  successful,  acting  in  a  similar  way. 

Operative. — The  foci  may  be  extirpated  mechanically,  either  by  simple 
incision  and  curetting  or  cauterization,  or  by  complete  excision.  Joints 
are  resected,  tuberculous  foci  in  bone  chiselled  out,  and  tuberculous  organs, 
such  as  the  kidney  or  the  testicle,  removed.  The  amputation  of  a  limb  may 
be  necessary. 

Tuberculin. — When  Koch  introduced  tuberculin  it  was  hoped  that  we 
had  obtained  a  selective  agent  which  could  be  injected  anywhere  in  the 
body  and  would  reach  the  tuberculous  foci  by  circulating  in  the  blood,  and 
destroy  the  germs  by  its  indirect  action  upon  the  tissues  in  which  they  lay. 
But  it  was  soon  found  that  a  favorable  effect  could  be  obtained  only  in  a  few 
cases,  and  its  use  has  been  almost  entirely  abandoned. 

Bactericidal  Applications. — Finally,  and  this  method  appears  to 
promise  most  in  the  future,  we  may  attempt  to  destroy  the  bacillus  in  the 
fociis  itself.  Various  substances  have  been  employed  for  this,  but  the  most 
generally  used  are  iodoform  and  balsam  of  Peru.  The  balsam  of  Peru  is 
used  in  full  strength. 

Iodoform  Injections. — The  iodoform  is  emjiloyed  in  a  ten  per  cent, 
emulsion  with  glycerin  or  olive  oil,  or  in  solution  in  ether.  The  fluid  is 
injected  into  the  focus  or  cavity  to  be  treated  in  as  large  amounts  as  possible, 
but  generally  only  a  small  quantity  can  be  forced  into  the  solid  masses.  Only 
in  the  case  of  cold  abscesses  is  an  overdose  to  be  feared,  and  it  is  safe  to  use 
fifteen  grains  of  iodoform  at  a  time.  The  iodoform-ether  has  the  disad- 
vantage of  causing  great  pressure  from  the  formation  of  vapor  at  the  body 
temperature,  and  the  emulsions  are  ciuite  as  effective.  We  have  also  used 
iodoform-vaseline  (ten  per  cent.)  liquefied  by  heat  for  injection.  The  injec- 
tion should  be  carried  out  with  full  asepsis,  the  needle  or  canula  and  syringe 
boiled,  the  skin  disinfected,  and  the  solution  stei'ilized  by  the  fractional 
method  ;  or  the  iodoform  can  be  washed  in  1  to  1000  bichloride  of  mercury 
solution,  and  the  glycerin  sterilized  separately  by  heat,  for  long-continued 
heating  or  a  high  temperature  decomposes  the  iodoform. 

Bier's  Constriction. — The  effect  of  these  various  methods  in  a  limb 
can  be  increased  by  constriction  with  a  rubber  band,  as  suggested  by  Bier, 
so  as  to  induce  a  venous  hyperaemia,  which  acts  either  by  the  direct  effect 
of  the  venous  blood,  or  by  retarding  the  circulation  and  causing  an  accumu- 


LEPROSY.  67 

lation  of  the  toxiiies  of  tlie  tubercle  bacillus  iu  the  parts,  and  the  consequent 
poisoning  of  the  germs  themselves. 

Scrofula. — This  is  an  old  term  applied  to  a  certain  constitutional  state 
in  which  there  is  an  unusual  tendency  to  tuberculous  infection,  and  a  close 
resemblance  to  hereditary  syi^hilis  in  its  mild  forms. 


Lepra,  Elephantiasis  Graecorum,  Leontiasis. — Leprosy  is  an  in- 
fectious disease,  probably  caused  by  the  bacillus  leprae,  characterized  by 
cutaneous  eruptions  and  by  inflammatory  infiltrations  in  the  skin,  mucous 
membranes,  peripheral  nerves,  lymph-nodes,  and  certain  viscera. 

The  bacillus  leprw  is  a  slender  rod,  5  micromillimetres  long  and  0.4  micro- 
millimetre  thick,  closely  resembling  the  bacillus  tuberculosis,  even  in  stain- 
ing, but  more  easily  decolorized.  It  is  found  in  the  local  lesions  and  in  the 
blood  during  the  last  stages  of  the  disease,  but  not  in  the  natural  secretions 
or  urine,  although  it  occurs  in  the  mucopurulent  discharge  of  the  ulcerated 
mucous  membranes.  It  has  been  observed  only  in  man,  and  all  attempts 
at  isolation  and  cultivation  have  failed,  as,  indeed,  have  attempts  at 
direct  inoculation  with  material  from  ulcers,  except  in  one  doubtful  case. 
The  disease,  however,  is  undoubtedly  contagious  by  close  and  long  contact, 
such  as  using  the  same  clothes  and  table-utensils.  Some  persons  are  evi- 
dently immune,  and  resist  infection  even  under  the  most  intimate  association 
with  lej)ers.  It  is  doubtful  whether  it  can  be  acquired  by  sexual  intercourse. 
Like  tuberculosis,  the  disease  is  not  directly  hereditary,  but  a  predisposition 
to  it  may  be  inherited.     Lei^rosy  is  found  in  all  climates. 

Symptoms. — It  appears  in  two  forms,  the  tirbercular,  affecting  chiefly 
the  skin,  and  the  antesthetic,  affecting  the  peripheral  nerves,  but  tiie  two 
forms  may  be  combined.  There  is  no  definite  primary  point  of  infection 
to  be  found  in  most  cases,  although  it  must  always  exist.  There  is  an  iyicu- 
hation  period  of  from  six  weeks  to  nine  months,  with  various  prodromal 
symptoms,  such  as  intermittent  fever,  epistaxis,  pruritis,  and  vague  nervous 
sensations.  In  the  tubercular  variety  the  first  eruptions  are  dark-colored 
papules,  which  may  come  and  go,  but  finally  persist  as  soft  tubercles  from 
the  size  of  a  pea  to  that  of  a  walnut.  These  appear  on  all  parts  of  the  bodj^, 
being  most  marked  upon  the  face  and  the  anterior  surface  of  the  forearms. 
On  the  face  the  great  thickening  of  the  skin  produces  the  characteristic 
leonine  expression.  These  tubercles  may  ulcerate,  producing  very  deep  and 
extensive  ulcers.  The  lymph-nodes  enlarge  and  suppurate,  and  the  hair  falls 
out  in  the  affected  areas  of  the  skin.  The  mucous  membranes  appear  to  be 
attacked  before  the  skin,  as  indicated  by  epistaxis,  rhinitis,  and  salivation, 
and  ulceration  may  make  great  ravages  in  the  nasal  and  oral  cavities.  The 
genito-urinary  membranes  usually  escape. 

In  the  anaesthetic  variety  bullous  and  erythematous  eruptions  appear 
on  the  skin,  followed  by  dark-colored  rounded  macules,  which  tend  to  fade  in 
the  centre  and  spread  at  the  edges.  These  spots  are  hypertesthetic  at  first, 
becoming  anaesthetic  as  they  grow  pale.  The  antesthesia  is  selective,  the 
tactile  sense  being  preserved  while  the  sense  of  pain  is  lost,  and  often  there 
will  be  a  loss  of  perception  of  heat  while  that  of  cold  is  preserved,  or  vice 


68  TETANUS. 

versa.  The  eruptions  are  located  on  the  lower  extremities,  on  the  backs  of 
the  arms,  and  also  on  the  trunk  and  face.  The  mucous  membranes  are  simi- 
larly affected,  and  the  antesthesia  of  the  pharynx  interferes  with  swallowing. 
The  changes  in  the  nerves  are  similar  to  those  of  a  neuritis,  the  ulnar  and 
peroneal  nerves  being  especially  affected.  There  are  neuralgic  pains,  grow- 
ing worse  at  night,  and  the  nerves  are  thickened  and  tender.  Paralysis  and 
muscular  atrophy  and  contractures  may  result,  especiallj'  in  the  interossei, 
the  muscles  of  the  arm,  the  deltoid  and  iDCctoralis,  and  the  muscles  of  the 
leg  and  face.  Plantar  ulcers  may  form,  and  other  trophic  changes  are 
seen  in  the  rarefaction  of  the  j)halauges,  the  fingers  and  toes  losing  entire 
phalanges  in  this  way  by  absorption,  without  any  ulcerative  process.  The 
disease  is  incurable,  although  there  are  cases  which  recover  spontaneously 
even  after  considerable  deformity  has  been  x^roduced. 

Treatment. — The  treatment  consists  in  isolation,  hygiene,  and  local 
treatment  of  the  lesions.  Chaulmoogra  oil  internally  and  local  applications 
of  gui'jun  oil  seem  to  influence  the  disease  favorably.  Tonics  are  required, 
and  above  all  a  favorable  climate.  Nerve-stretching  is  useful  for  the  paiu  of 
the  nervous  form,  and  is  reported  to  have  been  followed  by  disappearance 
of  the  local  lesions. 

TETANUS. 

Lockjaw  (Ger.  Wundstarrkramj)f ;  Fr.  Tetanos). — Tetanus  is  an  infec- 
tious disease  caused  by  a  special  bacillus  and  its  toxines,   affecting  the 
nervous  system,  and  characterized  by  persistent  contraction  of  the  voluntary 
muscles,  with  paroxysms  of  aggravated  spasm,  and,  occasionally,  local  i^a- 
„  ralysis.     The  bacillus  tetani  (Fig.  28),  disco'S'ered 

in  1885,  by  Mcolaier,  is  a  slender  rod,  growing  in 
y,  /    \  chains,  often  enlarged  at  one  end  by  the  forma- 

■^     J  O  /  .     \        tion  of  a  spore,  giving  it  a  characteristic  drum- 
^  ,  /        \  ^  stick  appearance,  motile,  found  in  garden-earth, 

„      vV'^  I  /       street-dust,  the  excrement  of  healthy  animals,  and 

\  9    /  ^/ ^  elsewhere.     It  grows  at  ordinary  temperatures, 

\      /      S    ^     /  I  rapidly  at  98°  to  102°  F.  (37°  to  39°  C),  being 

*^  Ns.   ^  anaerobic,  forming  a  fir-tree-shaped  stab-cultui-e 

Bacillus  of  tetanus.   (F.  c.         ju  gelatin,   and  liquefying  the  medium  in  one 
°°  '    ■  week.     It  takes  all  the  stains.     The  spores  resist 

a  temperature  of  176°  F.  (80°  C.)  for  one  hour,  but  are  killed  by  five  minutes' 
exposure  to  212°  F.  (100°  C.)  moist  heat.  A  mixture  of  equal  parts  of  a 
1  to  20  solution  of  carbolic  acid  and  a  1  to  1000  solution  of  bichloride  of 
mercury,  to  which  has  been  added  one-half  of  one  per  cent,  of  hydrochloric 
acid,  is  said  to  kill  the  spores  in  ten  minutes.  The  bacillus  iDroduces  several 
toxines,  all  of  which  excite  spasms,  and  one  causes  paralytic  symptoms  also. 
The  disease  is  found  in  nearly  three-quarters  of  the  cases  to  have  origi- 
nated from  wounds  of  the  hands,  feet,  and  lower  extremities,  and  in  one- 
tenth  of  the  cases  from  those  of  the  head  and  neck,  but  it  is  probable  that 
the  liability  of  wounds  of  these  parts  is  due  to  their  greater  exjDosure  to 
injury  and  infection.  The  opinion  once  held  that  the  prognosis  is  worse 
when  the  wound  is  on  the  head  has  been  shown  to  be  erroneous.  Age  and 
sex  make  no  difference  in  the  liability,  but  it  is  said  that  the  negro  is  more 


TETANUS.  69 

likely  to  contract  the  disease,  and  that  it  is  more  common  in  hot  climates, 
facts  which  may  also  be  dependent  uTpoa  other  causes,  such  as  unsanitary 
habits  of  life.  The  symptoms  following  thyroidectomy,  which  closely  re- 
semble tetanus,  have  nothing  to  do  with  that  disease,  depending  upon  some 
toxic  materials  circulating  in  the  blood.  Tetanus  is  frequently  seen  in  the 
new-born,  as  the  result  of  infection  of  the  umbilical  wound,  and  is  occasion- 
ally met  with  in  the  puerperal  woman,  in  which  case  it  must  not  be  mistaken 
for  eclampsia.  It  is  imj)ossible  for  tetanus  to  develop  without  inoculation 
through  a  wound,  although  the  latter  may  be  concealed  in  the  mouth  or 
elsewhere,  the  cases  reported  to  have  followed  eating  the  flesh  of  animals 
which  had  died  of  the  disease  not  being  beyond  criticism.  It  has  been  pro- 
duced exioerimentally  by  compelling  auimals  to  breathe  air  impregnated 
with  the  dust  of  dried  tetanus  cultures,  the  inoculatiou  taking  place  through 
minute  lesions  of  the  respiratory  mucous  membranes.  The  bacillus  of  tetanus 
does  not  prevent  primary  union,  and  the  wound  may  be  healed  soundly  be- 
fore the  disease  breaks  out.  The  pathological  changes  produced  by  the  dis- 
ease are  not  fully  known,  the  appearances  formerly  supposed  to  indicate  an 
ascending  neuritis  and  myelitis  not  being  conclusive,  for  the  principal  change 
observed  is  capillary  congestion,  which  may  be  only  a  passive  result  of  the 
circulatory  disturbances.  Certain  definite  minute  changes  have  lately  been 
found  in  the  nuclei  of  the  ganglion  cells  of  the  cerebro-spinal  axis.  The 
tetanus  bacilli  are  rarely  found  in  the  tissues,  for  Kitasato  has  shown  that 
they  disappear  from  the  point  of  inoculation  within  ten  hours,  and  they 
have  very  seldom  been  discovered  in  the  blood  or  other  parts.  They  appear 
to  need  the  assistance  furnished  by  the  presence  of  sloughs,  foreign  bodies, 
or  the  bacteria  of  supiiuratiou  in  order  to  live,  tetanus  being  most  frequently 
seen  in  connection  with  wounds  in  which  these  conditions  are  present,  such 
as  gunshot  wounds  and  frost-bite. 

The  sterilized  toxines  produce  the  same  effects  as  the  living  bacillus, 
even  including  the  occurrence  of  a  period  of  quiescence  or  incubation  after 
their  introduction,  and  the  typical  regular  spread  of  the  disease,  which  always 
begins  at  the  point  of  introduction,  unless  the  poison  be  thrown  directly 
into  the  circulation  or  into  the  peritoneal  cavity,  when  general  symptoms 
are  produced  at  once.  The  period  of  incubation  is  not  due  to  retarded 
absorption,  for  if  a  minute  quantity  of  the  toxines  be  injected  into  the  end  of 
a  rat's  tail,  amiautation  done  much  higher  up  at  the  end  of  forty-five  minutes 
fails  to  save  the  animal.  The  delay  is  explained  by  the  hypothesis  that  the 
toxines  are  unable  to  excite  symptoms  until  some  chemical  reaction  has 
taken  place  between  them  and  certain  substances  in  the  body.  The  time  of 
incubation  is  shortest  when  the  toxine  is  injected  into  the  cerebrospinal  axis. 
The  intense  virulence  of  the  toxine  is  indicated  by  the  fact  that  an  experi- 
menter accidentally  pricked  himself  in  the  hand  with  a  hypodermic  needle 
which  was  simpiy  moistened  with  it,  and  in  three  days  developed  the  ordi- 
nary symptoms. 

The  seat  of  the  disease  is  not  in  the  muscular  fibres  themselves,  for  the 
spasms  aie  arrested  by  paralyzing  the  terminal  plates  of  the  motor  nerves 
with  curare,  which  leaves  all  the  rest  of  the  neuromuscular  apparatus  intact, 
simply  breaking  tlie  connection  at  that  point.     It  is  not  in  the  terminal 


70  TETANUS. 

plates,  for  division  of  the  motor  roots  of  the  nerves  arrests  the  spasm.  Ifor 
is  it  in  the  motor  nerve,  for  destruction  of  the  corres23onding  section  of  the 
cord  arrests  the  spasm.  On  the  other  hand,  it  is  not  in  the  brain,  or  in  the 
other  parts  of  the  siiiual  cord,  for  destruction  of  the  former  and  division  of 
the  latter  above  and  below  the  affected  segment  do  not  arrest  the  spasm. 
The  division  of  the  sensory  root  of  the  affected  segment  of  the  cord,  the 
cord  itself  being  left  intact,  diminishes  but  does  not  arrest  the  spasm.  But 
if  the  cord  is  divided  just  above  the  affected  segment,  and  the  sensory  root 
is  also  divided  so  that  the  segment  is  entirely  deprived  of  sensory  stimula- 
tion, the  spasm  disappears.  It  is  evident  that  the  seat  of  the  disease  must 
be  in  the  affected  segment  of  the  cord,  and  that  the  spasms  are  due  to  sen- 
sory reflexes  acting  upon  the  ganglion  cells  of  that  part. 

Two  varieties  of  tetanus  can  be  distinguished,  although  both  are  pro- 
duced by  the  same  bacillus  and  its  toxines.  When  the  germ  or  its  toxines 
are  inoculated  in  the  lower  animals,  the  contractions  first  appear  in  the  mus- 
cles nearest  the  i^oint  of  infection,  and  gradually  spread  to  those  next  above 
them,  as  if  the  poison  reached  the  spinal  cord  directly  by  the  nerves  and  then 
ascetided  towards  the  head.  In  man,  no  matter  where  the  inoculation  takes 
place,  contraction  of  the  masseter  and  of  the  posterior  cervical  muscles  are 
almost  invariably  the  first  symptoms,  and  the  rigidity  travels  down  the  body 
from  the  head.  If  the  infection  has  occurred  through  a  wound  on  the  hand, 
the  upper  extremities  may  remain  free  from  contractions  throughout  the 
disease.  In  a  small  proportion  of  cases,  j)erhaps  one-tenth,  sojne  rigidity  and 
local  spasm  have  been  observed  in  the  muscles  near  the  site  of  the  primary 
infection,  but  even  these  exceptional  cases  do  not  present  the  regular  ascend- 
ing type  of  the  experimental  form.  A  recent  experimenter  (Zupnik)  has 
succeeded  for  the  first  time  in  producing  in  animals,  at  will,  with  the  same 
culture  material,  the  descending  form  of  the  disease  as  it  is  observed  in 
man,  and  the  exx^erimental  ascending  variety,  jproving  the  absolute  identity 
of  the  two.  He  thinks  that  the  difference  between  the  two  forms  is  owing 
to  the  varying  conditions  of  the  experimental  and  accidental  inoculations  of 
the  poison.  The  best  theory  offered  to  explain  the  form  with  local  muscular 
spasm  is  that  of  Brunner,  who  assumes  that  the  toxines  create  a  state  of  irri- 
tation in  the  nerve-centres,  but  that  the  explosion  of  nerve-force  is  not 
produced  unless  the  corresponding  peripheral  nerve-terminations  are  also 
subjected  to  the  local  effect  of  the  poison  as  it  spreads  through  the  tissues 
by  direct  diffusion  or  lymphatic  conveyance  from  the  point  of  inoculation. 

The  presence  of  the  toxines  in  the  blood  causes  the  ijrodnction  in  the 
serum  of  an  antitoxine  which  has  the  power  of  conferring  immunity  from. 
tetanus  when  injected  into  another  animal,  and  even  of  assisting  in  the 
resistance  to  the  disease  when  already  developed. 

Symptoms. — The  disease  begins  from  one  to  twenty  days,  usually  about 
one  week,  after  infection.  In  some  cases  the  regular  symptoms  are  pre- 
ceded by  more  or  less  pain  in  the  part  where  the  infection  has  taken  place, 
extending  up  to  and  involving  the  nearest  part  of  the  spine.  More  rarely 
there  is  rigidity,  spasm,  or  paralysis  of  the  muscles  near  the  seat  of  infec- 
tion. We  may  distinguish  several  stages  in  the  disease  (Eose) :  (1)  The 
masseters  and  the  muscles  of  the  back  of  the  neck  are  first  contracted.    The 


TETANUS.  71 

patient  complains  of  stiffness  and  soreness  in  these  parts,  and  cannot  sepa- 
rate the  jaws  widely  or  bend  the  head  forward.  (2)  The  muscles  of  the  face 
are  so  contracted  as  to  i^roduce  a  sort  of  grin,  in  strange  contrast  with  the 
weary  eyes  and  half-shut,  drooping  lids.  The  contraction  of  the  muscles 
proceeds  downward  in  regular  course,  attacking  the  back  and  lower  ex- 
tremities. The  arms  may  be  held  close  to  the  sides  by  the  muscles  of  the 
shoulders,  but  the  hands  and  forearms  are  very  seldom  affected.  In  a  child 
with  tetanus  following  gunshot  wounds  of  the  hands,  however,  we  have 
observed  severe  contractions  and  spasms  in  the  muscles  of  those  parts.  If 
the  muscles  of  the  back  are  severely  contracted,  the  body  is  bent  back- 
ward into  an  arch,  a  condition  known  as  opisthotonos.  There  is  hyi)er- 
exteusion  at  the  hix^-,  knee-,  and  ankle-joints  when  the  lower  extremities  are 
affected.  The  abdominal  muscles  are  rigidly  contracted.  (3)  After  a  vari- 
able period  of  time  clonic  spasms  occur  in  the  contracted  muscles,  but  at 
first  there  is  no  undue  sensory  irritability,  and  the  spasms  are  central  in 
origin.  (4)  Later  the  spasms  are  caused  by  the  least  sensory  reflex,  such  as 
the  slamming  of  a  door,  the  touch  of  a  finger,  even  a  draught  of  air,  or 
attempts  to  swallow.  In  the  intervals  the  patient  lies  as  still  as  possible,  to 
avoid  exciting  another  spasm.  Priapism  is  sometimes  present.  The  tem- 
j)erature  rises  in  some  cases  to  an  extreme  degree,  even  110°  F.  (43.3°  C.) 
having  been  observed,  while  105°  F.  (40.5°  C.)  or  more  is  common,  and  after 
death  it  sometimes  rises  a  degree  or  more  higher,  113°  F.  (45.5°  C.)  being 
recorded.  In  mild  cases  there  is  little  or  no  fever,  and  even  in  the  severest 
it  may  be  absent.  The  elevation  of  temperature  is  to  be  ascribed  partly  to 
the  violent  muscular  action,  and  partly  to  the  direct  effect  of  the  toxines 
upon  the  heat-centres.  Sweating  is  observed  in  the  iiaroxysms.  The  pulse 
in  mild  cases  follows  the  temperature  and  grows  rapid  and  feeble  as  the 
strength  fails  ;  but  in  the  severe  cases  it  is  very  weak  and  rapid  from  the  very 
beginning,  owing  to  the  enfeebling -action  of  the  toxines  ui^on  the  circulation. 
The  mind  is  clear,  although  apprehensive,  and  sleeplessness  is  the  rule. 
The  muscular  action  is  very  intense  and  painful ;  in  fact,  ruptures  of  the 
muscles  or  of  the  tendons  are  not  uncommon.  Great  emaciation  sets  in,  from 
exhaustion  and  the  difficulty  of  feeding  the  patient  through  the  locked  jaws. 
In  some  cases  there  is  a  reflex  spasm  of  the  cesoishagus  and  of  the  glottis. 
Death  by  asphyxia  during  a  paroxysm  is  not  unusual,  and  can  generally  be 
ascribed  to  spasm  of  the  glottis  (as  is  proved  by  the  fact  that  tracheotomy 
usually  gives  relief),  although  in  some  instances  it  may  be  due  to  the  tonic 
contraction  of  the  respiratory  muscles  and  even  of  the  diaphragm.  (5) 
Finally  a  paralytic  condition  develops  in  which  the  jaw  relaxes,  the  convul- 
sions cease,  and  the  patient  may  appear  to  be  improving,  but  death  soon 
ensues  from  exhaustion.  While  this  is  the  typical  development  of  the  dis- 
ease there  are  many  irregular  cases.  A  fatal  termination  may  occur  at  any 
j)eriod  and  recovery  may  take  place  in  any  but  the  paralytic  stage.  Some 
cases  linger  for  weeks  with  nothing  more  than  contraction  of  the  jaws  and 
back  of  the  neck,  and  then  die  or  recover,  while  others  pass  almost  immedi- 
ately into  the  stage  with  reflex  convulsions. 

Prognosis. — The  cases  vary  in  their  severity,  the  acute  cases,  with  a 
short  incubation  period  and  rapid  generalization  of  the  symptoms,  being 


72  TETANUS. 

apt  to  terminate  fatallj',  while  the  so-called  chronic  cases,  in  which  the  dis- 
ease usually  develops  slowly  and  some  time  after  infection,  run  a  course  of 
from  four  to  twelve  weeks,  and  not  infrecxueutly  recover.  Death  has  been 
known  to  occur  within  a  few  hours  of  the  infection,  and  frequently  takes 
place  within  one  day  after  the  first  symptom.  If  the  patient  survive  for  ten 
days  or  a  fortnight,  recovery  may  be  expected.  The  mortality  has  been 
estimated  at  ninety  per  cent,  for  the  acute,  and  forty  per  cent,  for  th^ 
chronic  cases,  without  antitoxine  treatment  (Lambert). 

Facial,  Paralytic,  or  Hydrophobic  Tetanus.— One  peculiar 
variety  of  tetanus  deserves  separate  consideration, — namely,  that  which  fol- 
lows wounds  in  the  distribution  of  the  cranial  nerves,  the  so-called  facial  or 
head  tetanus,  also  known  as  hj-drophobic  or  paralytic  tetanus.  It  is  marked 
by  the  occm-rence  of  paralysis  in  the  muscles  most  affected  (usually  those 
supplied  by  the  facial  nerve)  and  by  reflex  spasm  of  the  oesophagus,  which 
is  in  some  cases  so  marked  as  closely  to  resemble  hydrophobia.  The  disease 
begins  with  contracture  of  the  muscles  nearest  the  injury,  on  both  sides  of 
the  face  if  the  wound  is  in  the  middle  line,  otherwise  unilateral,  followed  by 
spasms,  gradually  extending  to  the  muscles  of  the  other  side,  while  those 
first  affected  become  paralyzed.  If  the  infection  is  severe  the  symptoms  of 
general  tetanus  follow,  with  a  mortality  of  seventy  per  cent.  (Willard),  and 
the  mortality  of  all  cases  is  only  fifty-eight  per  cent.  (Brunner),  showing 
that,  as  a  rule,  the  disease  is  milder  than  ordinary  tetanus.  The  paralj'sis 
is  easily  overlooked  if  not  sought  for,  and  in  some  cases  there  is  none.  The 
instances  of  marked  oesophageal  s^jasm  are  rather  rare.  The  paralysis 
depends  uj)on  a  paralyzing  agent  among  the  toxiues  of  the  tetanus  bacillus. 
It  is  always  limited  to  the  part  first  affected,  although  the  spasms  generally 
extend  to  the  rest  of  the  body. 

Treatment. — The  most  important  recent  addition  to  treatment  has  been 
the  discovery  of  the  apparent  curative  effects  of  the  tetanus  antitoxine  by 
Tizzoni  and  Cattani.  The  protective  serum  is  obtained  by  injecting  animals 
with  sterilized  cultures  of  the  germ  until  they  become  immune,  and  draw- 
ing blood-serum  from  them.  It  is  also  possible  to  obtain  an  antitoxine  from 
laboratory  cultures  of  the  bacillus  (Behring).  The  antitoxine  may  be  in- 
jected hyijodermically,  into  the  spinal  canal,  into  the  brain  through  a 
small  trephine  opening,  or  diluted  with  normal  salt  solution  and  thrown  into 
a  vein.  Which  is  the  best  of  these  methods  is  still  uncertain,  but  in  any 
case  the  ordinary  treatment  by  local  disinfection  of  any  suppurating  lesion 
and  the  use  of  drugs  must  not  be  neglected.  The  antitoxine  should  be  given 
within  thirty  hours  after  symptoms  have  begun  if  any  eifect  is  to  be  ob- 
tained. In  cases  treated  by  antitoxine,  Lambert  found  a  mortality  of  only 
forty  per  cent., — seventy-five  per  cent,  in  forty-seven  acute  cases,  and  six- 
teen ]Der  cent,  in  sixty-one  chronic  cases.  Wasserman  discovered  that  normal 
brain-substance  contained  a  natural  antitoxine  to  tetanus,  and  ten  cases 
with  eight  cures  are  on  record  as  having  been  treated  with  subcutaneous 
injection  of  fresh  rabbit-brain  made  into  an  emulsion.  We  must  also 
mention  Baccelli's  method  of  ti'eatment  by  hypodermic  injections  of  a  two 
per  cent,  solution  of  carbolic  acid  in  large  doses,  which  has  given  remark- 
able results  according  to  Italian  reports. 


HYDROPHOBIA.  73 

Other  treatment  avails  little.  The  first  necessity  is  thoroughly  to  disin- 
fect any  siippurating  wound  which  may  be  found,  to  remove  sloughs  and 
foreign  bodies,  and  to  secure  proper  drainage.  Chloroform  or  amyl  nitrite 
may  be  given  by  inhalation  to  palliate  the  paroxysms,  and  their  effect  will 
be  increased  by  morphine  in  one-fourth  to  one-half  grain  doses  hypoder- 
mically.  In  mild  cases  chloral  hydrate  aud  bromide  of  potassium  in  from 
fifteen-  to  twenty-grain  doses  up  to  the  limit  of  safety  have  proved  useful. 
Curare  has  been  recommended,  but  is  dangerous  and  not  of  mai'ked  benefit. 
Nourishment  must  be  maintained  by  a  catheter  passed  into  the  ijharyns 
through  the  nose,  as  it  will  be  impossible  to  open  the  jaws.  It  is  generally 
necessary  to  move  the  bowels  with  euemata  and  to  draw  the  urine.  The 
patient  must  be  confined  in  a  dark,  quiet  room,  under  the  care  of  one  or  two 
persons  only,  and  every  noise  or  sudden  motion  must  be  avoided,  as  well  as 
any  unnecessary  handling  of  the  body.  Verueuil  has  suggested  wrapping 
the  entire  body  in  cotton  and  confining  it  in  splints.  The  former  operative 
treatment  by  neurotomy  or  nerve-stretching  or  amputation  was  based  on  an 
erroneous  theory,  which  ascribed  the  disease  to  reflex  irritation  due  to  wounds 
or  scars,  and  has  been  abandoned.  Amputation  may  be  practised  when 
the  thorough  disinfection  of  the  injured  limb  is  impossible  or  other  con- 
ditions demand  it,  and  operations  are  usually  well  borne  by  such  patients 

if  performed  early. 

HYDEOPHOBIA. 

Lyssa,  Rabies. — Hydrophobia  is  an  iufectious  disease  affecting  the  ner- 
vous system,  marted  by  spasm  of  the  pharynx  and  glottis,  excited  by  at- 
tempts at  swallowing,  followed  by  general  muscular  convulsions  and  death. 
It  originates  in  animals  of  the  dog  and  wolf  tribe,  but  is  communicable 
through  the  saliva  of  any  rabid  animal  when  inoculated  in  a  wound  of  any 
of  the  warm-blooded  animals.  Although  there  can  be  no  doubt  of  its  bac- 
terial origin  because  of  the  period  of  incubation,  the  infectiousness,  and  the 
possibility  of  destroying  the  virus  by  the  ordinary  germicidal  methods,  the 
specific  microbe  has  not  yet  been  discovered.  The  poison  is  found  in  the 
central  nervous  system,  aud  can  be  communicated  by  inoculations  from  those 
parts. 

There  are  two  clinical  varieties,  the  "furious,"  which  is  the  more  com- 
mon, and  the  "dumb."  In  the  dog  the  "furious"  form  begins  with  a  pro- 
dromal state  of  unusually  affectionate  behavior,  succeeded  by  paroxysms  of 
rage,  in  which  he  snaps  at  everything,  followed  by  dulness,  moroseness,  aud 
a  disposition  to  avoid  comjsany.  He  becomes  unable  to  swallow,  but  never 
shows  any  fear  of  attempting  to  do  so  ;  in  fact,  he  tries  by  every  means  to 
assuage  his  thirst  up  to  the  end.  He  appears  insensible  to  pain,  and  wan- 
ders about  with  drooping  head  and  saliva  dropping  from  his  mouth  until 
death  ensues  from  exhaustion.  Towards  the  end  the  muscles  of  the  jaw 
become  paralyzed,  the  jaw  drops,  and  the  animal  is  unable  to  bite.  The 
paralysis  gradually  spreads  and  becomes  general.  The  duration  of  the  dis- 
ease is  from  two  to  ten  days.  In  the  dumb  form,  the  paralytic  stage  sets  in 
at  once,  without  the  previous  stage  of  excitement.  The  bite  of  a  rabid  dog 
on  unprotected  skin  is  dangerous,  but  even  then  about  one-third  of  the 
victims  escape  the  disease  by  their  constitutional  powers  of  resistance.     If 


74  HYDROPHOBIA. 

the  bite  is  given  throngli  clothing,  the  latter  may  prevent  inoculation  with 
the  saliva.  Inoculation  may,  on  the  other  haud,  take  place  without  a  bite, 
by  the  mere  contact  of  the  saliva  of  a  rabid  animal  with  an  open  wouud. 
After  death  from  rabies  the  dog's  stomach  is  found  to  contain  foreign  bodies 
but  no  food.  It  is  said  that  characteristic  changes  take  j)lace  in  the  ganglion 
cells  of  the  spinal  cord  and  medulla. 

Symptoms. — lu  man  there  is  tisvlbIIj  an  incubation  jieriod  oi  about  six 
weeks,  but  in  some  cases  this  has  been  as  short  as  one  day,  and  in  others 
even  eight  months  have  i^assed  before  symptoms  apx^eared.  The  suiDposed 
instances  with  a  longer  incubation  period,  lasting  even  for  years,  are  doubt- 
ful. There  may  be  prodromal  symptoms,  such  as  nervousness,  anxiety,  and 
pain  in  the  scar  of  the  wouud,  which  is  generally  healed  by  that  time.  The 
incubation  is  said  to  be  shortest  in  wounds  on  the  head,  longer  in  those  of 
the  hands,  and  still  longer  in  wounds  elsewhere.  The  disease  begins  with 
severe  dyspnoea  and  difficulty  in  swallowing  from  spasm  of  the  glottis  and 
pharynx.  The  respiration  is  jerky  and  sounds  may  be  produced  like  the 
bark  of  a  dog.  General  reflex  convulsions  follow,  brought  on  by  a  draught 
of  air,  or  a  loud  noise.  The  temperature  may  reach  104°,  and  glycosuria 
and  albuminuria  may  appear.  Death  may  occur  in  asiDhyxia.  Finally,  a 
paralytic  stage  develops,  similar  to  that  in  the  dog.  The  "dumb"  form  of 
rabies  is  rare  in  man.  Death  is  inevitable,  occurring  two  or  three  days 
after  the  iirst  convulsion. 

Treatment. — It  is  said  that  fully  two-thirds  of  the  patients  bitteu  by 
rabid  dogs  fail  to  develop  the  disease  if  the  bite  is  thoroughly  cauterized  or 
excised.  In  any  doubtful  case,  the  animal  which  gave  the  bite  should  be 
kept  alive  in  order  to  ascertain  whether  it  is  rabid,  the  post-mortem  diag- 
nosis being  often  impossible.  Experimental  inoculations  with  portions  of 
the  spinal  cord  may  assist  in  making  the  diagnosis,  but  they  require  from 
two  to  six  weeks'  time,  and  it  may  be  too  late  to  be  of  service.  The  treat- 
ment is  similar  to  the  antispasmodic  treatment  of  tetanus,  but  it  is  only 
palliative.  Pasteur  has  introduced  a  method  of  protective  inoculation  which 
it  is  claimed  would  prevent  rabies  or  enable  the  patient  to  resist  it  if  admin- 
istered during  the  incubation  period.  Under  the  stimulus  of  this  discovery 
the  number  of  rej)orted  cases  of  this  rare  disease  in  Prance  has  increased 
immensely,  a  sufficient  indication  that  all  statistics  upon  this  subject  are 
misleading.  Even  with  the  best  showing  the  treatment  is  effective  only 
when  applied  before  any  symptoms  develop  ;  it  often  fails  even  then,  and 
it  has  dangers  of  its  own,  multiple  neuritis  and  even  rabies  having  been 
observed  to  follow  its  use.  A  protective  serum  for  conferring  immunity 
against  rabies  has  recently  been  introduced  by  Tizzoni  and  Cattani,  but  its 
usefulness  in  man  is  as  yet  undetermined. 


CHAPTEE    VIII. 

REPAIR  OF  "WOUNDS—REGENERATION  OF   TISSUES. 
t 

By  B.  Faequhar  Curtis,  M.D. 

The  reparative  powers  of  the  tissues  of  the  human  body  are  considerable, 
although  not  comxjarable  with  those  of  the  lower  animals,  in  the  lowest 
orders  of  which  the  reproduction  of  an  entire  limb  or  even  one-half  of  the 
body  regularly  takes  place.  In  order  to  understand  the  regeneration  of 
tissue  we  must  first  consider  briefly  the  life-history  of  the  cells.  A  cell 
consists  of  a  mass  of  protoplasm,  generally  enclosed  in  a  cell-membrane, 
and  containing  a  nucleus  and  a  nucleolus.  The  nucleus  represents  the  most 
vital  part  of  the  cell  protoplasm,  staining  most  intensely  with  the  various 
dyes  used  in  histological  methods,  and  having  a  more  granular  appearance. 
The  nucleolus  is  a  minute  solid  spot  in  the  nucleus,  appearing  to  be  much 
more  highly  refractive. 

Cell  Division. — "When  the  cell  is  quiescent  the  protoplasm  appears 
evenly  granular  (Fig.  29,  1),  but  when  it  is  stirred  to  active  life,  slender 


Karyomitosis.     (P.  C.  Wood,  M.D.) 

twining  threads  are  to  be  traced  in  the  nucleus,  resembling  the  coils  of  the 
capillary  vessels  in  the  glomerulus  of  the  kidney,  and  perhaps  consisting 
merely  of  one  long  thread  twisted  upon  itself.  On  account  of  their  readi- 
ness to  take  up  the  dyes  used  in  staining,  the  threads  are  called  chromattne 
threads.  "When  the  cells  are  about  to  divide,  the  chromatine  threads  are 
seen  to  arrange  themselves  about  the  equator  of  the  nucleus  in  a  rosette  or 
star  shape,  known  as  the  mother-star.  (Fig.  29,  2  to  ib.  ia  is  a  polar  and 
4&  an  equatorial  view  of  the  same  cell.)  Some  larger  granules  then  appear 
at  the  ends  of  an  axis  passing  perpendicularly  through  this  equatorial 
rosette,  at  the  poles  of  the  nucleus,  and  the  loops  of  the  threads  are  directed 
towards  the  poles.  Gradually  these  threads  become  arranged  in  radiating 
lines,  converging  at  the  poles,  and  then  break  away  from  their  former  con- 

75 


76  REPAIR  OF  AVOUNDS. 

nection  with  tlie  ecxnator,  forming  a  daughter -star  at  each  pole,  a  bi'ight  sj)ace 
appearing  at  the  equator.  (Fig.  29,  5.)  A  constriction  nest  appears  in 
the  nucleus  at  the  equator,  and  the  nucleus  divides  into  two  distinct  nuclei, 
eaxh  containing  one  of  the  daughter  stars.  (Fig.  29,  6.)  Simultaneously 
with  this  division,  or  immediately  following  it,  the  protoplasm  of  the  cell- 
body  divides  in  the  same  place,  and  thus  two  complete  cells  are  produced. 
(Fig.  29,  8.)  The  chromatine  threads  lose  their  rosette  arrangement,  and 
gradually  become  imperceptible  as  the  new  cell  returns  to  the  quiescent 
state.  This  x^rocess  of  cell  division  is  known  as  JcaryoJdmsis  or  karyomt- 
tosis,  from  the  Greek  -/.dpuu'^,  a  nucleus,  ■/.i^yjai<;,  motion,  and  /./.iVo?,  a  thread. 
(Flemming.)  In  simple  cells  like  the  leucocytes,  reproduction  may  take 
place  by  simple  fission,  a  constriction  apiiearing  in  the  nucleus  and  in  the 
body  of  the  cell  in  the  same  plane,  and  the  two  dividing  without  any  visible 
protoplasmic  changes,  but  such  a  mode  of  division  probably  does  not  occur  in 
the  more  highly  specialized  cells  of  the  various  tissues.  If  the  karyokinetic 
action  be  not  vigorous,  the  nucleus  may  divide,  but  the  cell-body  remains 
intact,  producing  cells  with  two  or  more  nuclei  so  commonly  observed. 

Every  cell  reproduces  its  kind,  connective-tissue  cells  producing  con- 
nective tissue,  epithelial  cells  epithelium,  bone  producing  bone.  It  has 
recently  been  shown  that  in  the  connective  tissue  the  cells  may  become  so 
quiescent  as  to  be  invisible  to  microscopic  examination,  only  fibres  being 
discerned  until  some  irritation  has  been  applied  to  the  tissues,  wheu  nuclei 
and  cells  appear  in  all  directions  among  the  fibres  as  suddenly  as  if  by 
magic.  Grawitz  has  aptly  called  these  quiescent  cells  slumbering  cells.  The 
demonstration  of  these  cells  explains  the  extremely  rapid  appearance  of  im- 
mense numbers  of  new  cells  in  tissues  subjected  to  irritation,  although  large 
numbers  of  the  new  cells  are  supplied  by  the  leucocytes  which  emigrate 
from  the  blood-vessels,  as  has  been  exj)lained  in  the  chapter  on  inflamma- 
tion. These  emigrating  leucocytes  take  no  active  part  in  the  restoration  of 
tissue,  for  the  multiplying  cells  of  the  tissues  alone  have  that  power,  but 
the  leucocytes  may  furnish  food  for  the  other  cells.  The  power  of  restora- 
tion is  most  marked  in  the  connective-tissue  cells,  which  are  c&We^  fixed  cells, 
but  it  is  also  active  in  the  cells  of  the  periosteum,  bone-marrow,  endothelial 
lining  of  the  vessels,  and  the  various  epithelial  structures.  It  is  very  feeble 
in  the  striped  muscle  cells,  and  entirely  absent  in  the  cells  of  cartilage. 

Repair  of  Wounds  and  Healing  by  Apposition. — When  a  wound 
or  "loss  of  continuity"  has  occurred  in  the  tissues,  the  latter  retract  at  once 
at  the  point  of  division  on  account  of  their  elasticity,  and  the  gap  is  more  or 
less  filled  with  blood  or  serum.  If  no  bacterial  or  chemical  irritant  is  intro- 
duced, there  are  no  true  inflammatory  changes.  The  divided  blood-vessels 
are  occluded  by  coagulation  of  the  blood  in  their  open  ends,  and  this  coagu- 
lation extends  to  the  nearest  patent  branch.  (Fig.  30.)  The  caj)illaries 
around  the  seat  of  injury  dilate  slightly,  the  fixed  cells  of  the  tissues  be- 
come active,  dividing  by  karyokinesis  and  becoming  loosened  fi-om  their 
beds,  while  other  uew  cells  are  furnished  sparingly  by  the  leucocytes.  The 
endothelial  cells  of  the  divided  blood-vessels  multiply  and  take  an  active 
pax't  in  the  process.  In  spite  of  the  slight  congestion  and  the  new  cells  pro- 
duced, the  reaction  is  much  less  than  that  of  inflammation.     The  new  cells 


HEALING  BY   APPOSITION. 


Fig.  30. 


l\ 


S 


'M 


^5■y^ 


i' 


A 


:?A 


=•-^6*7° 


/- 


-») 


Section  through  skin  of  guinea  pig  eight  hours  after  a 
wound :  a,  the  wound,  filled  with  clot,  the  capillaries  throm- 
bosed onhoth  sides ;  round-cell  infiltration ;  be,  sweat-gland ; 
d,  hair-follicle. 


invade  tlie  blood-clot,  consuming  it  and  also  any  foreign  matter  or  any 
tissue  which  may  have  been  killed  by  the  injury.  Prom  the  loops  of  the 
occluded  capillaries  at  the  sides 
of  the  wound  spring  buds  of 
endothelial  cells,  which  grow 
like  the  roots  of  a  tree  iuto  the 
mass  of  blood-clot  and  cells,  be- 
coming thicker  and  then  hollow 
as  they  extend,  blood-cells  form- 
ing in  them,  and  blood  entering 
them  also  from  behind.  (Fig. 
31.)  These  advancing  endothe- 
lial tubes  anastomose  with  their 
neighbors,  and  also  with  those 
which  have  started  from  the 
other  side  of  the  wound,  and 
thus  the  growing  tissues  are 
supplied  with  blood-vessels. 
(Fig.  32.)  It  is  said  that  new 
vessels  are  also  formed  by  the 
pre-existing  lymph  spaces  and 
by  independent  cells.  Mean- 
while, the  connective-tissue  cells 

have  been  forming  fibres  across  the  clot,  and  epithelial  cells  begin  to  spread 
over  its  surface  if  skin  or  mucous  membrane  be  involved  in  the  injury. 

The  new  vessels  disappear, 
and  the  new  connective  tissue 
forms  the  cicatrix.  (Fig.  33.) 
This  is  the  process  of  primary 
union  in  a  wound  in  which 
there  is  not  a  marked  cavity 
or  a  loss  of  tissue  on  any  of 
the  exposed  surfaces  of  the 
body,  and  no  matter  how 
closely  the  edges  of  such  a 
wound  may  lie  in  contact  it 
can  heal  by  no  other  method. 
Even  the  closest  apposition  of 
the  sides  of  a  wound  cannot 
prevent  the  interi^osition  of  a 
thin  layer  of  clot  and  the  par- 
~     ^,        -        —  -^  ~'  tial  death  and  absorption  of 

The  same  at  a  later  stage.  The  clots  m  the  capillaries  a  Very  thin  layer  OU  itS  SUT- 
almost  removed,  new  vessels  forming  towards  the  gap,  new  faceS  SO  that  the  former 
connective-tissue  spindle-cells  replacing  the  round  cells.   The     , ,        '  j.  .  ■.  7   ^  ■ 

epithelium  has  united  on  the  surface.    (Shakespeare.)  theory     Ot     UUlOn     by    aggluti- 

nation is  untenable,  although 
in  some  aseptic  wounds  only  careful  microscopic  examination  can  dis- 
prove it. 


Fig  31 


-% 


t 


m^ 


^' 


?m 


78 


HEAXING   BY   GRANULATION. 


The  same  later.    The  gap  flUed  with  new  connective  tissue 
and  young  blood-vessels. 


Healing  by  Granulation.— When  a  wide  gap  has  been  produced 
by  retraction  or  actual  loss  of  tissue,  healing  takes  place  by  granulation, 

as  it  is  called,  a  process  which 
differs  from  that  just  described 
merely  in  the  fact  that  more 
tissue  has  to  be  reproduced. 
The  outpouring  of  blood  and 
serum,  occlusion  of  vessels, 
congestion,  multij)lication  of 
fixed  cells,  emigration  of  leu- 
cocytes, and  production  of 
vascular  buds  and  loops  goes 
on  as  before.  But  as  the  for- 
mative changes  advance,  small, 
round  elevations  of  a  rosy  color 
appear  on  the  new  surface, 
making  it  look  like  velvet. 
These  rounded  elevations  are 
called  granulations,  and  they 
are  simply  the  projecting  loops 
of  new  blood-vessels,  covered 
with  a  few  cells.  The  least 
touch  lacerates  the  vessels  and  causes  hemorrhage.  The  granulations 
advance  steadily  on  all  sides,  filling  the  gaping  wound  until  the  level  of  the 
original  surface  is  reached,  the 
new  tissue  organizing  behind 
them,  and  contracting  as  it 
organizes,  so  that  the  space  to 
be  filled  is  daily  made  smaller 
by  this  contraction  as  well  as 
by  the  production  of  new  tis- 
sue. (Fig.  34.)  As  the  sur- 
face is  reached  the  epithelial 
cells  on  the  edges  of  the  gran- 
ulating area  slowly  spread 
over  it,  the  granulations  gen- 
erally jyrojecting  above  the 
adjoining  surface,  and  the  epi- 
thelium growing  over  them  as 
they  contract  again  to  their 
proper  level.  The  advancing 
line  of  epidermis  is  visible  as 
a  pale-pink  line,  the  new  cells 
graduall  J'  whitening  with  time. 
When  a  wound  has  been 
left  gaping,  or  has  been  packed 
until  its  sides  have  granulated,  rapid  adhesion  of  these  granulating  surfaces 
can  often  be  obtained,  and  septic  wounds  or  abscess- cavities  can  be  closed  by 


Fig.  33. 


Cicatrix  formed  in  the  wound,  the  young  hlood-i 
disappeared.     (Shakespeare.) 


REPAIR  OF  TENDONS  AND  MUSCLE.  79 

takiug  advantage  of  this  fact  and  bringing  tlie  granulating  surfaces  together 
by  deep  secondary  sutures  when  all  trace  of  sepsis  has  been  removed  by  the 
oiDeu-wouud  treatment. 

Fic4.  34. 


\  X 


Healing  of  a  wound  "by  granulation :  a,  layer  of  iilDrin,  leucocytes,  and  detritus  over  surface  of  granula- 
tions ;  6,  advancing  edge  of  epidermal  cells  from  skin ;  c,  skin  at  edge  of  wound ;  d,  corium  with  some  in- 
flammatory infiltration  ;  e,  blood-vessel  in  normal  tissue  differing  in  its  structure  from  those  in  the  granula- 
tion-tissue ;  /,  blood-vessel  in  latter  with  a  leucocyte  emigrating  through  its  walls ;  g,  new  connective-tissue 
cells,  called  fibroblasts  ;  h,  points  to  an  epithelial  cell,  and  on  the  other  side  of  h  are  two  cells  in  process  of 
division,  showing  their  rapid  growth.     (F.  C.  Wood,  M.D.) 

Repair  of  Epithelium. — Defects  of  the  superficial  epithelial  surfaces 
and  in  the  glandular  organs  are  repaired  by  a  growth  of  the  epithelial  cells 
with  partial  reproduction  of  the  gland-tissue  destroyed,  as  has  been  ob- 
served in  the  liver  and  testicle  ;  but  reproduction  is  seldom  complete  in  the 
glands. 

Repair  of  Tendons. — Eepair  of  tendons  is  accomplished  by  the  growth 
of  connective  tissue  from  the  sides  of  the  tendon-sheaths,  the  tissue  of  the 
tendon  itself  taking  very  little  part  in  the  process.  If  there  is  no  extrava- 
sation of  blood  into  the  sheath,  the  latter  collax)ses  where  it  is  left  emjity  by 
the  retraction  of  the  divided  ends  of  the  tendon,  becomes  adherent  to  the 
latter,  and  then  forms  a  band  connecting  the  two  ends  and  permitting  of 
restoration  of  function,  while  the  collapsed  sheath  is  thickened  by  connec- 
tive-tissue growth.  More  commonly  there  is  an  effusion  of  blood  in  the 
sheath,  and  the  clot  fills  the  space  between  the  ends  of  the  tendon,  being 
finally  replaced  by  the  production  of  granulation-tissue,  which  starts  from 
the  inner  surface  of  the  sheath  and  becomes  converted  into  connective 
tissue. 

Repair  of  Muscle. — Non-striated  muscular  cells  have  considerable 
reparative  powers,  but  it  is  ouly  recently  that  the  power  of  reproduction 
of  striated  muscidar  fibres  has  been  jjroved.     The  regeneration  of  the  latter 


80 


REPAIR   OF  BOICE   AFTER   FRACTURE. 


is  feeble,  and  it  is  accomplislied  by  budding  from  the  muscle-fibres  them- 
selves, the  processes  from  the  latter  extending  into  the  granulation-tissue 
or  young  connective  tissue  of  the  cicatrix,  and  becoming  interlaced  -with 
those  from  the  opposite  side  of  the  wound.  This 
reproduction  is  so  feeble  that  practically  every  wound 
of  muscle  is  repaired  by  a  cicatrix  of  connective  tissue 
only. 

Repair  of  Bone. — In  the  process  of  repair  of  the 
bones  after  fracture,  the  blood-clot  and  exuded  serum 
make  a  fusiform  swelling  without  definite  bounda- 
ries, extending  into  the  soft  parts,  called  the  callus. 
(Pig.  35.)  That  portion  of  it  which  is  formed  by  the 
periosteum  and  soft  parts  is  known  as  the  external 
callus,    and  that  which   forms   from  the   medullary 

Fig.  36. 


^i' 


Section  of  fractured  clavi- 
cle, three  weeks  after  injury, 
showing  internal  and  ex- 
ternal callus. 


^> 


Formation  of  callus  in  a  fracture  seven  days  old  :  a,  prolif- 
erating periosteum  fibroblasts  "with  mitoses ;  &,  newly  formed 
cartilage ;  c,  small  blood-vessel  with  swollen  endothelium ; 
d,  granulation-tissue ;  e,  a  layer  of  bone  which  takes  no  part 
in  the  process.    (F.  C.  Wood,  M.D.) 


bone-cavity  in  the  case  of  fracture  of  the  shaft  of  a  long  bone  is  called  the 
internal  callus.  The  intermediary  callus  is  merely  that  part  between  the 
two  which  is  derived  from  both  sources.  The  first  change  observed  is  the 
emigration  of  leucocytes  into  the  exudation ;  then  the  cells  of  the  deeper 
layers  of  the  periosteum  and  of  the  adjacent  bone  proliferate  and  form  fusi- 
form, stellate,  or  angular  cells,  the  bone- cells  being  concerned  especially  in 
the  internal  callus.  (Fig.  36.)  These  cells  acquire  a  halo  like  cartilage-cells, 
and  the  substance  in  which  they  lie  becomes  solid,  and  is  known  as  the  osteoid 
substance.  Near  the  centre  of  the  callus  true  hyaline  cartilage  is  produced. 
These  cells  are  called  osteoblasts.  Lime  salts  are  dexjosited  in  the  osteoid 
substance  and  cartilage,  trabeculse  appear,  and  the  osteoblasts  form  bone- 
cells.  Haversian  canals  containing  blood-vessels  appear,  running  in  different 
directions  fi'om  those  of  the  subjacent  normal  bone.  The  internal  callus 
thus  forms  a  bridge  of  bone  uniting  the  ends.  The  external  callus  has  mean- 
while undergone  similar  changes,  and  both  are  altered  into  spongy  bone. 


UNION  OF  BONE  AFTER  FRACTURE. 


81 


the  spaces  of  which  are  filled  by  granulation-tissue,  with  a  layer  of  osteo- 
blasts between  it  and  the  bone,  which  constantly  add  new  bone  to  the 
trabeculse.     (Figs.  37  and  39.)    As  the  bone  increases  in  amount  the  hya- 


./- 


Callus  from  fracture  of  a  small  bone,  two  weeks  old :  a,  fibrous  capsule  of  the  callus ;  b,  trabeculse 
of  osteoid  tissue  formed  from  the  periosteum  and  in  the  granulation-tissue  of  the  callus ;  c,  the  shaft  of 
the  bone  containing  the  fatty  bone-marrow;  d,  new-formed  cartilage;  e,  a  small  fragment  of  bone 
which  has  been  pushed  into  the  marrow ;  /,  intermediary  callus  formed  from  the  periosteum  and  also 
from  the  bone-marrow. 


line  cartilage  disappears,  some  believing  that  it  changes  by  calcification  and 

This  larae  amount  of  callus  is 


Fig.  .38. 


Oj 


00 


the  alteration  of  its  cells  into  bone-cells, 
called  the  provisional  callus;   when 
union  is  complete  it  grows  smaller, 
and  the  remaining  portion,  known  as 
the  definitive  callus,  becomes  denser,     a  J 
Associated  with  the  absorption  of  : 

the  callus  is  the  presence  of  large 
cells  with  many  nuclei  (so-called 
giant-cells  or  osteoclasts),  which  lie 
in  little  excavations  along  the  edges  ,. 
of  the  trabecule  of  bone,  making  it 
appear  as  if  they  caused  the  absorj)- 
tiou  of  the  bone,  although  this  is 
not  absolutely  proved.  (Pig.  38.) 
By  this   absorption  the  medullary 

spaces  between  the  trabecule  enlarge,  and  the  latter  disappear.  ,  By  similar 
means  the  medullary  canal  is  formed  through  the  centre  of  the  callus  (Fig. 
40),  and  the  cortical  portion  of  the  included  broken  ends  is  absorbed,  so 
that  it  may  finally  become  imiDossible  to  locate  the  point  of  injury. 

6 


•  Osteoclast,  liisihly  iiia;;nuiod  from  ,-,  yhg.  37:  a, 
boue-marrow  with  fat;  b,  osteoclast  causing  absorp- 
tion of  bone ;  c,  hard  bone.    (F.  C.  Wood,  M.D.) 


82 


OCCLUSION   OF  BLOOD-VESSELS. 


Occlusion  and  Repair  of  Blood- Vessels. — When  an  artery  is 
ligated,  a  clot  forms  at  the  seat  of  ligature  and  speedily  becomes  penetrated 
witli  endothelial  cells,  produced  by  the  multiplication  and  emigration  of 
those  lining  the  vessel.  Simultaneously  with  this  there  is  an  exudation 
around  the  outside  of  the  vessel  in  which  the  granulation-tissue  is  formed, 


Fig  39 


"r  1  , 


^  "^ 


Fig.  40. 


Highly  magnified  part  of  h.  Fig.  .37.  Formation  of  boue  in  the 
granulation-tissue  two  weeks  after  fracture:  a,  hard  bone;  b,  trabec- 
ula3  of  osteoid  tissue,  later  to  become  true  bone  by  deposition  of  lime 
salts  :  c,  remains  of  the  granulation-tissue.    X 100.    (F.  C.  Wood,  M.D.) 


Section  of  fractured  femur, 
showing  medullary  canal  in  pro- 
cess of  re-formation  by  absorption 
of  internal  callus.    (Paget.) 


and  the  latter  absorbs  the  exudate,  penetrates  the  artery  where  it  is  ligated, 
or  enters  the  ends  of  the  divided  vessel,  and  replaces  the  internal  clot. 
There  is  also  a  proliferation  of  the  connective  tissue  and  of  the  muscular 
cells  of  the  vessel  wall.  After  several  months  the  result  is  a  cicatrix,  which 
forms  at  the  point  of  injury  and  in  which  every  layer  of  the  vascular  wall 
is  ref)resented,  although  the  connective  tissue  is  in  the  ijreponderance. 
Veins  are  occluded  in  a  similar  way.  Primary  union  of  the  edges  of  a 
lateral  wound  in  a  vein,  and  even  in  an  artery,  has  been  shown  to  be  possi- 
ble in  man.  Circular  suture  of  the  ends  of  a  vessel  divided  transversely  has 
also  been  successfully  performed.  The  reunited  vessel  remains  pervious  if 
it  is  a  vein,  but  usually  becomes  occluded  by  endothelial  growth  if  it  is 
an  artery.  The  union  of  wounds  of  vessels  is  undoubtedly  obtained  by 
connective-tissue  growth,  followed  by  restoration  of  the  walls  in  all  their 
elements,  and  it  makes  apparently  very  little  difference  whether  the  endo- 
thelial surfaces  or  the  surfaces  of  the  adventitia  are  brought  into  contact 
by  the  suture,  although  later  experimenters  prefer  the  latter,  for  it  is  very 


EEPAIR  OF  NERVES.  83 

important  that  the  siitures  shall  not  be  exposed  in  the  Inmen  of  the  vessel, 
as  a  clot  would  form  about  them. 

Repair  of  Nerves. — It  is  questionable  whether  the  nerve-cells  of  the 
gray  matter  of  the  brain  and  si^inal  cord  are  capable  of  reproduction,  but 
the  iieripheral  nerves  will  unite  after  division.  When  a  nerve  is  divided, 
the  fibres  beyond  the  point  of  division  degenerate  at  once,  the  myeline 
sheaths  and  axis-cylinders  disappearing,  and  the  spaces  thus  left  in  the 
endoneurium  are  filled  by  nuclei  of  the  neurilemma,  which  proliferate  and 
emigrate.  Protoplasm  collects  around  these  nuclei,  and  embryonic  nerve- 
fibres  are  formed.  If  the  ends  of  the  nerve  are  not  united,  these  new  fibres 
remain  indefinitely  in  their  embryonic  state.  If  the  continuity  of  the  nerve 
is  restored,  however,  the  embryonic  fibres  begin  to  develop  axis-cylinders 
and  myeline  sheaths  at  the  ijoint  of  union,  and  when  the  changes  have 
spread  downward  to  the  terminal  filaments,  the  function  of  the  injured  nerve 
returns.  Even  if  the  ends  of  the  nerve  are  united  by  suture  immediately 
after  division,  the  same  jirocess  of  degeneration  of  the  former  fibres  and 
reproduction  of  embryonic  fibres,  with  their  subsequent  development,  must 
take  place  before  comi:)lete  restoration  is  possible,  so  that  the  function  of  the 
nerve  will  always  be  suspended  for  about  three  weeks.  Sometimes  the  ends 
of  the  nerve  become  united  by  connective  tissue,  originating  from  the  fibrous 
sheath,  and  the  cicatricial  tissue  prevents  the  union  and  complete  develop- 
ment of  the  embryonic  fibres.  By  cutting  out  the  fibrous  tissue  and  suturing 
the  freshened  ends  of  the  nerve,  reunion  and  full  regeneration  can  be  ob- 
tained, although  function  may  be  very  slow  in  returning.  The  separation 
of  the  ends  of  the  nerve  has  been  overcome  in  some  cases  by  placing  strands 
of  catgut  between  them,  the  new  fibres  having  grown  downward  from  the 
old  through  the  spaces  between  the  threads  of  catgut. 


CHAPTEE    IX. 

CONDITIONS  AFFECTING  THE   RESULTS  OP   OPERATIONS  AND     . 
INJURIES. 

By  Hekey  E.  Whautois^,  M.D. 

OPEKATIONS  IlSr  GENERAL. 

Tbue  propriety  of  operation  in  many  cases  whicli  come  under'tlie  care  of 
the  surgeon  is  very  clear ;  in  others,  however,  there  often  arises  the  question 
whether  the  patient  is  in  condition  for  oi3eration,  or  whether  his  exxjectation 
of  life  would  be  increased  by  the  procedure  :  it  is  in  such  cases  that  the  sur- 
geon has  the  opportunity  to  exercise  that  very  desirable  attribute,  surgical 
judgment,  which  is  much  more  essential  to  his  success  and  the  welfare 
of  his  patient  than  mere  operative  skill.  In  considering  the  question  of 
operation  the  patient  and  his  friends  are  apt  to  turn  to  the  surgeon  for  an 
opinion  as  to  the  possible  risks  of  the  procedure  and  the  results  to  be  gained 
by  it ;  the  patient,  in  our  opinion,  is  entitled  to  the  fullest  information  upon 
these  subjects.  The  surgeon  should  not  be  an  alarmist  and  unduly  excite 
the  fears  of  the  x)atient,  nor,  on  the  other  hand,  should  he  treat  lightly  the 
dangers  of  the  operation.  Timid  and  nervous  patients  often  require  the 
fullest  amount  of  encouragement  that  the  surgeon  can  give  them.  Some- 
times the  true  natm^e  of  the  illness  cannot  be  explained  to  the  patient  in 
cases  of  malignant  disease,  or  of  great  danger,  or  because  of  the  excitability 
or  ignorance  of  the  patient ;  the  family  or  friends  should  then  be  consulted. 
It  should  not  be  forgotten  that  comparatively  trivial  oj)erations  may  be  fol- 
lowed by  a  fatal  result,  due  to  the  anaesthetic,  hemorrhage,  or  sepsis. 

The  surgeon  and  his  assistants  should  remember  that  the  patient  and  his 
fi'iends  may  look  upon  the  operation  with  the  deepest  anxiety  and  even 
terror,  and  should,  therefore,  avoid  any  excitement,  and  should  proceed 
with  their  several  duties  in  a  quiet  manner.  The  surgeon  should,  so  far  as 
possible,  make  up  his  mind  as  to  the  plan  of  operation  and  its  various 
details  before  it  is  undertaken,  and  should  endeavor  to  follow  this  plan 
unless  uMoreseen  difliculties  arise  during  its  performance.  The  develop- 
ment of  unexpected  complications  during  an  operation  should  not  cause  the 
siu'geon  to  lose  his  head ;  should  he  do  so,  the  assistants  are  also  apt  to 
become  demoralized  and  the  safety  of  the  patient  thereby  much  endangered  ; 
indeed,  we  know  of  no  attribute  of  the  surgeon  worthy  of  greater  admiration 
than  that  steadfastness  which  in  the  face  of  great  and  unexpected  danger 
during  oijerations  enables  him  to  act  with  coolness  and  judgment. 

The  surgeon  is  often  placed  in  a  perplexing  i^osition  in  regard  to  the  con- 
sent of  the  patient  in  operations  of  urgency,  such  as  primary  amputations, 
herniotomy,  tracheotomy,  operations  which  must  necessarily  be  performed 
promptly  to  save  life.  K"o  surgeon  should  undertake  such  an  operation 
upon  a  patient  who  is  in  his  right  mind  and  refuses  to  give  his  consent  to 


EEST  AND   DIET  AFTER  OPERATIONS.  85 

its  performance.  In  children  or  minors  it  is  unwise  to  oj^erate  without 
the  consent  of  the  parents  or  guardians.  Fortunately,  in  private  x^ractice 
this  complication  is  not  apt  to  arise,  as  the  parents  or  guardians  are  usu- 
allj^  present,  but  frequently  children  are  injured  at  a  distance  from  their 
homes  and  brought  to  hospitals  ;  in  such  cases,  where  immediate  operation 
is  required  as  a  life-saving  measure,  if  efforts  to  find  the  ijarents  are  un- 
successful, the  surgeon  should  perform  the  operation  and  place  himself  in 
loco  parentis,  fortiiying  his  position,  if  possible,  by  a  consultation  with  his 
colleagues.  In  the  case  of  an  intoxicated  person  who  requires  immediate 
opei'ation,  and  whom  it  is  impossible  to  make  understand  what  is  to  be  done, 
or  who  refuses  his  consent  to  its  performance,  it  is  well,  if  possible,  to  wait 
until  the  patient  regains  his  senses  ;  but  if  this  is  impossible,  the  consent  of 
near  relatives  may  be  obtained,  or  if  this  cannot  be  done,  and  the  operation 
is  urgently  demanded,  the  surgeon  must  assume  the  resj)onsibility  of  the 
operation.  In  the  case  of  an  insane  or  unconscious  ijerson  the  case  should 
be  decided  uidou  the  same  grounds. 

The  surgeon  should  protect  himself :  1.  By  having  another  xjhysiciau  see 
with  him  every  case  of  proposed  important  operation  or  severe  injury. 
2.  He  should  not  give  a  general  anaesthetic  except  in  the  presence  of  a  third 
person,  preferably  a  physician,  in  view  of  the  possibility  of  unexpected 
emergencies.  3.  He  should  express  a  guarded  opinion  as  to  the  result  of 
operations,  or  of  fractures  or  joint  injuries,  as  the  ultimate  result  may  be 
modified  by  circumstances  over  which  he  has  no  control,  such  as  infection 
and  non-union. 

Rest  and  Diet  after  Operations. — The  surgeon  should  give  ex- 
plicit directions  as  regards  the  management  of  the  patient  after  serious 
injuries  or  operations.  A  patient  who  has  undergone  a  serious  operation  or 
received  a  severe  injury  should  be  kept  at  rest  in  bed  with  the  best  hygienic 
surroundings,  and  should  not  be  subjected  to  any  excitement ;  his  diet 
should  be  simple,  and  for  a  few  days,  at  least,  should  consist  of  milk  and 
broths ;  the  former  is  to  be  preferred  if  it  can  be  taken  ;  the  addition  of  a 
little  lime  water  to  the  milk  is  often  an  advantage  if  there  is  an  irritable 
condition  of  the  stomach.  After  a  few  days,  if  the  patient  craves  solid 
food,  he  may  be  given  a  more  liberal  diet,  but  it  should  consist  of  plain, 
easily  digested,  and  nutritious  food. 

Causes  of  Death  after  Operations.— The  consideration  of  the  causes 
of  death  after  operations  must  always  be  a  matter  of  the  greatest  interest  to 
the  practical  surgeon.  Every  surgeon  appreciates  the  fact  that  a  certain 
number  of  patients  die  after  operations  from  causes  directly  or  indirectly 
traceable  to  the  oi)eration.  These  deaths  do  not  always  occur  in  the  weak 
and  exhausted  only,  but  also  in  those  who  before  operation  were  considered 
most  favorable  subjects,  nor  is  the  fatal  termination  in  many  of  these  cases 
in  any  way  due  to  a  lack  of  skill  in  the  operator.  The  principal  causes  of 
death  after  operations  are  shock,  hemorrhage,  and  wound  complications,  such 
as  septiciemia  and  pytemia. 

Circumstances  affecting  Results  of  Operations. — Various  cir- 
cumstances influence  the  results  of  oj)erative  procedures.  The  success  of  an 
operation  does  not  always  depend  upon  the  skill  of.  the  surgeon  ;  the  consti- 


86  CONDITIONS  AFFECTING   OPEKATIONS. 

tutioual  condition  of  the  patient  is  often  a  factor  of  the  first  importance  in 
determining  the  result  of  an  operation.  There  is  an  unknown  element,  the 
power  of  constitutional  resistance,  which  even  the  most  experienced  surgeon 
cannot  definitely  determine.  The  following  conditions  should  be  considered 
in  deciding  the  question  of  operation. 

Age. — In  many  oi^erations  where  the  surgeon  is  called  upon  to  operate 
to  save  life  the  question  of  age  cannot  be  considered.  ]N"o  judicious  surgeon 
would  hesitate  to  operate  upon  a  strangulated  hernia  or  remove  a  crushed 
limb  in  an  infant  or  an  aged  j)erson  who  was  in  condition  for  operation, 
whereas  he  would  probably  refuse  to  perform  an  extensive  plastic  operation 
in  an  infant  for  the  relief  of  a  congenital  deformity,  or  to  remove  a  deep- 
seated  benign  tumor  from  the  neck  of  an  aged  person  whose  expectation  of 
life  at  best  is  very  short. 

Infants  and  aged  persons  do  not  bear  o]3erations  as  well  as  children  and 
those  in  middle  life  ;  the  results  of  operative  i^rocedures  in  children  after 
the  period  of  infancy  are  usually  very  satisfactory,  the  successful  results  in 
this  class  of  patients  probably  being  largely  due  to  the  fact  that,  as  a  rule, 
they  are  not  in  any  degree  affected  by  anxiety  as  to  the  operation,  that  their 
organs  are  in  a  healthy  and  vigorous  condition,  that  they  bear  confinement 
to  bed  well,  and  that  the  nutritive  activity  of  the  tissues  is  in  its  best  con- 
dition, so  that  wounds  heal  promptly.  Infants  and  young  children,  how- 
ever, suffer  inordinately  from  shock,  which,  if  prolonged,  may  produce  a 
condition  of  collapse,  and  they  possess  a  remarkably  excitable  condition  of 
the  nervous  system,  which  is  apt  to  develop  a  high  temperature  or  nervous 
symptoms  under  slight  provocation.  They  also  manifest  the  constitutional 
sj^mptoms  from  the  loss  of  blood  more  rapidly  than  do  adults,  but  if  reaction 
occurs  they  recuperate  very  rapidly.  Aged  persons  are  not  as  good  subjects 
for  operative  procedures  as  those  in  middle  life  ;  they  are  likely  to  be  affected 
with  visceral  disease,  bear  the  shock  and  loss  of  blood  badly,  and  are  apt 
to  become  bedridden,  so  that  they  should  be  got  out  of  bed  as  soon  as  pos- 
sible. Age  is  not  a  true  test  of  the  ability  of  the  individual  to  bear  oiiera- 
tive  procedures,  but  rather  the  vitality  of  the  tissues,  and  in  this  connection 
the  saying  "that  a  man  is  as  old  as  his  blood-vessels"  is  a  very  true  one. 
We  have  seen  a  patient  fifty  years  of  age  who  presented  evidence  of  vascu- 
lar degeneration  which  would  have  been  unusual  in  a  man  of  eighty  years. 
The  mere  question  of  years  in  such  a  case  would  be  misleading.  Active, 
spare-built  i)ersons  of  sixty  or  seventy  years  or  older  often  bear  operations 
and  injuries  exceptionally  well.  Aged  persons  who  have  sustained  injuries 
of  the  lower  extremities  or  of  the  trunk,  which  involve  long  confinement  in 
the  recumbent  posture,  are  apt  to  suffer  from  congestion  of  the  lungs  and 
from  bed-sores.  TJrfemia  is  the  principal  cause  of  death  in  the  aged  after 
operations. 

Sex. — Women  bear  operations,  especially  those  involving  the  perito- 
neum, better  than  men.  Their  "expectation  of  life"  at  from  twenty  to  forty 
years  is  better.  They  are  accustomed  to  a  sedentary  life  and  confinement  to 
bed.  Menstrual  ditficulty  accustoms  them  to  pain  and  recovery  from  hemor- 
rhage, and  causes  slight  repeated  infectious  of  the  peritoneum,  which  render 
it  immune  to  some  extent. 


CONDITIONS  AFFECTING   OPERATIONS.  87 

Pregnancy. — Operations  should,  if  possible,  be  avoided  during  preg- 
nancy. Patients  in  this  condition  may  as  the  result  of  oi^eration  abort, 
which  accident  adds  greatly  to  the  danger  of  the  operation.  Operations 
of  necessity,  however,  have  often  to  be  iDcrformed  upon  x^regnant  women, 
and  often  result  satisfactorily.  We  have  seen  a  number  of  successful  ab- 
dominal sections  during  pregnancy  without  abortion.  We  have  also  seen  a 
successful  amputation  of  the  femur  in  a  woman  advanced  in  pregnancy,  and 
Keen  has  had  a  successful  amputation  of  the  hip-joint  in  a  pregnant  woman, 
but  only  stringent  necessity  justifies  such  operations. 

Lactation  does  not  affect  operations,  but  malignant  tumors  of  the  breast 
grow  more  rapidly  during  lactation  and  pregnancy. 

Menstruation  contraindicates  operations  upon  the  vagina  and  uterus, 
and  those  in  the  region  of  the  vulva  on  account  of  the  risk  of  infection  by 
the  discharge,  but  has  no  marked  influence  upon  those  in  other  j)ortions  of 
the  body.  The  menopause  has  no  marked  influence  as  regards  the  result  of 
operations. 

Feeble  Patients. — Those  who  have  been  reduced  to  the  condition  of 
extreme  exhaustion,  for  instance,  by  suppuration  of  one  of  the  larger  joints, 
often  bear  operations  in  a  remarkable  manner.  In  such  cases  the  patient's 
system  has  accommodated  itself  to  confinement,  and  the  relief  from  pain  and 
septic  intoxication  afforded  by  the  removal  of  the  diseased  joint  or  by  the 
amputation  of  the  limb,  and  the  cutting  off  of  the  drain  u^pon  the  system 
from  profuse  suppuration,  if  the  patient  withstands  the  shock  of  the  opera- 
tion, will  often  be  followed  by  a  very  prompt  recovery  and  a  remarkable 
improvement  in  the  constitutional  condition. 

Corpulent  Persons. — Corisulent  persons  after  middle  life  are  not  good 
subjects  for  operation,  often  presenting  a  sluggish  circulation  and  a  tendency 
to  piilmonary  congestion.  In  such  patients  confinement  in  bed  is  a\)t  to  be 
badly  borne  :  it  is  difficult  to  change  their  position,  they  are  apt  to  suffer 
from  bed-sores,  and  the  vitality  of  the  wound  itself  seems  to  be  largely 
affected  by  the  immense  amount  of  adii:)ose  tissue,  which  is  poorly  supplied 
with  blood,  so  that  repair  is  slow  and  imperfect. 

Gout  and  Chronic  Rheumatism. — Persons  suffering  from  gout  and 
chronic  rheumatism  are  not  unfa^'orable  subjects  for  operation,  if  it  is  not 
done  during  an  acute  attack  of  either  of  these  diseases.  It  should  always 
be  remembered  that,  although  the  diathesis  itself  does  not  affect  the  result, 
there  may  be  present  cardiac  or  renal  changes  which  will  have  some  influ- 
ence upon  it. 

Alcohohsm. — Persons  suffering  fi'om  chronic  alcoholism,  whose  di- 
gestive and  excretory  organs  are  deranged,  whose  nervous  system  is  ex- 
hausted, and  whose  power  of  assimilating  food  is  diminished,  are  the  worst 
possible  subjects  for  surgical  operations.  Operations  in  this  class  of  patients 
should  be  undertaken  with  great  caution,  and  as  far  as  possible  should  be 
restricted  to  those  which  are  urgent  and  necessary  to  save  life.  It  is  not 
only  in  the  hard  drinkers  that  the  constitutional  effects  of  alcohol  may  com- 
plicate operations  unfavorably,  but  also  in  the  class  of  patients  who  use  alco- 
hol habitually  but  never  to  the  point  of  intoxication.  Serious  operations  in 
alcoholics  occasionally  do  remarkably  well,  but  at  other  times  wound  com- 


88  CONDITIONS  AFFECTING   OPERATIONS. 

plications  develop,  and  the  patient,  even  after  lie  has  abstained  from  alcohol 
for  some  weeks,  may  after  an  operation  or  a  severe  injury  suddenly  develop 
an  attack  of  delirium  tremens. 

Condition  of  the  Urine. — Examination  of  the  urine  should  be  made  in 
all  cases  where  it  is  possible  before  subjecting  patients  to  serious  operations, 
as  information  obtained  from  this  source  may  result  in  a  modification  of  the 
operation. 

Diabetes. — Diabetics  are  generally  considered  most  unfavorable  subjects 
for  surgical  operations.  All  authorities  are  agreed  upon  the  unfavorable 
course  of  wounds  and  the  gravity  of  operations  in  diabetic  patients.  Strict 
asepsis,  however,  has  rendered  operations  in  these  subjects  more  favorable. 
Amputations  in  diabetic  subjects  are  often  required  and  are  frequently  suc- 
cessful. 

Chronic  Nephritis. — No  variety  of  visceral  disease  alfects  the  results 
of  operations  so  unfavorably  as  chronic  nephritis,  and  grave  operations 
should  not  be  undertaken  upon  patients  suffering  from  this  affection  unless 
urgently  called  for  to  save  life.  A  patient  suffering  from  nephritis  may 
present  a  fairly  healthy  appearance,  especially  in  cases  of  contracted  kid- 
ney, where  no  albumin  is  detected  in  the  urine.  A  trifling  operation  on 
such  a  subject  may  be  a  most  serious  and  dangerous  procedure.  Ether  is  a 
dangerous  antesthetic  when  the  patient  suffers  fi-om  nephritis.  When  dimi- 
nution or  suppression  of  urine  occurs  after  an  operation,  with  a  hard,  tense 
pulse,  the  administration  of  nitroglycerin  accompanied  with  strychnine  is 
often  of  great  service.  In  such  cases  we  have  successfully  employed  venesec- 
tion, removing  a  quart  of  blood  and  replacing  the  blood  at  once  by  an  equal 
amount  of  saline  solution  introduced  by  intravenous  injection  or  infusion. 

Cardiac  Disease. — Patients  who  suffer  from  valvular  disease  of  the 
heart  do  not  seem  to  be  especially  unfavorable  subjects  for  operation,  if  the 
valvular  lesion  has  been  compensated  for,  but  those  who  suffer  from  a 
feeble  or  fatty  heart  are  especially  exposed  to  risk  from  the  shock  of  the 
operation.  It  has  been  pointed  out  by  Verneuil  that  cardiac  affections  may 
affect  the  results  of  operations  unfavorably  by  causing  oedema,  passive 
hemorrhages,  thrombosis,  and  embolism.  The  results  of  operations  uijon 
patients  suffering  from  aneurism  of  the  larger  arteries  do  not  seem  to  be 
particularly  unfavorable. 

Bronchitis. — This  condition  is  aggravated  by  the  use  of  ether,  and  the 
coughing  may  prove  a  serious  complication  after  laparotomy  and  the  opera- 
tion for  the  radical  cure  of  hernia,  as  it  causes  pain  and  jeopardizes  the 
soundness  of  the  scars.  Operations,  therefore,  should  be  avoided  if  possible 
when  this  condition  exists. 

Atheroma  of  the  arteries  does  not  appear  to  exercise  a  markedly 
unfavorable  influence  upon  the  results  of  operations.  Our  own  experience 
with  amiDutations  of  limbs  in  which  atheromatous  vessels  were  present  would 
lead  us  to  believe  that  secondary  hemorrhage  is  not  more  likely  to  occur  than 
in  wounds  of  healthy  vessels ;  the  principal  risk  in  amputations  in  these 
cases  is  from  sloughing  of  the  flaps. 

Diseases  of  the  Liver. — Verneuil  has  pointed  out  that  affections  of  the 
liver  exercise  a  very  serious  influence  upon  operations  and  injuries.     Cir- 


CONDITIONS  AFFECTING  OPERATIONS.  89 

rliosis  and  fatty  and  amyloid  degeneration  of  the  liver  should  be  considered 
conditions  which  render  the  results  of  surgical  operations  most  unfavorable, 
and  in  subjects  sulfering  from  these  affections  only  operations  of  urgency 
should  be  undertaken. 

Diseases  of  the  Nervous  System. — Insane  patients  usually  bear 
operations  extremely  well  if  they  are  otherwise  healthy  and  do  not  require 
restraint ;  if,  however,  they  sufler  from  chronic  melancholia  or  dementia, 
they  are  apt  to  be  broken  down  in  health,  and  are  then  very  unfavorable 
subjects.  Persons  suffering  from  diseases  of  the  nervous  system,  such  as 
ataxia,  paralysis,  or  chorea,  or  those  who  have  received  injuries  of  the  brain 
or  spinal  cord,  are  not  good  subjects  for  operative  procedures. 

Tuberculosis. — The  subjects  of  tuberculosis  are  not,  as  a  rule,  unfavor- 
able ones  for  operative  i^rocedures,  and  this  is  especially  true  in  the  case  of 
children.  If,  however,  there  is  serious  visceral  disease,  tuberculous  indi- 
viduals are  not  good  subjects  for  operative  procedures,  especially  if  advanced 
in  years.  Woiinds  often  heal  very  ijromptly  in  tuberculous  patients,  but  are 
apt  to  break  down  and  reopen. 

Syphilis. — Syphilis  does  not  appear  to  affect  unfavorably  to  any  marked 
extent  the  repair  of  wounds  or  the  course  of  operations.  The  healing  of 
woiinds  seems  to  be  practically  unaffected  even  in  secondaiy  syphilis  ;  but 
they  may  subsequently  break  down,  so  that  preliminary  antisyphilitic  treat- 
ment is  indicated  in  these  cases  before  operation.  In  the  later  stages  of  the 
disease,  if  the  wound  involves  tissues  affected  by  gummatous  infiltration,  its 
repair  is  usually  unsatisfactory,  and  healing  may  not  be  accomplished  until 
constitutional  treatment  has  been  administered. 

Epidemics. — The  question  of  operating  during  the  prevalence  of  epi- 
demics should  be  carefully  considered  by  the  surgeon,  and,  as  a  rule,  unless 
the  case  be  a  most  urgent  one,  operative  interference  should  be  postponed 
until  different  conditions  prevail. 

Weather. — Operations  should  also  be  avoided  if  possible  during  very 
hot  weather,  although  the  ordinary  weather  of  summer  is  not  unfavorable  for 
operative  procedures.  This  should  be  particularly  observed  in  the  case  of 
young  children,  as  hot  weather  often  gives  rise  to  intestinal  affections,  which 
complicate  unfavorably  the  result  of  an  operation.  We  have  seen  both 
children  and  adults  die  of  heat-stroke  or  heat  exhaustion  after  operations 
during  extremely  hot  weather.  It  is  possible  also  that  atmospheric  condi- 
tions, such  as  dryness,  humidity,  and  electrical  disturbances,  have  some 
effect  upon  the  results  of  operations. 

Hsemophilia. — Hiemophilia,  or  the  hemorrhagic  diathesis,  is  a  congeni- 
tal, constitutional  condition  in  which  the  subjects  are  liable  to  severe  and 
obstinate  hemorrhage,  which  may  be  spontaneous  or  follow  injuries,  often 
very  slight  ones.  The  condition  is  usually  hereditary,  and  is  apt  to  affect 
males  rather  than  females,  although  it  may  be  transmitted  by  females  to  their 
offspring.  The  subjects  of  this  condition  are  commonly  known  as  "bleeders." 
These  patients  often  lose  a  large  amount  of  blood,  and  present  marked  con- 
stitutional signs  of  excessive  hemorrhage,  but  usually  recover  very  rapidly 
when  the  bleeding  is  arrested. 

The  pathology  of  hsemophilia  has  never  been  satisfactorily  explained. 


90  CONDITIONS  AFFECTING   OPERATIONS. 

It  lias  been  stated  tliat  tlie  ■walls  of  the  arteries  ia  this  condition  are  abnor- 
mally thin,  especially  the  intima.  ISo  other  evidence  of  abnormality  in  the 
vascular  system  has  been  observed. 

A.  patient  possessing  this  constitutional  condition  will  often,  upon  the 
reception  of  a  slight  wound,  such  as  a  scratch,  or  an  incision  of  the  skin,  or 
the  extraction  of  a  tooth,  suffer  from  a  continuous  and  profuse  hemorrhage 
■which  may  prove  fatal.  Contusions  may  be  followed  by  extensive  sub- 
cutaneous hemorrhage.  A  spontaneous  hemorrhage  may  occur  from  the 
mucous  membrane  or  from  the  serous  surface  of  the  synovial  membrane  of 
the  joints.  The  diathesis  usually  manifests  itself  at  the  beginning  of  the 
first  dentition  or  at  puberty,  and  there  has  been  noted  in  these  cases  a  ten- 
dency to  swollen  and  painful  joints  due  to  effusion  of  blood  into  them,  and 
muscular  pains  often  mistaken  for  rheumatism.  The  condition  is  certainly 
not  common,  or  more  cases  would  be  observed  by  surgeons  in  extensive  hos- 
pital work.  The  few  cases  we  have  observed  have  occurred  in  wounds  of 
the  lips  and  mouth,  castration,  radical  cure  of  hernia,  and  epistaxis,  and 
these  generally  ended  in  recovery. 

Treatment. — In  cases  of  spontaneous  hemorrhage  the  patient  should 
be  kept  at  rest  in  the  recumbent  posture,  and  should  be  given  acetate  of  lead 
and  ergot  in  full  doses.  In  traumatic  hemorrhage,  if  a  cavity  exists,  it 
should  be  firmly  plugged  with  iodoform  gauze,  or  the  actual  cautery  may  be 
applied,  or,  if  the  bleeding  be  from  an  incision,  a  compress  should  be  firmly 
applied,  and  at  the  same  time  the  patient  should  be  given  constitutional 
treatment.  Monsel's  solution  and  solutions  of  adrenal  chloride  and  gelatin 
have  also  been  successfully  employed.  Transfusion  of  blood  has  been  prac- 
tised in  these  cases,  but  apparently  has  been  of  little  service,  and  the  wound 
made  in  its  performance  subjects  the  patient  to  the  risk  of  additional  bleed- 
ing, so  that  infusion  of  saline  solution  should  be  preferred. 


CHAPTEE  X. 

SHOOK,  TRAUMATIC  FEVER,  DELIRIUM  TREMENS,  FAT  EMBOLISM. 
By  Heney  E.  Whartos,  M.D. 

Shock,  or  collapse,  is  a  condition  of  physical  depression  or  prostration 
of  the  vital  functions,  especially  of  the  circulation,  which  generally  occurs 
after  severe  injuries  or  operations,  and  should  not  be  confounded  with  syn- 
cope, which  is  a  condition  essentially  due  to  auremia  of  the  brain,  and  may 
result  from  mental  perturbation,  from  pain,  from  actual  loss  of  blood,  or 
from  the  derivation  of  blood  from  one  part  of  the  body  to  another,  as  occurs 
in  the  syncope  following  the  too  rapid  removal  of  a  large  quantity  of  fluid 
from  the  abdominal  cavity.  The  condition  which  suiDervenes  upon  serious 
injuries  of  the  head  and  spine  is  often  confounded  with  shock  ;  the  two  con- 
ditions may  coexist,  and  it  is  often  difficult  to  differentiate  them  in  such 
cases.  That  shock  may  be  developed  independently  of  mental  emotions  is 
evidenced  by  the  fact  that  it  often  manifests  itself  during  complete  anaes- 
thesia. Shock  may  develop  immediately  upon  or  some  time  after  the  recep- 
tion of  the  injury.  The  rapidity  of  its  development  is  best  shown  in  cases 
where  vigorous  subjects  meet  with  serious  accidents,  such  as  crushes  of  the 
limbs  or  body,  in  whom  there  develop  instantaneously  pallor  and  coldness 
of  the  skin,  feeble  respiration,  and  almost  imperceptible  pulse.  During 
operations  shock  may  be  developed  gradually,  except  when  important  struc- 
tures are  divided  ;  its  manifestation  may  then  be  very  sudden. 

Pathology. — Various  theories  have  been  advanced  to  explain  the 
pathology  of  the  condition  which  we  recognize  as  shock  :  it- has  been  attrib- 
uted to  paralysis  of  the  vasomotor  centres,  causing  dilatation  of  the  abdom- 
inal vessels,  which  become  so  distended  that  the  amount  of  blood  in  other 
parts  of  the  body  is  greatly  diminished.  Paralysis  of  the  vascular  tone  in 
the  arteries,  with  coincident  feebleness  of  the  action  of  the  heart,  causes  an 
unequal  distribution  of  the  blood,  and  the  balance  of  the  circulation  is  dis- 
turbed. The  abdominal  veins  become  distended  and  the  riglit  side  of  the 
heart  becomes  engorged,  and  thus  the  amount  of  blood  in  the  arteries  is 
correspondingly  lessened.  The  brain  and  lungs  become  antemic,  and  if  the 
condition  persists  the  action  of  the  heart  is  arrested.  The  view  which  is 
now  most  generally  accejated  is  that  shock  is  due  to  severe  irritation  of  the 
peripheral  ends  of  the  sensory  and  sympathetic  nei-ves,  producing  a  state  of 
exhaustion  of  the  medulla  and  pneumogastric  nerves,  or  a  general  functional 
paralysis  of  the  nerve-centres,  both  spinal  and  cerebral,  which  causes  arrest 
or  enfeeblement  of  the  cardiac  action  and  disturbed  respiratory  action. 
The  essential  condition  in  shock  is  inhibition  of  nerve-force  and  reflex 
paralysis. 

Death  from  shock  may  be  immediate  and  result  from  cardiac  arrest. 

91 


92  SHOCK. 

Post-mortem  examination  of  these  cases  visually  shows  the  right  cavities  of 
the  heart  and  the  great  venons  trunks  distended  with  blood. 

Causes. — Every  traumatism  is  probably  followed  by  a  certain  amount 
of  shock,  but  it  may  be  so  slightly  developed  as  to  escaj)e  observation,  and, 
as  a  rule,  the  degree  of  shock  is  proportionate  to  the  severity  of  the  injury 
received.  Yet  this  rule  is  not  without  exception  ;  certain  classes  of  injuries 
are  attended  with  marked  shock,  and  the  part  of  the  body  sustaining  the 
injury  will  have  an  important  influence  upon  the  degree  of  the  development 
of  shock.  Contusions  of  the  viscera,  wounds  of  the  testicle,  contused  and 
lacei-ated  wounds  of  the  trunk  and  extremities,  if  extensive  and  accompanied 
by  free  hemorrhage,  are  usually  followed  by  marked  and  often  fatal  shock. 
The  experimental  researches  of  Crile  have  largely  confirmed  our  clinical 
observations  as  regards  the  development  of  shook  in  injuries  and  operations 
in  different  regions  of  the  body.  Gunshot  wounds  causing  perforation  of 
important  cavities  of  the  body,  injuries  of  the  viscera,  and  shattering  of  the 
bones  are  also  well  recognized  as  giving  rise  to  shock  in  a  marked  degree. 

Burns  and  scalds  if  they  involve  a  considerable  surface  of  the  body  are 
attended  with  severe  shock,  and  those  who  see  this  class  of  injuries  cannot 
fail  to  be  impressed  with  the  profoundness  of  the  shock  and  its  very  frequent 
fatal  termination.  Excessive  loss  of  blood  certainly  renders  the  patient 
more  liable  to  the  development  of  shock. 

Symptoms. — A  patient  suffering  from  shock  presents  pallor  of  the 
surface,  paleness  of  the  lips,  dilated  pujiils,  clammy  moisture  of  the  skin, 
muscular  debility,  occasionally  relaxation  of  the  sphincters,  frequent,  feeble, 
irregular  x^ulse,  subnormal  temperature,  and  feeble,  short,  sighing  respira- 
tion ;  in  many  cases  extreme  thirst  is  a  prominent  symptom.  The  senses 
are  often  perfectly  retained  ;  occasionally  there  is  diminished  sensibility,  or 
the  patient  may  be  in  a  drowsy  condition  and  indifferent  to  surrounding 
objects.  The  temj)erature  is  always  subnormal,  and  may  vary  from  a  point 
a  little  below  the  normal  to  a  point  below  90°  P.  (32°  C).  A  depression 
of  temperature  below  97°  P.  (36°  C),  if  it  persists  for  a  few  hours,  usually 
indicates  a  grave  condition  of  shock,  and  reaction  may  not  occur,  although 
it  has  been  observed  in  cases  where  the  temperature  was  as  low  as  90°  P. 
(32°  C).  We  have  seen  reaction  occur  in  a  case  where  the  temperature 
remained  at  92°  P.  for  a  short  time.  The  condition  of  shock  may  persist 
from  a  few  hours  to  thirty-six  hours,  reaction  or  death  usually  occui-ring 
before  the  latter  period. 

Diagnosis. — The  condition  of  collapse  resulting  from  purely  emotional 
causes  is  usually  not  profound  or  prolonged,  and  can  readily  be  differentiated 
from  that  resulting  from  corporal  injuries  by  the  history  of  the  case.  The 
condition  arising  from  excessive  hemorrhage  presents  many  symptoms  in 
common  with  shock,  but  here  the  nature  of  tlie  injury  will  often  assist  in 
the  diagnosis,  and  in  doubtful  cases  an  examination  of  the  blood  may  be  of 
service,  for  if  such  an  examination  shows  that  the  red  blood-cells  are  con- 
siderably diminished,  being  3,500,000  or  less,  it  is  probable  that  the  con- 
dition is  due  to  hemorrhage  rather  than  shock.  Fat  embolism  may  also  be 
confounded  with  shock,  but  it  should  be  remembered,  in  differentiating 
the  conditions,  that  shock  usually  appears  promptly,  while  the  symptoms 


REACTION   FROM  SHOCK.  93 

of  fat  embolism  generally  appear  from  tbirtj^-six  hours  to  three  clays  after 
the  injury. 

Reaction  from  Shock. — When  a  patient  recovers  from  shock  he  passes 
through  a  stage  of  reaction  which  is  characterized  by  a  rise  of  temperature 
which  may  reach  or  pass  slightly  above  the  normal ;  the  skin  loses  its  pallor 
and  assumes  a  natural  appearance,  becomes  warm,  and  the  moisture  which 
covered  it  disappears ;  the  pulse  grows  fuller  and  stronger,  the  respirations 
deeper,  and  the  patient  is  apt  to  change  his  position  and  may  fall  into  a 
natural  sleep.  All  things  being  equal,  the  longer  the  symptoms  of  reaction 
are  delayed  the  graver  is  the  prognosis. 

Eeaction  may  be  incomplete,  and  the  patient  exhibit  evidences  of  cere- 
bral excitement,  i^resenting  a  dry,  hot  skin,  flushed  face  and  anxious  ex- 
pression, rapid  and  compressible  pulse,  hurried  respiration,  restlessness, 
jactitation,  and  delirium  of  various  degrees,  a  condition  which  has  been 
described  by  Travers  asjn'ostration  with  excitement.  The  reaction  from  shock 
may  also  be  excessive,  the  temperature  rising  much  above  the  normal,  and 
being  accompanied  with  great  mental  excitement,  constituting  a  condition 
which  is  termed  trcmmatic  deliriimi.  There  is  a  form  of  reaction  from  shock 
in  which  the  temperature  rises  very  suddenly,  and  may  reach  a  point  sev- 
eral degrees  above  the  normal  in  a  short  time,  and  there  is  no  corresponding 
improvement  in  the  iDulse  or  respiration,  the  patient  becoming  gradually 
comatose  ;  these  cases  we  have  always  seen  terminate  fatally  in  a  few  hours. 
Excessive  reaction  from  shock,  if  it  has  been  delayed,  is  said  by  some 
observers  to  be  due  to  seiitic  intoxication,  and  this  view  is  sustained  by  the 
fact  that  excessive  reaction  is  much  less  frequently  seen  now  than  it  was 
befoi-e  the  introduction  of  the  modern  methods  of  wound  treatment.  No 
more  distressing  or  discouraging  cases  come  under  the  care  of  the  surgeon 
than  those  suffering  from  profound  shock.  Often  in  this  condition,  in  spite 
of  the  most  careful  treatment,  reaction  does  not  occur,  and  the  surgeon  is 
comiDelled  to  see  a  patient  who  has  met  with  a  serious  accident,  who  was  a 
few  hours  before  in  robust  health,  rapidly  die  of  shock. 

Prophylaxis  of  Shock. — Eecognizing  the  dangers  which  the  condi- 
tion of  shock  entails,  treatment  to  prevent  its  development  is  worthy  of 
consideration.  Unfortunately,  many  of  the  worst  cases  of  shock  are  due  to 
accidents,  and  here  treatment  can  be  directed  only  to  the  condition  of  shock 
itself,  but  the  surgeon  is  often  able  to  diminish  to  some  extent  the  amount 
of  shock  following  operations  by  judicious  prophylactic  treatment.  The 
elaborate  antiseptic  details  employed  in  operations  at  the  present  time  tend 
to  favor  the  development  of  shock.  In  oi^erations  upon  patients  in  whom 
his  experience  teaches  him  that  shock  is  apt  to  be  markedly  developed,  as 
in  children  or  feeble  or  aged  subjects,  or  in  certain  classes  of  operations, 
he  may  give  the  patient  stimulants  before  the  operation,  and  also  see  that 
the  surface  of  the  body  is  not  unnecessarily  exposed  to  chilling  during  the 
operation,  that  the  field  of  operation  is  isolated  by  dry  sterilized  towels  or 
sheets  rather  than  by  those  wet  with  antiseptic  solutions,  that  the  operation 
is  not  needlessly  prolonged,  and  that  as  little  blood  as  possible  is  lost  during 
its  performance.  The  trunk  should  be  exposed  as  little  as  possible  and  the 
lower  extremities,  if  not  involved  in  the  operation,  should  be  covered  with 


94  PROPHYLAXIS  OF  SHOCK. 

woollen  stocklDgs  or  drawers  or  flannel  bandages.  The  bodily  temj)erature 
may  also  be  maintained  by  surrounding  the  patient  with  hot- water  bags  or 
hot-water  bottles.  Irrigation  of  the  wound  with  antiseptic  solutions  should 
also  be  avoided  as  far  as  possible,  and  if  irrigation  is  employed  hot  solutions 
should  be  preferred.  Prolonged  exposure  of  the  brain  and  abdominal  vis- 
cera should  as  far  as  possible  be  avoided.  The  electro -thermic  mattress  may 
be  used  with  advantage,  but  care  should  be  exercised  that  too  great  an 
amount  of  heat  is  not  developed,  as  serious  electric  burns  have  oc- 
curred from  the  use  of  this  appliance.  The  previous  administration  of  an 
ounce  of  whiskey  and  the  hypodermic  injection  of  from  one-twentieth  to 
one-thirtieth  of  a  grain  of  sulphate  of  strychnine  with  from  two  to  three 
grains  of  caffeine  citrate,  and  sometimes  the  use  of  a  small  dose  of  morphine, 
in  feeble  and  aged  patients,  will  often  be  followed  by  good  results.  A  full 
dose  of  quinine  given  an  hour  or  two  before  the  operation  is  also  said  to 
arrest  the  development  of  shock. 

Treatment. — The  first  indication  in  the  treatment  of  shock  is  to  estab- 
lish reaction,  and,  as  death  from  shock  is  usually  due  to  cardiac  arrest,  such 
means  should  be  employed  as  will  stimirlate  the  cardiac  action.  The  patient 
should  be  covered  with  woollen  blankets,  the  head  should  be  kept  low,  and 
dry  heat  should  be  applied  to  the  surface  of  the  body  by  means  of  hot- water 
bags,  hot  bottles,  or  hot  bricks  ;  these  should  be  wrapped  in  towels  to  pre- 
vent them  from  coming  directly  in  contact  with  the  surface  of  the  patient's 
body  ;  neglect  of  this  precaution,  which  is  most  important  if  the  patient  is 
unconscious,  often  produces  burns  which  may  be  followed  by  extensive 
sloughing.  If  the  patient  can  swallow,  he  should  be  given  small  quantities 
of  whiskey  or  brandy,  with  thirty-drop  doses  of  aromatic  spirit  of  ammonia, 
and,  as  absorption  by  the  stomach  is  probably  A^ery  slow  in  these  cases, 
stimulants  should  be  administered  hypodermically  :  in  our  judgment,  strych- 
nine is  the  most  valuable  stimulant  that  can  be  employed.  From  one- 
twentieth  to  one-thirtieth  of  a  grain  should  therefore  be  injected,  and  the 
injection  shoiild  be  repeated  every  hour  or  half-hour  until  several  doses 
have  been  given.  Sulphuric  ether,  thirty  minims,  may  also  be  injected  into 
the  cellular  tissue  at  intervals,  as  well  as  digitalin  or  tincture  of  digitalis. 

If  shock  develops  during  an  operation  under  ether  anaesthesia,  the  use 
of  ether  hypodermically  is  contraindicated.  A  stimulating  enema  of  whis- 
key and  warm  water  may  be  employed.  In  cases  of  shock  where  there  is 
profuse  sweating,  the  use  of  one-sixtieth  of  a  grain  of  atropine,  repeated  as 
required,  is  often  followed  by  good  results.  A  large  enema  of  warm  saline 
solution  may  also  be  employed.  As  patients  often  complain  of  urgent  thirst, 
it  is  well  to  let  them  take  a  little  black  coffee,  but  not  large  quantities  of 
water  ;  free  indulgence  in  water  does  not  seem  to  quench  the  thirst,  and  is 
apt  to  be  followed  by  vomiting.  Intravenous  injection  or  iufusion  of  saline 
solution  may  be  employed  with  good  results,  and  is  likely  to  be  of  the  most 
service  when  the  condition  has  been  i^receded  by  the  loss  of  a  large  quantity 
of  blood. 

The  surgeon  should  treat  the  condition  actively,  and  should  not  be  dis- 
couraged if  reaction  is  slow,  for  reaction  and  subsequent  recovery  have 
often  occurred  in  apparently  hopeless  cases. 


SECONDARY  SHOCK.  95 

Operations  during  Shock. — The  question  of  operation  during  sliock 
often  confronts  the  surgeon,  and  we  think  it  is  generally  conceded  that  when 
an  operation  is  not  immediately  necessary  to  save  life  it  is  better  to  postpone 
its  performance  until  reaction  has  occurred.  Modern  methods  of  wound 
treatment,  although  they  have  in  no  way  diminished  the  development  of 
shock,  allow  us  to  M^ait  for  reaction  without  increasing  the  danger  to  the 
patient  from  infection  of  the  wound  ;  in  such  cases  the  region  of  the  wound 
and  the  wound  itself  should  be  thoroughly  disinfected,  and  an  antiseptic  or 
aseptic  dressing  should  be  applied.  The  cases  in  which  this  question  is  to 
be  considered  are  usually  those  of  crushes  of  the  extremities  requiring  am- 
putation, or  gunshot  or  stab  wounds  of  the  abdomen  ;  in  the  former  cases  it 
is  better  to  control  hemorrhage  and  direct  attention  to  bringing  about  reac- 
tion from  the  condition  of  shock.  In  cases  where  it  is  impossible  to  control 
the  bleeding  or  where  the  means  of  controlling  the  bleeding  cause  the  patient 
great  pain,  and  his  temperature  is  not  below  97°  P.,  it  may  be  justifiable  to 
administer  ether,  and  if  the  patient's  condition  improves  under  its  employ- 
ment, the  amputation  may  be  jjerformed,  often  with  success.  In  gunshot  or 
stab  wounds  of  the  abdomen,  even  if  the  patient  presents  marked  symptoms 
of  shock  and  exhibits  signs  of  internal  hemorrhage,  this  condition  should 
not  deter  the  surgeon  from  opening  the  abdomen  to  close  visceral  wounds  or 
control  hemorrhage,  for  if  operative  treatment  is  not  instituted  death  is 
almost  certain. 

Secondary  Shock. — This  condition  of  shock  may  develop  after  re- 
action from  shock  is  comijlete,  or  after  operations  in  which  primary  shock 
was  not  marked.  The  history  of  secondary  shock  is  usually  as  follows  : 
a  patient  who  has  reacted  from  shock,  and  is  doing  well  twenty-four  or 
thirty-six  hours  afterwards,  suddenly  again  develops  marked  symptoms  of 
shock.  It  is  at  the  present  time  rarely  seen,  but  is  mentioned  by  the  older 
writers  as  a  frequent  cause  of  death  after  operations  and  injuries.  The  pos- 
sibility that  the  occurrence  of  fat  embolism  is  responsible  for  the  symptoms 
presented  in  this  condition  should  not  be  overlooked.  It  is  characterized 
by  the  usual  symj)toms  of  shock,  and  is  a  very  fatal  complication  of  injuries 
or  operations.  The  iiathology  of  this  secondary  shock  is  explained  by  the 
formation  of  heart- clots,  which  embarrass  the  action  of  the  heart  or  indi- 
rectly lead  to  the  occurrence  of  embolism.  Modern  writers  incline  to  the 
view  that  it  is  caused  by  intense  septic  intoxication,  due  to  infective  changes 
taking  place  in  the  wound.  The  latter  view  would  seem  to  be  sustained  by 
the  fact  that  secondary  shock  is  very  rarely  seen  as  a  complication  of  wounds 
or  oiierations  at  the  present  time,  when  rigid  aseptic  methods  are  adopted. 
It  is  well  for  the  surgeon  to  bear  in  mind  the  jjossibility  of  the  development 
of  secondary  shock  after  serious  operations  and  injuries,  and  to  guard  against 
its  occurrence  as  far  as  possible.  The  administration  of  carbonate  of  am- 
monium in  five-grain  doses,  or  of  thirty-drop  doses  of  aromatic  spirit  of 
ammonia,  every  two  hours  for  the  first  twenty-four  hours,  and  then  at  less 
frequent  intervals,  is  strongly  recommended. 

Traumatic  Fever. — In  the  repair  of  wounds  after  operations  or  inju- 
ries there  is  usually  present  a  certain  amount  of  constitutional  disturbance, 
depending  upon  the  processes  taking  place  in  the  wound.     If  the  wound 


96  TRAUMATIC  FEVER. 

remains  aseptic  the  disturbance  is  slight ;  if,  however,  suppuration  or  spe- 
cific infection  occurs,  the  constitutional  disturbance  becomes  very  marked. 
We  now  recognize  two  forms  of  fever  which  may  be  developed  during  the 
rejiair  of  wounds, — aseptic  fever,  and  traumatic  or  inflammatory  fever. 

Aseptic  Fever. — This  is  a  rise  of  temperature  following  operations  and 
injuries  due  to  the  absorption  of  nou-pyogenic  substances,  serum,  blood- 
clot,  sterile  toxines,  urine,  bile,  etc.  Many  aseptic  wounds  may  heal  with 
scarcely  any  febrile  disturbance,  but  it  is  not  unusual  in  such  wounds  to 
have  the  patient  develop  within  twenty-four  hours  a  slight  elevation  of 
temperature,  100°  to  102°  P.  (37.5°  to  39.4°  C),  which  in  a  few  days  returns 
to  the  normal.  A  similar  rise  of  temperature  is  occasionally  observed  for 
a  feAV  days  after  simple  fractures.  The  i>atient  usually  presents  no  disturb- 
ance other  than  the  slight  fever,  and  comj)lains  of  no  ill  feeling,  and  the 
condition  requires  no  special  treatment,  but  the  surgeon  must  beware  of 
attributing  every  rise  of  temperature  to  this  cause,  for  in  the  great  majority 
of  cases  the  fever  is  to  be  charged  to  slight  infection. 

Traumatic  or  Inflammatory  Fever. — This  is  a  rise  of  temperature 
caused  by  the  absorption  of  toxines  and  bacteria  of  the  pyogenic  varieties. 
In  the  repair  of  wounds  which  are  uot  aseptic  there  will  always  be  observed 
more  or  less  constitutional  disturbance.  Before  the  introduction  of  anti- 
septic and  aseptic  methods  in  wound  treatment  it  was  usual  to  have  this  con- 
dition develop  in  all  cases  of  open  wounds,  and  its  j)resence  was  considered 
an  essential  element  in  wound  repair.  Traumatic  fever  usually  runs  the 
following  course :  The  temperature  rises  gradually  after  the  infliction  of 
the  wound,  and  at  the  end  of  twenty-four  or  forty-eight  hours  reaches  101° 
or  102°  P.  (38.3°  or  39.4°  C),  with  a  slight  morning  remission;  it  may 
remain  about  this  point  for  a  few  days,  and  then  gradually  fall  to  the  normal. 
Coincideutly  with  the  rise  in  temperature  the  patient  exhibits  constitutional 
symptoms,  such  as  dryness  of  the  skin,  loss  of  appetite,  acceleration  of  the 
pulse,  and  diminution  of  the  excretions ;  the  edges  of  the  wound  become 
red  and  swollen,  and  more  or  less  purulent  discharge  escaiDCS  from  it.  The 
constitutional  disturbance  arises  from  the  absorption  of  septic  products  due 
to  the  growth  of  pyogenic  bacteria  in  the  wound.  If  the  discharges  have 
free  exit,  as  soon  as  the  wound  is  covered  with  granulations  the  fiu-ther 
absorption  of  septic  products  is  arrested,  the  temperature  falls,  and  the 
evidences  of  constitutional  disturbance  gradually  subside.  If,  however, 
there  is  free  suppuration  and  drainage  of  the  wound  is  imj)erfect,  the  pus 
may  burrow  through  the  tissues,  the  temperature  continues  elevated,  and 
the  constitutional  disturbance  is  still  marked. 

Treatment. — A  patient  who  presents  well-marked  traumatic  fever 
should  be  kept  at  rest,  and  should  be  allowed  a  nutritious  and  easily 
digested  diet,  milk,  broth,  and  semisolids  ;  a  milk  diet  is  the  best  if  it  can 
be  taken.  A  saline  laxative  is  often  employed  with  good  results,  and  the 
administration  of  a  diuretic  and  diaphoretic  fever  mixture  will  often  render 
the  patient's  condition  much  more  comfortable.  The  wound  should  also 
be  inspected,  and  if  pus  is  present  and  cannot  escape,  free  drainage  should 
be  provided  by  removing  sutures  and  introducing  a  drainage-tube,  or  by 
making  counteropenings  if  necessary.      In  such  an  inflamed  condition  of 


DELIRroM  TREMENS.  97 

the  wound  moist  cli'essiiigs  will  often  be  more  comfortable  than  dry  ones, 
and  will  facilitate  the  escape  of  pus. 

Traumatic  Delirium. — This  aifection  may  follow  injuries  or  opera- 
tions, and  may  be  developed  after  the  reaction  from  shock  has  been  well 
established.  Hunt  holds  that  it  Is  due  to  anaemia  or  functional  disturbance 
of  the  cortical  gray  matter  of  the  brain,  or  to  inflammation  of  the  cortex  or 
meninges.  It  may  be  developed  after  severe  operations  or  injuries,  or  after 
excessive  hemorrhage,  and  severe  pain  itself  accompanying  an  injury  may 
give  rise  to  this  condition  of  mental  aberration. 

Symptoms. — The  symptoms  of  traumatic  delirium  usually  appear  from 
twenty-four  to  forty-eight  hours  after  the  reception  of  the  injury  ;  the  patient 
develops  a  slight  elevation  of  temperatui-e,  acceleration  of  the  pulse,  constant 
muscular  action,  sleeplessness,  and  wandering  delirium,  and  usually  becomes 
very  locxuacious,  talking  incessantly  upon  many  subjects,  but  constantly  re- 
curring to  those  which  occupied  his  mind  immediately  before  the  injury. 
We  have  seen  a  school-boy,  who  had  received  on  his  way  from  school  a 
compound  fracture  of  the  skull  and  of  the  bones  of  the  leg,  develop  in  a  few 
hours  an  incessant  chattering  delirium,  repeating  the  multiplication-table  for 
thirty-six  hours,  apparently  without  a  minute's  intermission.  In  addition 
to  the  delirium,  patients  often  seem  bent  upon  removing  their  dressings, 
and  will  attemjit  to  move  fractured  members  unless  carefully  watched.  In 
hospital  practice,  where  the  majority  of  the  patients  are  addicted  to  the  use 
of  alcohol,  it  is  sometimes  a  matter  of  difficulty  to  say  whether  the  case 
is  one  of  ti'aumatic  delirium  or  delirium  tremens.  In  delirium  tremens 
tremulousness  of  the  hands  and  li]DS  is  a  marked  symptom ;  in  traumatic 
delirium  this  symptom  is  not  observed.  Death  may  result  from  trau- 
matic delirium,  aud  the  fatal  termination  of  these  cases  seems  to  be  due 
to  exhaustion. 

Treatroent. — In  the  treatment  of  this  affection  it  must  be  borne  in 
mind  that  the  condition  is  one  of  exhaustion,  and  stimulants  are  generally 
indicated.  The  j^atient  should  be  kept,  if  possible,  in  a  dark  room,  free 
from  any  excitement  or  noise,  an  ice-bag  should  be  applied  to  the  head,  con- 
centrated nourishment  should  be  administered  at  regular  intervals,  and  the 
administration  of  whiskey  should  be  guided  by  the  condition  of  the  pulse. 
The  drug  which  seems  to  be  followed  by  the  best  effects  in  this  condition  is 
opium  ;  this  should  be  administered  freely.  If,  however,  this  is  not  used, 
a  combination  of  chloral  hydrate,  five  grains,  and  bromide  of  potassium, 
ten  grains,  given  every  two  or  three  hours,  will  often  quiet  the  patient  and 
produce  sleep.  After  a  few  hours'  quiet  sleep  has  been  obtained,  when  the 
patient  awakes  he  is  usually  free  from  delirium. 

Delirium.  Tremens.— This  is  an  affection  of  the  nervous  system 
characterized  by  disturbed  mental  condition,  tremor  of  the  muscles,  and 
delirium,  which  not  infrequently  comes  on  after  operations  and  injuries  in 
persons  who  are  addicted  to  the  habitual  and  excessive  use  of  alcohol.  It 
may  follow  an  injury  received  while  the  patient  is  on  a  debauch,  or  may 
develop  upon  the  reception  of  an  injury  some  weeks  after  the  patient  has 
entirely  abstained  from  the  use  of  alcohol.  Patients  usually  recover  from 
an  attack  of  delirium  tremens,  but  occasionally  death  results  from  this  affec- 

7 


98  INSANITY   AFTER   OPEEATIONS. 

tion,  and  post- mortem  examinations  show  congestion  and  serous  exudation 
of  the  membranes  of  the  brain  and  ventricles. 

Symptoms. — The  development  of  this  affection  following  an  injury  is 
usually  rather  rapid  ;  the  patient  is  restless,  and  marked  tremor  of  the  mus- 
cles is  observed  ;  he  is  disinclined  to  take  food  and  does  not  sleep.  When 
the  disease  is  fully  developed,  the  muscular  tremor  is  increased,  there  is 
absolute  insomnia,  the  patient  is  extremely  restless,  attempts  to  remove  his 
dressings  and  to  get  out  of  bed,  is  delirious,  and  is  often  the  subject  of  delu- 
sions. He  imagines  persons  or  objects  are  present  to  do  him  an  injury,  and 
attempts  by  persuasion  or  threats  to  deter  them  from  their  purpose.  When 
the  delusional  stage  of  the  affection  is  well  developed,  the  patient  is  often  in 
an  excited  state,  both  mentally  and  physically.  The  temperature  is  usually 
elevated,  but  seldom  reaches  103°  F.  (39.5°  C). 

Treatment. — When  the  surgeon  observes  that  the  patient  is  threatened 
with  an  attack  of  delirium  tremens  he  can  often  ward  off  the  development 
of  further  symptoms  by  the  use  of  sedatives :  bromide  of  ijotassiitm  and 
chloral  in  full  doses  should  be  administered,  and  the  patient  should  be 
given  nourishment  in  a  concentrated  form  :  if  iinder  this  treatment  he  ob- 
tains sleep,  the  symptoms  usually  disappear  rapidly.  When  the  affection  is 
fully  developed,  it  is  often  necessary  to  restrain  the  patient  in  bed  by  securing 
the  arms,  legs,  and  body  by  bands  made  from  sheets,  care  being  taken  that 
they  are  so  applied  that  he  cannot  injure  the  parts  included  in  the  bands  by 
his  uncontrollable  movements.  It  is  a  matter  of  the  greatest  importance  to 
secure  sleep  for  the  patient :  hence  bromide  of  potassium  and  chloral  or 
mori^hine  should  be  freely  administered.  He  should  be  given  at  the  same 
time,  at  intervals  of  two  or  three  hours,  concentrated  nourishment,  milk, 
and  beef  tea,  and  the  addition  of  a  little  tincture  of  capsicum  or  Cayenne 
pepper  to  the  latter  will  often  be  found  of  great  advantage.  If  the  restless- 
ness does  not  subside  and  the  patient  is  not  able  to  retain  nourishment  and 
there  is  evidence  of  cardiac  failure,  it  may  be  necessary  to  administer  whiskey, 
aromatic  spirit  of  ammonia,  or  strychnine ;  it  is,  however,  not  often  that 
alcohol  has  to  be  resorted  to  in  these  cases.  In  some  cases  in  which  quiet 
cannot  be  obtained  by  these  means,  a  blister  applied  to  the  nape  of  the  neck 
will  be  followed  by  marked  amelioration  of  the  symptoms.  If  under  the 
treatment  of  sedatives  and  nourishing  food  sleep  is  obtained,  the  nervous 
symptoms  usually  disappear  rapidly  and  convalescence  is  soon  established. 
We  have  seen  patients  who  developed  delirium  tremens  after  injuries,  the 
acute  symptoms  having  subsided,  and  who  were  taking  nourishment  well, 
develop  a  condition  of  mental  disturbance,  characterized  by  mild  delirium, 
hallucinations,  insomnia,  restlessness,  and  tendency  to  get  out  of  bed,  this 
condition  being  always  more  marked  at  night  than  during  the  day  ;  this 
affection  we  have  seen  persist  for  some  weeks  and  finally  end  in  recovery. 
The  treatment  which  we  have  found  most  satisfactory  is  the  administration 
of  one-twentieth  of  a  grain  of  nitrate  of  strychnine  three  times  a  day  and  a 
full  dose  of  bromide  of  potassium  and  chloral  at  night. 

Insanity  after  Operations  or  Injuries.— A  form  of  insanity  de- 
scribed as  confusional  insanity  is  occasionally  observed  as  a  complication 
of  operations  and  injuries.     It  has  been  attributed  to  the  shock  of  the  opera- 


TEAUMATIC   HYSTERIA  OR  NEURASTHENIA.  99 

tion  or  injury,  or  to  the  nervous  tension  or  anxiety  preceding  the  operation, 
or  to  the  use  of  an  antesthetic.  It  has  been  most  often  observed  after  inju- 
ries of  the  head,  as  would  be  expected,  but  is  a  rare  sequela  of  surgical 
operations  ;  it  is  apt  to  occur  when  there  is  a  complete  absence  of  heredity, 
and  in  persons  free  from  any  neurotic  taint.  When  the  affection  develops 
after  an  injury  or  operation  there  is  usually  a  period  of  cxuiescence  of  from 
three  to  eight  days,  but  it  has  been  observed  as  late  as  eight  weeks  after  an 
operation.  When  it  occurs  after  the  emjjloyment  of  an  anaesthetic  it  is 
developed  directly  after  its  use.  Its  occurrence  has  also  been  attributed  to 
the  toxic  action  of  certain  drugs,  such  as  carbolic  acid  or  iodoform  employed 
in  the  dressing  of  wounds:  we  have  seen  a  case  develop  after  iodoform 
poisoning  in  an  elderly  man. 

That  it  may  occur  independently  of  the  use  of  autesthetics  or  drugs  is 
proved  by  its  occurrence  in  cases  of  injury  where  no  antesthetic  was  em- 
ployed, and  in  patients  in  whom  the  aseptic  method  only  was  employed. 
We  have  seen  the  affection  develop  after  the  operation  of  nephrectomy 
and  after  a  fracture  of  the  femur,  as  well  as  after  injuries  of  and  operations 
upon  the  brain.  In  the  majority  of  cases,  if  the  affection  is  moderately 
acute,  complete  recovery  follows.  A  slight  cerebral  disturbance  is  seen  in 
elderly  persons  after  injuries  or  operations,  especially  marked  at  night. 
This  can  often  be  avoided  by  having  them  sit  up  for  a  jpart  of  the  day  and 
by  giving  a  milk  xjunch  at  bedtime. 

Traumatic  Hysteria  or  Neurasthenia.— This  is  a  condition  which 
is  sometimes  observed  after  a  severe  physical  combined  with  a  mental 
shock.  The  subjects  of  this  affection  are  usually  those  who  have  been  in 
railway  accidents,  but  it  is  also  observed  after  other  accidents.  (See  Eail- 
way  Spine.)  The  affection  is  rarely  developed  after  surgical  operations. 
It  is  said  to  occur  most  frequently  in  middle  life,  and  is  observed  both  in 
males  and  in  females. 

Symptoms. — Patients  often  complain  of  uneasiness,  headache,  pain  in 
certain  portions  of  the  body,  relaxation  of  the  sphincters,  disturbance  of 
vision  and  of  the  sexual  organs,  incontinence  of  urine,  ijaralysis,  hyperses- 
thesia,  and  anesthesia.  Direct  injury  of  nerve-trunks  seems  to  j)redispose 
to  the  development  of  this  condition,  and  a  neurotic  temperament  also 
favors  it.  The  exciting  cause  of  the  condition  is  usually  an  injury,  and  the 
gravity  of  the  injury  seems  to  bear  no  direct  relation  to  its  development, 
rather  being  dependent  upon  the  terror  and  shocking  surroundings  at  the 
time  of  the  accident. 

Treatment. — Under  favorable  circumstances,  if  the  patient's  mind  can 
be  diverted  from  his  condition  and  the  element  of  expectancy  eliminated 
from  the  case  if  it  be  one  in  which  compensation  is  sought  for  by  settle- 
ment of  the  claim,  recovery  will  usually  take  place.  Isolation  of  the  patient 
from  sympathizing  friends,  the  use  of  tonics  and  massage,  with  faradism, 
and  a  form  of  rest  treatment  such  as  is  recommended  by  Weir  Mitchell 
will  often  be  followed  by  complete  recovery. 

Pat  Embolism. — This  affection  results  from  the  absorption  of  fluid 
fat  or  oil-globules  from  the  crushed  cancellated  structures  and  marrow  of 
the  bones,  or  from  other  adipose  tissue,  which  enter  the  circulation  and  are 


100  FAT  EMBOLISM. 

carried  to  the  heart,  and  then  to  the  pulmonary  capillaries,  giving  rise  to 
embolism  of  these  vessels  ;  the  fat  may  also  reach  the  capillaries  of  the  brain 
and  spinal  cord.  In  the  majority  of  cases  the  fat  is  probably  disposed  of 
in  the  liver  aad  kidneys. 

Fat  is  present  in  the  urine  after  fractures  of  the  bones,  either  simple  or 
compound,  in  two  forms,  as  fluid  fat  and  as  an  emulsion.  Scriba  demon- 
strated the  presence  of  fat  in  the  uriiie  from  two  to  four  days  after  the  injury 
in  eighty  per  cent,  of  cases  of  bone  injury,  including  simple  and  compound 
fractures,  operations  upon  bone,  and  inflammatory  condition  of  the  bones ; 
he  found  it  present  in  ninety  per  cent,  of  fractures  alone.  Halm  found  it 
present  in  twenty-eight  per  cent,  and  Eiedel  in  forty-two  per  cent,  of  the 
cases  examined,  but  both  of  these  observers  failed  to  recognize  the  emulsified 
form,  which  is  the  more  common.  Boyd  and  Horsley,  in  a  similar  investi- 
gation, found  its  presence  in  the  urine  exceptional. 

This  affection  following  fractures  must  be  comparatively  rare,  for  many 
surgeons  whose  experience  with  fractures  has  been  very  extensive  have  never 
seen  a  case.  We  have  personally  seen  two  cases  of  fat  embolism  following 
simple  fractures  which  resulted  in  death.  One  of  the  cases  was  a  boy  eight 
years  of  age,  who  by  a  fall  sustained  simple  fractures  of  the  bones  of  both 
thighs  and  of  both  arms,  and  of  the  upper  jaw :  he  did  well  for  ten  days, 
when  he  suddenly  developed  urgent  dyspnoea,  frothy  and  bloody  expectora- 
tion, delirium,  and  coma,  and  died  in  a  few  hours  ;  the  other  case  occurred 
in  a  simple  fracture  of  the  femur. 

Symptoms. — The  affection  usually  develops  suddenly  from  forty-eight 
to  seventy-two  hours  after  the  injury,  but  may  occur  at  a  much  later  period. 
It  is  characterized  in  mild  cases  by  restlessness,  sliglit  dyspnoea,  and  in- 
creased rapidity  of  the  pulse ;  these  symj)toms  may  last  for  a  few  hours 
and  gradually  subside.  In  more  severe  cases  there  are  developed  marked 
dyspnoea,  oedema  of  the  lungs,  frothy  and  bloody  expectoration,  cyanosis, 
delirium,  and  coma,  usually  leading  to  a  fatal  termination. 

Diagnosis. — Fat  embolism  following  injury  to  the  bones  is  most  likely 
to  be  confounded  with  shock  or  pulmonary  embolism,  but  a  differential 
diagnosis  can  usually  be  made  without  difliculty  if  the  time  of  the  appear- 
ance of  the  symptoms  is  noted.  The  symptoms  of  shock  usually  develop  in 
a  few  hours,  fat  embolism  not  often  before  three  days,  while  pulmonary 
embolism  appears  as  late  as  the  second  or  third  week. 

Treatment. — The  treatment  of  fat  embolism  complicating  fractures  con- 
sists in  securing  absolute  rest  of  the  injured  ijart  to  prevent  further  breaking 
up  or  dissemination  of  the  fat  at  the  seat  of  injury,  by  the  employment  of 
splints  or  other  fixation  apparatus.  The  next  indication  is  to  sustain  the 
action  of  the  heart  so  that  the  fat  may  be  forced  from  the  venous  to  the 
arterial  system,  where  it  may  undergo  oxygenation  or  saponification  in  the 
alkaline  blood.  This  may  be  accomplished  by  the  administration  of  digi- 
talis, strychnine,  and  alcohol ;  digitalis  is  esj)ecially  indicated  in  these  cases 
for  its  action  upon  the  kidneys.  The  inhalation  of  oxygen  has  been  recom- 
mended by  Park.  In  the  severer  cases,  unfortunately,  little  can  be  done  by 
treatment :  the  symptoms  develop  with  great  rapidity,  and  the  i^atient 
usually  dies  in  a  few  hours.     Cupping  the  chest  may  relieve  the  dyspnoea. 


CHAPTER    XL 

GANGRENE. 
By  Henry  E.  Wharton,  M.D. 

Gangrene  and  mortification  are,  terms  employed  to  indicate  the  death 
of  the  soft  tissues  in  smaller  or  greater  masses.  The  term  sloughing  is  also 
used  as  synonymous  with  gangrene,  and  the  dead  tissue  is  known  as  a  slough 
or  sphacelus.  The  essential  cause  of  gangrene  is  the  deprivation  of  the  tis- 
sues of  arterial  blood.  Gangrene  results  from  the  sudden  or  gradual  occlu- 
sion of  the  main  arteries  or  veins  of  the  part,  or  from  mechanical  injuries  to 
the  tissues,  as  seen  in  extensive  crushing  or  laceration,  mechanical  strangu- 
lation, or  the  devitalization  of  the  parts  by  heat,  cold,  or  caustic  siibstances. 
Gangrene  may  result  from  the  stasis  and  exudation  consequent  upon  inflam- 
mation, the  blood-vessels  themselves  being  so  compressed  that  their  function 
or  vitality  is  destroyed.  It  may  also  result  from  specific  infection  of  the 
tissues.  Localized  gangrene,  following  injuries  of  the  cerebrospinal  axis, 
is  sometimes  observed ;  here  the  predisijosing  cause  of  the  affection  is  a 
disturbance  of  the  vasomotor  equilibrium. 

The  terms  moist  and  d,nj  gangrene  are  employed  to  describe  two  condi- 
tions observed  in  gangrenous  tissue.  Dry  gangrene  results  where  the  tissues 
previous  to  their  death  have  been  drained  of  fluids  and  become  shrivelled, 
and  raijidly  lose  their  moisture  ;  slowly  developing  arterial  obstruction  is  usu- 
ally the  cause  of  this  form  of  gangrene.  Moist  gangrene  results  when  death 
occurs  in  tissues  which  are  full  of  fluids.  It  may  arise  from  acute  arterial 
obstruction,  but  is  most  commonly  due  to  venous  obstruction,  or  may 
result  from  simultaneous  arterial  and  venous  obstruction,  and  this  condition 
is  one  which  favors  the  development  of  putrefactive  organisms. 

In  both  dry  and  moist  gangrene,  when  the  gangrenous  process  is  arrested, 
the  dead  tissue  is  separated  from  the  living  by  a  process  of  inflammation  ; 
the  living  tissue  at  its  point  of  contact  with  the  dead  tissue,  and  for  some 
distance  from  it,  becomes  i-ed  and  swollen,  and  exhibits  all  the  signs  of  acute 
inflammation ;  the  line  of  intense  hypertemia  between  the  dead  and  living 
tissue  is  known  as  the  line  of  demarcation,  and  the  line  of  granulation  which 
separates  the  dead  tissue  from  the  living  is  known  as  the  line  of  separation. 
Separation  of  the  dead  tissue  is  effected  by  granulations,  which  spring  up 
from  the  living  tissue  as  the  result  of  inflammation,  and  there  is  also  a  cer- 
tain amount  of  ijus  secreted  from  the  granulations.  In  moist  gangTCue  the 
lines  of  demarcation  and  separation  are  most  fully  develoi^ed,  and  in  dry 
gangrene,  on  the  other  hand,  these  lines  are  usually  imperfectly  developed. 

Varieties  of  Gangrene. — It  is  difflcult  to  classify  definitely  the 
varieties  of  gangrene,  as  all  forms  are  essentially  due  to  the  same  cause, 
and  each  variety  has  symptoms  in  common  with  the  others.  Clinically  we 
recognize  three  varieties  of  gangrene, — gangrene  which  arises  from  vasctdar 

101 


102 


SENILE  GANGRENE. 


and  constitutional  couditious,  and  in  whicli  traumatism,  if  present,  plays 
little  part  in  its  development,  traumatic  gangrene,  and  infective  gangrene. 

Gangrene  from  vascular  and  constitutional  conditions  includes 
senile  gangrene,  sometimes  classified  as  anaemic  or  dry  gangrene ;  embolic 
gangrene,  gangrene  from  ergot,  white  gangrene,  symmetrical  gangrene,  or 
Eaj-naud's  disease,  and  diabetic  gangrene. 

Traumatic  gangrene  includes  direct  traumatic  gangrene,  indirect  trau- 
matic gangrene,  gangrene  from  burns,  scalds,  and  from  caustic  or  corrosive 
substances,  gangrene  from  frost-bite,  and  gangrene  from  pressure. 

Infective  gangrene  includes  traumatic  spreading  gangrene,  hospital  gan- 
grene, and  noma. 

Senile  Gangrene. — This  variety  of  gangrene,  also  termed  ansemic 
or  dry  gangrene,  occurs  especially  in  old  persons,  and  is  rarely  seen  in  sub- 
jects under  fifty  years  of  age.  Senile  gangrene  essentially  results  from  a 
gradual  diminution  of  the  arterial  blood-supply,  depending  u]3on  a  feeble 
heart,  or  upon  obstruction  of  the  arteries  by  atheromatous  deposits,  and 
sometimes  from  thrombosis  or  embolism,  the  return  of  venous  blood  being 
usually  not  interfered  with  in  this  form  of  gangrene.  Heidenhain  claims 
that  the  obstruction  is  never  entirely  due  to  endarteritis,  but  that  a  clot 
always  comj^letes  the  obstruction. 

Symptoms. — Typical  senile  gangrene  usually  develops  in  the  toes  and 
feet,  and  the  principal  symptoms  which  point  to  its  development  are  cold- 
ness, numbness,  pain,  and  ting- 
Fi°-  ■*!•  ling  in  the  feet  and  muscles  of 

the  leg.  Persons  about  to  be 
affected  with  this  form  of  gan- 
grene often  complain,  for  months 
before  any  local  signs  of  gan- 
grene are  apparent,  of  severe 
burning  pain  in  the  feet  at  night 
when  warm  in  bed.  A  trivial 
injury,  such  as  a  bruise,  the 
friction  of  the  shoe,  or  the  cut- 
ting of  a  corn,  may  act  as  the 
exciting  cause  of  the  affection. 
The  part  becomes  congested  and 
gradually  assumes  a  dark-pur- 
]3le  color,  finally  becoming  black 
and  dry  (Fig.  41)  :  it  is  insensi- 
tive, but  the  surrounding  parts 
are  congested  and  may  be  the 
seat  of  intense  pain.  The  dead 
part  becomes  black,  shrivelled,  and  dry,  and  emits  little  odor.  Senile  gan- 
grene usually  spreads  very  slowly  :  one  or  two  toes  may  first  be  involved, 
and  the  disease  may  gradually  spread  to  the  rest  of  the  foot  and  the  leg. 
(Fig.  42.)  There  may  be  little  fever  at  first,  but  if  a  large  extent  of  tissue 
is  involved  a  certain  amount  of  septic  fever  develops.  During  the  progress 
of  the  disease  pain  is  usually  present  to  a  greater  or  less  degree,  sometimes 


Senile  gangrene  ot  toe. 


SENILE  GANGRENE. 


103 


Fig.  42. 


being  iuteuse  ;  this  is  accounted  for  by  the  fact  that  the  nerves  are  usually 

the  last  structures  to  die.     During  the  course  of  the  disease  the  patient  loses 

much  sleep  from  the  continued  pain,  and  he  becomes  worn  out  and  may  die 

of  exhaustion.     In  this  form  of  gangrene  there  is  usually  no  well-marked 

attempt  at  the  formation  of  lines  of 

demarcation    and    separation,    but  in 

some  cases,    if  the   amount  of  tissue 

involved  is  small,  one  or  two  toes  oi' 

a  part  of  the  foot,  for  instance,  and  the 

patient's  strength  can  be  sustained,  the 

line  of  separation  forms,  and  the  dead 

tissue  may  be  cast  off,  leaving  the  bones 

exposed  in  the  wound. 

Treatment.  —  When  senile  gan- 
grene is  actually  developed,  the  part 
should  be  disinfected  thoroughly  and 
wrapped  in  dry  bichloride  gauze,  or  senile  gangrene  of  tiie  feet.   (Agnew.) 

in  bichloride  cotton.      Dry  dressings 

such  as  these  permit  evaporation  of  moisture  from  the  tissues  and  facilitate 
the  drying  of  the  parts.  Wet  dressings  and  ointments  should  not  be  em- 
ployed, as  they  soften  the  tissues  and  favor  decomposition.  The  constitu- 
tional condition  of  the  patient  also  requires  attention.  He  should  be  given 
a  generous  diet,  with  tonics,  and  care  should  be  taken  that  a  sufficient 
amount  of  sleep  is  obtained.  Pain  is  often  a  prominent  symptom,  and 
should  be  relieved  by  the  free  use  of  opium ;  the  deodorized  tincture  of 
opium  is  the  preparation  which  we  have  employed  with  good  results.  In 
some  cases  codeine,  given  in  doses  of  half  a  grain,  repeated  frequently,  acts 
well. 

The  question  of  amputation  often  requires  the  gravest  consideration  in 
cases  of  senile  gangrene.  As  this  form  of  gangrene  is  usually  very  slow  in 
its  progress,  if  the  patient's  strength  can  be  sustained,  the  oi^eration  maybe 
deferred  until  it  is  evident  that  the  limb  is  likely  to  be  involved,  or  until 
there  is  an  attempt  at  the  formation  of  a  line  of  demarcation.  At  the 
present  time  the  results  following  amputation  for  senile  gangrene  are  more 
satisfactory,  owing  to  the  employment  of  aseptic  and  antiseptic  methods, 
and  to  the  fact  that  ampiitation  is  now  done  at  a  point  far  above  the  diseased 
tissues,  and  the  oj)eratiou  is  therefore  much  more  freciuently  resorted  to. 
The  employment  of  spinal  cord  cocaiuization,  dispensing  with  a  general 
anaesthetic,  is  likely  to  be  of  great  value  in  these  cases. 

In  a  case  of  senile  gangrene,  therefore,  if  one  or  two  toes  are  involved, 
wait  for  the  line  of  separation  ;  if  the  sole  or  dorsum  of  the  foot  is  in- 
volved, if  the  patient  is  not  too  feeble,  amputation  should  be  performed  at 
the  upper  third  of  the  leg,  knee-joint,  or  in  the  lower  part  of  the  thigh  ;  the 
latter  position  is  preferred  by  some  surgeons,  as  the  blood-suj^ply  of  the  flaps 
in  this  region  comes  from  the  profunda  femoris. 

Embolic  Gangrene. — When  the  main  artery  of  a  part  is  occluded 
by  an  embolus  or  thrombus,  if  the  collateral  circulation  is  not  promj^tly 
established  gangrene  results.     This  condition  is  more  likely  to  result  if  the 


104  EMBOLIC  GAJv^GRENE. 

vitality  of  the  tissues  has  been  previously  imjaaired  by  disease.  It  may 
occur  in  the  young  or  aged,  and  may  be  of  the  moist  or  dry  variety.  If  the 
parts  beyond  the  seat  of  obstruction  were  primarily  antemic  by  reason  of  a 
diseased  condition  of  the  arteries,  dry  gangrene  resiilts ;  if,  on  the  other 

hand,    the    vessels    are 
Fig.  43.  .  healthy  and  the  part  is 

"' j     filled,  with  blood,  moist 
gangrene   results.      An 
embolus    is    apt    to   be 
arrested  at  the  point  of 
division    of    the    main 
I     trunk  of  an   artery,    or 
I     at  the  origin  of  a  large 
I     branch.    In  gangrene  re- 
i      suiting  from  embolism  or 
;     thrombosis  there  is  usu- 
j     ally  a  well-marked  line 

Gangrene  of  skin  of  thigh  from  phlebitis     Separation  of  slough  of    demarcation.         (Fig. 

43.) 

This  form  of  gangrene  is  occasionally  seen  after  the  acute  fevers,  espe- 
cially typhoid  fever,  and  develops  during  convalescence ;  the  parts  most 
frequently  attacked  are  the  extremities.  It  is  usually  unilateral,  and  the 
gangrene  is  of  the  dry  variety.  We  have  recently  seen  a  patient  who  devel- 
oped during  convalescence  from  typhoid  fever  a  large  patch  of  gangrene 
upon  the  anterior  surface  of  the  leg. 

Symptoms. — Pain  is  usually  a  prominent  sj'mj)tom,  and  is  referred  to 
the  seat  of  lodgement  of  the  embolus,  and  extends  downward  in  the  course 
of  the  vessel.  The  function  of  the  part  is  more  or  less  completely  arrested, 
and  the  sensation  and  temj)erature  are  diminished.  The  gangrene  appears 
at  the  periphery  and  gradually  extends  upward,  until  a  point  is  reached 
where  the  tissues  have  sufficient  blood-supply  to  maintain  their  vitality. 

Treatment. — In  a  case  presenting  the  symptoms  of  embolic  occlusion  of 
the  main  artery  of  a  part  before  gangrene  is  absolutely  present,  great  care 
should  be  taken  to  favor  the  development  of  the  collateral  circulation,  with 
the  hope  that  gangrene  may  be  avoided.  The  part  should  be  carefully 
washed  with  an  antiseptic  solution,  and  dried  and  wrapped  in  sterilized 
gauze  or  cotton  and  supported  by  a  carefully  applied  bandage ;  it  should 
then  be  moderately  elevated  to  favor  the  return  of  venous  blood.  It  should 
also  be  surrounded  by  hot- water  bags,  to  maintain  its  temperature.  When 
gangrene  has  developed,  if  the  limb  be  involved,  the  question  of  amputation 
must  be  considered.  Here  it  is  advisable  to  wait  until  the  lines  of  demarca- 
tion and  separation  are  well  established  before  resorting  to  amputation  ;  if, 
however,  the  patient  exhibits  symptoms  of  sepsis  before  these  lines  are 
established  it  may  be  well  to  amputate  some  distance  above  the  gangrenous 
tissue,  or  at  the  point  of  the  arterial  obstruction. 

Gangrene  from  Ergot. — This  form  of  gangrene  has  occurred  from 
the  use  of  bread  made  from  diseased  rye,  producing  contraction  of  the  ter- 
minal arterioles,  leading  to  thrombosis,  and  thus  causing  chronic  anaemia  of 


DDVBETIC  GANGRENE.  105 

the  part.  The  conditiou  of  gangrene  is  preceded  by  symptoms  of  peripheral 
neuritis,  cramps,  coldness,  and  hyperajsthesia  of  the  extremities  and  diar- 
rhoea. It  has  been  observed  both  in  adults  and  children.  The  fingers  and 
toes  are  the  parts  most  frequently  involved,  but  the  ears,  nose,  and  limbs 
may  also  be  involved  in  the  process.  The  gangrene  is  of  the  dry  variety, 
and  the  separation  of  the  dead  tissue  is  very  slowly  accomplished,  often 
requiring  many  months.  Treatment. — -This  consists  in  removing  the  dead 
parts  as  soon  as  the  spread  of  the  gangrene  has  been  arrested,  and  subse- 
quent amputation  may  be  required  to  form  a  useful  stump. 

White  Gangrene. — This  form  of  gangrene  arises  from  general  causes, 
and  is  supposed  to  result  from  auiemia  of  a  part  due  to  a  localized  vaso- 
motor condition.  The  lower  extremities  are  usually  attacked,  but  it  may- 
occur  in  any  part  of  the  body ;  it  is  said  to  occur  in  eaiiy  adult  life  in 
those  in  whom  nutrition  is  defective.  Pain  in  the  nerve  or  nerves  leading 
to  the  part  about  to  be  involved  is  noticed  for  some  time  ;  later  a  circum- 
scribed white  spot  forms,  often  circular  in  outline,  or  a  toe  or  a  finger  may 
be  involved  ;  the  skin  becomes  white  and  shrivelled,  and  soon  an  inflamma- 
tory area  develops  around  this  spot,  forming  a  line  of  separation,  and  the 
dead  tissue  separates,  leaving  a  healthy  ulcer.  If  the  destruction  of  tissue 
is  confined  to  the  skin,  the  affection  is  not  a  serious  one,  but  if  the  deeper 
tissues  are  involved,  the  conditiou  may  be  dangerous.  Treatment. — The 
patient  should  be  given  tonics  and  a  nutritious  diet,  and  if  the  gangrenous 
process  is  not  fully  developed  the  use  of  the  galvanic  current  may  arrest  the 
further  progress  of  the  affection.  The  treatment  of  the  gangrenous  parts  is 
that  applicable  to  cases  of  traumatic  gangrene. 

Symmetrical  Gangrene. — Raynaud's  Disease. — This  is  a  rare 
form  of  gangrene,  which  I'esults  from  persistent  vasoconstrictor  spasm  de- 
pendent upon  i^eripheral  neuritis  or  obscure  lesions  of  the  spinal  cord.  The 
parts  attacked  are  commonly  the  fingers  and  toes,  but  symmetrical  portions 
of  the  trunk,  thighs,  legs,  and  arms  may  be  involved.  The  disease  is  usually 
observed  in  antemic  children  or  young  adults,  and  especially  in  chlorotic  and 
neurotic  young  women.  The  parts  about  to  be  attacked  by  this  form  of  gan- 
grene are  liable  to  be  cold,  pale,  and  numb  for  some  time,  presenting  a  bluish 
and  congested  appearance,  which  is  accompanied  by  burning  pain,  and  later 
gangrene  sets  in,  generally  of  the  dry  form,  although  moist  gangrene  has 
been  observed  in  such  cases.  Treatment. — The  i^rotection  of  the  ijarts 
from  cold  and  the  application  of  the  galvanic  current  have  apisareutly  ar- 
rested the  progress  of  the  disease.  When  gangrene  has  actually  developed, 
the  dead  tissue  should  be  kept  dry  and  aseptic  by  suitable  dressings,  and  in 
time  it  will  separate. 

Diabetic  Gangrene. — The  development  of  gangrene  in  diabetics 
results  from  the  facts  that  these  subjects  have  thickened  vessels,  due  to  the 
occui-reuce  of  endarteritis,  and  that  the  tissues  in  diabetic  individuals  are 
feeble  and  less  able  to  resist  injuries  and  the  infection  of  pyogenic  organisms 
than  healthy  tissues.  Diabetics  also  may  suffer  from  a  form  of  peripheral 
neuritis,  or  enervation  of  the  parts  from  disturbance  of  the  central  nervous 
system. 

Diabetic  gangrene  may  be  due  directly  to  the  presence  of  diabetes  or  may 


106  TRAUMATIC  GANGRENE. 

result  from  trifling  injuries  because  the  patient  suffers  from  diabetes.  This 
affection  runs  a  rapid  course,  is  characterized  by  excessive  inflammation, 
and  is  of  the  moist  variety.  The  prognosis  in  diabetic  gangrene  is  always 
grave,  the  patient  being  in  a  markedly  asthenic  condition,  and  death  usually 
resulting  from  septicaemia,  exhaustion,  or  diabetic  coma.  In  some  cases, 
however,  the  glycosuria  seems  a  temporary  condition,  the  sugar  disappear- 
ing from  the  urine  after  operation,  and  the  patient  regaining  fair  health. 

Diabetic  patients  should  be  warned  of  the  dangerous  consequences 
which  may  follow  from  slight  injuries,  such  as  the  cutting  of  corns,  abra- 
sions, etc.  In  the  treatment  of  wounds  in  diabetics  strict  asepsis  should 
be  observed. 

Treatment. — Formerly  operation  in  cases  of  diabetic  gangrene  was  not 
considered  justifiable,  but  at  the  present  time,  with  the  employment  of  asep- 
tic and  antiseptic  means,  operation  in  these  cases  may  be  undertaken  with 
a  fair  prospect  of  success.  In  this  form  of  gangrene  involving  the  extremi- 
ties, amputation  should  be  done  at  some  distance  above  the  seat  of  disease ; 
the  most  rigid  asepsis  should  be  practised,  so  that  the  wound  shall  not  be 
infected,  and  if  these  precautions  are  observed  the  condition  is  not  apt  to 
recur  in  the  stump.  The  drugs  which  seem  to  exert  the  most  favorable 
influence  in  diabetic  gangrene  are  opium  and  codeine  ;  one  or  the  other  of 
these  should  be  used  freely :  the  patient  should  be  placed  upon  an  anti- 
diabetic diet,  consisting  of  animal  food,  eggs,  fish,  and  milk,  and  should 
avoid  foods  containing  sugar  and  starch. 

Diabetic  Cellulitis. — Patients  suffering  from  diabetes,  owing  to  the 
proneness  of  the  tissues  to  septic  infection,  are  liable  to  the  development  of 
cellulitis  upon  the  reception  of  a  slight  wound,  such  as  a  scratch  or  an  abra- 
sion. Cellulitis  may  develop  rapidly  and  involve  a  large  extent  of  tissue, 
presenting  inflammation  and  ulceration  of  the  skin  and  extensive  sloughing 
of  the  subcutaneous  tissues.  If  the  patient  does  not  succumb  to  the  attack, 
an  ulcer  may  remain  in  which  there  is  little  tendency  to  repair.  The  treat- 
ment of  this  condition  consists  in  the  emploj^ment  of  free  incisions  into  the 
inflamed  cellular  tissue  and  moist  antiseptic  dressings,  and  the  administra- 
tion of  tlie  remedies  appropriate  to  the  diabetic  condition. 

Traumatic  Gangrene. — This  form  of  gangrene,  sometimes  de- 
scribed as  moist  gangrene,  may  occur  from  the  direct  mechanical  destruction 
of  the  vitality  of  the  tissues,  such  as  occurs  in  extensive  crushing  and  lacer- 
ation of  the  parts  in  machinery  accidents,  or  from  the  passage  of  heavy 
bodies  and  wheels  of  wagons  and  cars  over  the  parts.  It  may  also  result 
from  the  sudden  obstruction  of  the  main  arterial  current  from  division  or 
ligation  of  an  artery,  or  from  an  embolus  or  thrombus  or  obstruction  of 
the  main  veins,  as  is  observed  in  cases  of  strangulation  of  parts  by  tight 
bandaging  or  ligatures.  It  may  result  also  from  obstruction  of  the  blood- 
supply  by  the  exudations  resulting  from  inflammation,  or  from  the  pri- 
mary or  secondary  effects  of  heat  and  cold,  as  is  seen  in  burns,  scalds,  or 
fi'ost-bite,  and  from  the  action  of  caustic  or  corrosive  substances.  It  may 
occur  in  two  forms,  direct  traumatic  gangrene  and  indirect  traumatic  gangrene. 

Direct  Traumatic  Gangrene. — This  variety  of  gangrene  results  from 
the  immediate  crushing  of  the  tissues  by  an  accident,  their  vitality  being 


INDIRECT  TRAUMATIC  GANGRENE 


107 


instantly  destroyed.  Examples  of  this  form  of  death  of  tissues  are  eommou 
in  machinery  and  railroad  accidents  and  in  parts  crushed  by  heavy  bodies  ; 
here  the  parts  are  cold  and  discolored,  and  present  no  signs  of  putrefaction 
unless  exposed  to  the  air  for  some  time. 

Indirect  Traumatic  Gangrene. — This  form  of  gangrene  may  result 
from  crushing  or  laceration  of  the  tissues,  from  injuries  of  the  main  veins 
interfering  with  the  return  of  venous  blood,  from  injury  or  sudden  obstruc- 
tion of  the  principal  arteries  of  a  ijart,  from  the  simultaneous  obstruction 
of  the  principal  arteries  and  veins,  or  from  sudden  constriction  of  the  parts 
by  tight  bandages  or  ligatures  ;  it  may  also  develop  as  the  result  of  burns, 
scalds,  exposure  to  extreme  cold,  the  application  of  caustic  substances, 
or  from  pressure.  Veuous  obstruction  plays  a  very  important  part  in  the 
production  of  this  form  of  gangrene.  Gangrene  arising  from  such  causes  is 
commonly  of  the  moist  variety,  as  the  tissues  are  filled  with  blood  and 
liquid  exudates,  but  it  is  possible  to  have  traumatic  gangrene  of  the  dry 
type  if  the  tissues  are  anaemic  and  do  not  subsequently  become  infected.  A 
certain  amount  of  tissue  is  often  devitalized  as  the  result  of  the  injury,  but 
in  addition  to  this  there  is  a  considerable  destruction  of  contiguous  tissues 
as  the  result  of  inflammatiou  and  septic  infection ;  inflammatory  exudates 
diminish  the  vascular  supply  of  the  parts  by  compressing  the  vessels,  so 
that  the  damaged  tissue  as  well  as  the  surrounding  parts  becomes  gangre- 
nous ;  the  process  does  not  extend  indefinitely,  but  soon  becomes  localized. 

Symptoms. — When  a  part  which  has  had  its  vitality  seriously  interfered 
with  becomes  gangrenous,  pain  which  may  have  been  present  suddenly 
ceases,  the  part  becomes  insensitive,  and  the  skin  is 
cold,  pale,  and  mottled,  purple,  green,  or  red,  and 
finally  dark-colored ;  blebs  containing  brownish 
serum  form  upon  the  surface ;  the  wound,  if  one 
is  present,  assumes  a  grayish  color ;  an  offensive 
discharge  escapes  from  it,  and  the  dead  tissue  rap- 
idly undergoes  putrefactive  changes.  (Fig.  44.) 
Coincidently  with  these  changes  in  the  dead  tissue, 
the  living  tissue  in  contact  with  it  becomes  red 
and  swollen,  and  the  separation  of  the  dead  tissue 
from  the  living  is  effected  by  an  ulcerative  inflam- 
mation, granulations  from  the  living  tissue  lifting 
off  the  sloughs.  (See  page  23.)  The  patient  at 
the  same  time,  if  the  gangrenous  process  involves 
any  considerable  extent  of  surface,  exhibits  the 
constitutional  signs  of  inflammation,  fever,  rapid 
pulse,  and  in  some  cases,  if  the  septic  infection 
is  intense,  may  die  from  septicnemia. 

Treatment. — In  tissues  whose  vitality  has  been  impaired  by  iujm-y  the 
development  of  gangrene  luay  sometimes  be  averted  or  its  extent  may  be 
limited  by  careful  sterilization  of  the  wound  and  the  surrounding  parts,  by 
keeping  up  the  temiierature  of  the  parts  by  warm  sterilized  dressings,  and 
by  making  incisions  to  secure  free  drainage  and  to  relieve  tension  if  the 
liarts  are  much  swollen. 


108  gaxgre>st;  from  heat  asd  cold. 

In  direct  traumatic  gangrene,  where,  as  a  result  of  the  injury,  the 
part  is  absohitely  dead,  as  is  often  seen  in  injuries  of  the  limbs  in  railway 
and  machinery  accidents,  it  is  manifestly  unwise  to  wait  until  putrefactive 
changes  have  occurred  in  the  dead  tissues,  for,  although  it  is  possible  to 
keep  the  part  fi-om  putrefaction  for  a  few  days  by  careful  sterilization  of  the 
wound  and  the  use  of  antiseptic  dressings,  sooner  or  later  these  changes  will 
occur,  and  a  certain  amount  of  constitutional  infection  will  take  i^lace.  In 
such  a  case,  if  an  extremity  be  involved,  the  part  should  be  removed  by  am- 
putation as  soon  as  the  patient  has  reacted  from  the  shock  consequent  upon 
the  traumatism,  care  being  taken  that  the  operation  is  done  through  tissue 
the  vitality  of  which  has  not  been  impaired  by  the  injury. 

In  indirect  traumatic  gangrene  involving  the  extremities,  when  the 
gangrenous  process  is  well  established,  if  the  patient-s  constitutional  con- 
dition is  good,  it  is  wise  to  wait  for  lines  of  demarcation  and  of  separation  to 
form,  and  then  amputate  the  part  through  healthy  tissues  above  these  lines. 

In  localized  traumatic  gangrene  where'the  question  of  amputation  is 
not  to  be  considered,  incisions  should  be  made  to  relieve  tension  and  to 
favor  the  escape  of  discharges,  and  the  part  should  be  dressed  with  dry  an- 
tiseiitic  dressings.  Under  this  treatment  the  dead  tissue  will  be  thrown  off 
after  the  line  of  separation  is  well  established,  and  a  healthy  granulating 
surface  will  be  left,  which  should  be  treated  as  a  simple  ulcer. 

As  there  is  often  a  considerable  amount  of  constitutional  disturbance  in 
cases  of  traumatic  gangrene,  the  patient  should  be  given  stimulants  and 
quinine,  with  opium  to  relieve  jjain  and  secure  sleej),  and  should  also  have 
a  nourishing  diet. 

Gangrene  frora  Heat  and.  Cold  and  Caustic  Substances. — 

The  exposure  of  a  portion  of  the  body  to  flame,  heated  bodies  or  gases,  hot 
fluids  or  steam,  may  result  in  the  direct  destruction  of  the  tissues  with 
which  they  come  in  contact,  and,  in  addition,  there  develops  thrombosis  of 
the  contiguous  vessels,  causing  gangrene  of  the  surrounding  tissues,  which 

may  be  of  the  dry  or  moist  type.     Frost- 
^i<^-  "^^^  bite  may  also  result  in  gangrene,  which 

is  usually  of  the  moist  type,  from  the  di- 
rect action  of  the  low  temperature  uj)ou 
the  tissues  and  the  subsequent  engorge- 
ment of  the  vessels  of  the  parts  if  rapid 
reaction  occurs.  Caustic  and  corrosive 
substances  applied  to  the  sui-face  of  the 
liody  will  often  be  followed  by  a  local- 
ized traumatic  gangrene.  The  extent  of 
the  gangrene  will  depend  on  the  nature 
Gangrene  of  toe  from  carboUc  acid.  of  the  irritant  and  the  duration  of  its 

application. 
Gangrene  following  the  use  of  carbolic   acid  in  wounds  is  quite  common  ; 
the  continuous  application  of  quite  dilute  solutions  of  carbolic  acid  is  often 
followed  by  the  same  result.     (Fig.  45. ) 

Treatment. — In  gangrene  resulting  from  exposure  to  heat  or  cold,  or 
from  caustic  substances,  it  is  often  difficult  to  ascertain  how  extensively  the 


GANGRENE  FROM  PRESSURE.  109 

process  will  involve  the  tissue,  so  that  it  is  in  these  cases  wise  to  apply  dry 
antiseptic  dressings  and  wait  until  the  lines  of  demarcation  and  separation 
are  formed  before  resorting  to  operation,  if  such  is  demanded  by  the  nature 
of  the  case. 

Gangrene  from  Pressure. — Continued  pressure  upon  a  partwill  often 
result  in  the  production  of  localized  gangrene.  This  is  more  apt  to  result  in 
parts  where  the  circulation  is  feeble  and  the  conditions  are  favorable  for 
complete  stasis.  Decubitis  or  bed-sores  are  produced  in  this  manner  in 
aged  and  debilitated  subjects  by  long  rest  in  one  position  in  the  recumbent 
posture ;  the  parts  usually  attacked  are  the  skin  over  the  sacrum  and  that 
over  the  scapulse,  and  the  heels.  The  parts  exposed  to  pressure  become  red 
and  congested  and  dark-colored  when  gangrene  actually  develops ;  in  de- 
bilitated subjects  and  especially  in  those  presenting  symptoms  of  imperfect 
innervation  from  injury  or  disease  of  the  spinal  cord  the  process  may  extend 
deeply,  involving  the  fascia  and  muscles,  and  even  resulting  in  caries  or 
necrosis  of  the  subjacent  bone.  The  same  condition  may  result  from  the 
long-continued  or  too  firm  application  of  splints  ;  the  gangrenous  surface  in 
these  cases  is  known  as  a  splint-sore.  In  j)atients  who  are  to  be  kept  in 
one  position  for  a  considerable  time,  or  those  who  wear  splints  for  a  long 
time,  the  surgeon  should  bear  in  mind  the  possibility  of  the  development  of 
bed-sores  or  splint-sores. 

A  form  of  gangrene  known  also  as  neuropathic  gangrene  is  often 
observed  after  fractures  of  the  spine  or  injuries  of  the  spinal  cord,  or  in 
paralyzed  limbs ;  here,  on  account  of  the  imperfect  innervation,  sloughs 
form  rapidly  in  the  tissues  over  the  sacrum  and  heels  and  in  other  parts  sub- 
jected to  pressure.  Gangrene  in  these  cases  seems  to  be  due  to  a  functional 
disturbance  of  the  vasomotor  or  trophic  nerves. 

Treatment. — ^As  a  prophylactic  measure  all  parts  exposed  to  pressure 
should  be  frequently  washed  with  soap  and  water.  Care  should  be  taken 
that  the  bedding  does  not  become  saturated  with  urine  or  faeces,  and  that  the 
patient  has  dry,  smooth  sheets  in  contact  with  the  body.  The  iiosition  of 
the  patient  should  also  be  changed  as  often  as  possible,  so  that  continuous 
pressure  upon  certain  parts  of  the  body  may  be  avoided,  and  the  parts 
should  be  occasionally  sponged  with  dilute  alcohol,  dried,  and  dusted  with 
powdered  boric  acid  or  oxide  of  zinc.  Good  nursing  can  do  much  to  prevent 
the  develox)ment  of  bed-sores.  If  the  skin  shows  signs  of  pressure,  the  part 
should  be  protected  from  pressure  by  the  application  of  a  piece  of  soap  plas- 
ter, made  by  spreading  emplastrum  saijonis  upon  chamois-skin  ;  or  by 
placing  under  it  soft  pads  stuffed  with  hair,  or  a  perforated  air-cushion,  or  a 
ring-cushion.  In  injuries  of  the  spine  the  use  of  a  water-bed  will  often  pre- 
vent the  development  of  bed-sores.  When  bed-sores  have  actually  formed, 
the  separation  of  the  sloughs  may  be  facilitated  by  the  use  of  moist  dress- 
ings, such  as  gauze  saturated  in  acetate  of  aluminum  solution.  When  the 
sloughs  have  separated,  the  resulting  ulcer  should  be  dressed  with  powdered 
aristol  and  boric  ointment,  and  care  should  be  taken  to  keep  the  parts  free 
from  pressure  by  the  use  of  an  air-cushion. 

Infective  Gangrene. — Traumatic  Spreading  Gangrene. — This 
variety  of  gangrene  is  sometimes  described  as  gangrenous  emx^hysema,  or 


110  INFECTIVE   GANGRENE. 

bronzed  gangrene.  It  is  rapid  in  its  development  and  is  very  fatal,  and  may 
follow  apparently  insignificant  injuries,  or  severe  injuries,  such  as  extensive 
laceration  of  the  soft  parts,  compound  fractures,  or  dislocations.  The  essen- 
tial cause  in  this  form  of  gangrene  is  the  infection  of  the  tissues  by  the 
'bacillus  of  malignant  cedema,  by  the  bacillus  aerogenes  capsulatus,  or  by  the 
bacillus  cedematis  aerohicus.     (See  page  52. ) 

Symptoms. — After  a  lacerated  wound  or  compound  fracture  or  disloca- 
tion, a  dusky,  bronzed  hue  appears  on  the  skin  near  the  wound  and  rapidly 
extends,  so  that  in  a  few  hom-s  it  may  involve  the  whole  extremity.  The  in- 
flammatory jDrocess  rapidly  spreads  along  the  connective-tissue  planes  of  the 
limb,  which  become  swollen,  painful,  and  bi'awny.  The  part  becomes  hard, 
brawny,  and  cedematous,  aud  subcutaneous  emphysematous  crackling  is  felt, 
showing  the  presence  of  gas,  which  sometimes  extends  into  apiiarently 
healthy  tissues.  The  development  of  gas  in  the  tissues  results  partly  from 
putrefactive  changes,  but  is  probably  largely  associated  with  the  growth  of 
the  specific  organism.  If  the  patient  survives  long  enough,  the  usual 
necrotic  changes  of  moist  gangrene  take  i^lace.  At  the  same  time  that  the 
local  signs  of  gangrene  are  developing  the  patient  presents  symptoms  of 
profound  septic  intoxication,  as  evidenced  by  a  high  temperature,  rapid 
pulse,  and  delirium.  A  fatal  termination  usually  occurs  within  two  or  three 
days. 

Treatment. — N"o  surgical  affection  requires  more  prompt  and  radical 
treatment  than  this  form  of  gangrene.  Free  incisions  should  be  made  as  in 
cases  of  rapidly  spreading  cellulitis,  but  these  will  often  fail  to  arrest  the 
spread  of  the  disease.  In  cases  of  this  affection  involving  the  extremities, 
the  i)rompt  resort  to  high  amj)utation  offers  the  j)atient  the  best  hope  of 
recovery.  We  have  seen  a  number  of  cases  in  which  prompt  amputation 
well  above  the  diseased  tissue  was  followed  by  recovery.  In  one  case  ampu- 
tation at  the  shoulder-joint,  where  the  arm  was  extensively  involved,  was 
successful  in  arresting  the  spread  of  the  gangrene,  and  recovery  followed. 
The  use  of  antistreptococcus  serum  has  been  suggested  as  an  adjuvant  in 
the  surgical  treatment  of  cases  where  it  is  shown  that  streptococcus  infection 
is  present.  At  the  same  time  the  patient's  strength  should  be  sustained 
by  liquid  nourishment  and  diffusible  stimulants.  Gangrene  of  the  clieehs  or 
of  the  genitals  (noma)  occurring  in  the  course  of  measles  or  scarlet  fever  is 
considered  in  another  ijortion  of  this  work. 

Hospital  Gangrene. — This  form  of  gangrene,  sometimes  described  as 
■womid phagedena,  which  formerly  decimated  the  inmates  of  military  hospitals, 
is  now  practically  unknown  since  the  general  adoption  of  antiseptic  surgery 
and  the  increased  care  directed  to  ventilation  and  hospital  hygiene.  ISTo 
opportunity  for  a  satisfactory  bacteriological  study  of  this  affection  has  been 
afforded.  It  was  apparently  due  to  bacterial  infection,  and  most  probably 
to  one  of  the  ordinary  i^yogenic  varieties,  which  attained  unusual  virulence 
from  the  foul  wound  conditions  then  prevalent ;  but  some  of  the  cases 
resembled  the  condition  described  as  traumatic  spreading  gangrene,  due  to 
infection  with  the  bacillus  of  malignant  cedema,  or  the  bacillus  aerogenes  ca/psu- 
latxts.  When  hospital  gangrene  appeared  in  a  wound  a  thick,  ijultaceous, 
ash-colored  or  yellow  slough  formed,  followed  by  rapid  ulceration  spreading 


HOSPITAL   GANGRENE.  m 

at  the  edges  and  also  at  the  bottom  of  the  wound.  The  edges  of  the  wound 
were  everted,  the  skin  was  detached  and  dark-colored,  and  a  i^one  of  Inflam- 
mation lay  just  beyond.  In  a  few  hours  the  sloughing  would  involve  a  large 
part  of  a  limb,  or  destroy  the  entire  side  of  the  body,  laying  bare  the  deep 
vessels  and  nerves,  and  often  causing  rapid  death  by  hemorrhage  from  the 
arteries.  The  ulceration  presented  a  large  cu]3-shaped  cavity  filled  with 
sloughs  emitting  a  most  fetid  odor.  The  patients  developed  fever  and  an 
intense  degree  of  sepsis.  The  disease  could  be  ari-ested  only  by  thorough 
removal  or  destruction  of  the  infected  tissue  with  scissors  and  cautery,  and 
sometimes  hemorrhage  rendered  amputation  necessary.  We  describe  this 
disease  mainly  to  illustrate  the  remarkable  effect  of  antisepsis  in  banishing 
immediately  a  disease  of  such  virulent  contagiousness  and  such  universal 
occurrence. 


CHAPTER    XII. 

ASEPSIS  AND  ANTISEPSIS. 
By  Hbney  E.  Whaeton,  M.D. 

The  student  or  practitioner  of  to-day  who  witnesses  the  behavior  of 
wounds,  either  accidental  or  inflicted  by  the  surgeon,  which  have  been  sub- 
jected to  the  modern  methods  of  wound  treatment,  cannot  realize  the  very 
different  course  which  such  wounds  pursued  before  antiseptic  and  aseptic 
methods  were  adopted  :  those  only  who  saw  the  results  of  the  old  methods 
of  wound  treatment  can  fully  appreciate  the  value  of  the  new.  Before  the 
introduction  of  Lister's  method  of  treating  wounds,  based  u]5on  Pasteur's 
investigations  regarding  the  action  of  bacteria  in  producing  fermentation, 
it  was  the  I'ule  in  accidental  and  operative  wounds  to  have  profuse  sui^ijura- 
tion,  fever,  pain,  and  in  many  cases  such  wound  complications  as  septictemia, 
pytemia,  erysipelas,  and  hospital  gangrene,  and  it  is  not  remarkable,  there- 
fore, that  the  mortality  following  operative  and  accidental  wounds  was  very 
high.  The  mortality  in  compound  fractures  from  sepsis  was  formerly  very 
great,  but  by  modern  methods  of  wound  treatment  has  been  diminished  to 
an  insignificant  percentage.  The  same  diminished  mortality  has  been  found 
to  follow  amxjutatious  and  other  wounds,  accidental  or  operative. 

Asepsis. — Asepsis  aims  at  thorough  sterilization  of  the  field  of  opera- 
tion and  of  all  objects  brought  in  contact  with  the  wound,  and  the  exclusion 
of  germs  by  occlusive  dressings. 

Antisepsis. — Antisepsis,  on  the  other  hand,  is  that  method  of  wound 
treatment  which  keej)S  germicidal  agents  constantly  in  contact  with  the 
wound.     The  object  of  antisepsis  is,  therefore,  to  produce  asepsis. 

Since  the  majority  of  wound  comjilications  are  due  to  the  presence  in 
the  wouud  of  micro-organisms,  it  is  the  duty  of  the  surgeon  to  jjrevent 
their  cojitact  with  it,  or  to  employ  means  for  their  destruction.  We  must, 
however,  employ  means  of  disinfection  or  destruction  of  these  micro-organ- 
isms which  will  not  have  any  injurious  effect  upon  the  tissues  with  which 
they  come  in  contact.  Mechanical  disinfection  is  not  ap]Dlicable  to  wounds, 
but  is  employed  to  remove  any  micro-organisms  which  may  be  present 
upon  the  objects  which  are  to  come  in  contact  with  the  wound, — namely, 
the  hands  of  the  surgeon  and  assistants,  instruments,  and  the  skin  sur- 
rounding the  wound.  Mechanical  disinfection  is  accomplished  by  the  use 
of  friction  with  a  brush,  soajj,  and  water.  Germicidal  solutions  may  be  used 
for  disinfection  of  wounds,  but  are  most  useful  in  the  disinfection  of  the 
hands  of  the  operator,  the  skin  of  the  patient,  the  instruments,  and  the 
dressings.  If  these  have  been  carefully  employed  before  the  wound  is  made, 
their  subsequent  use  in  the  wound  is  unnecessary. 

Some  forms  of  bacilli  contain  spores  which  often  resist  the  action  of 
germicidal  substances,  while  the  bacilli  themselves  are  readily  destroyed 
112 


AGENTS  EMPLOYED  TO  SECUEE  ASEPSIS. 


113 


Fig.  46. 


by  these  agents  :  tlie  surgeon  should  therefore  employ  that  means  of  disin- 
fection which  is  generally  applicable  to  the  destruction  of  both  bacilli  and 
their  spores.  The  bacilli  of  anthrax,  tuberculosis,  and  tetanus  contain  spores  ; 
hence  to  destroy  these  organisms  is  a  matter  of  more  difficulty  than  to  render 
harmless  such  microbes  as  staphylococcus  pyogenes  aureus,  albus,  and  cilreus, 
streptococcus  pyogenes  and  streptococcus  erysipelatis,  and  the  bacilli  oi  diphtheria 
and  glanders,  which  contain  no  spores. 

AGENTS   EMPLOYED   TO   SECURE   ASEPSIS. 

A  great  variety  of  agents  possessing  more  or  less  germicidal  power  have 
oeen  at  different  times  employed  in  the  practice  of  asejitic  and  antiseptic 
surgery.  Those  most  emj)loyed  now  ai-e  heat,  bichloride  of  mercury,  car- 
bolic acid,  iodoform,  beta-naphtol,  formalin,  chloride  of  zinc,  sulphocar- 
bolate  of  zinc,  acetate  of  aluminum,  peroxide  of  hydro'gen,  pyrozone,  kreo- 
lin,  permanganate  of  potassium,  boric  acid,  salicylic  acid,  aristol,  silver 
salts,  airol,  and  sodium  chloride. 

Heat. — Heat,  either  dry  or  moist,  is  the  most  reliable  and  most  uni- 
versally applicable  agent  for  the  destruction  of  micro-organisms.  Many 
forms  of  bacteria  are  rendered  inert  by 
a  temperature  of  140°  F.  (60°  C),  and 
no  organisms  can  withstand  a  continued 
application  of  moist  heat  reaching  212° 
F.  (100°  0. ).  As  moist  heat  is  the  most 
efficient  sterilizer,  it  should  be  pre- 
ferred ;  boiling  instruments  and  dress- 
ings for  a  few  minutes  will  completely 
sterilize  them.  Steam  sterilizers  are 
now  generally  employed  for  this  pur- 
pose, as  by  their  use  the  dressings  may 
be  sterilized  by  moist  heat  and  finally 
dried.  (Pig.  46.)  An  improvised  ster- 
ilizer may  be  made  by  having  a  ]3erfo- 
rated  metal  stand  jilaced  inside  of  a 

large  kettle  so  that  only  the  steam  comes  in  contact  with  the  Instruments 
and  dressings.  Sterilization  of  dressings  by  this  method  is  as  complete  as 
that  j)roduced  under  pressure  by  the  steam  sterilizer.  Sterilization  may  also 
be  accomplished  by  the  employment  of  dry  heat,  the  dressings  being  baked 
for  an  hour  in  a  hot  oven  or  being  placed  in  a  dry  sterilizer.  Dry  heat  is 
not  as  efficient  for  sterilization  as  moist  heat,  for  some  spores  will  resist  dry 
heat  at  140°  C.  for  three  hours. 

Bichloride  of  Mercury. — This  is  employed  as  an  antiseptic  in  watery 
solutions  varying  in  strength  from  1  to  500  to  1  to  10,000.  A  solution  of 
1  to  1000  is  used  for  disinfection  of  the  hands  and  skin,  and  a  1  to  2000  to 
1  to  4000  solution  is  generally  employed  for  the  irrigation  of  wounds.  At 
the  present  time  bichloride  solutions  are  not  frequently  employed  in  fresh 
wounds  on  account  of  their  irritating  effects.  In  iising  bichloride  solution 
the  surgeon  should  watch  the  patient  carefully  for  symptoms  of  poisoning 
through  the  absorption  of  the  drug,  which  are  generally  manifested   by 


steam  sterilizer. 


114  AGENTS  EMPLOYED  TO   SECURE  ASEPSIS. 

vomiting,  fetid  breath,  salivation,  inflammation  of  tlie  gums,  diarrlioea,  and 
blood-stained  stools.  Locally  the  use  of  moist  bichloride  dressings  may 
cause  well-marked  dermatitis,  and  the  continuous  application  of  bichloride 
solution  to  the  hands  of  the  surgeon  causes  them  to  become  roughened  and 
cracked  and  the  nails  blackened.  A  ten  per  cent,  bichloride  solution  may 
be  made  as  follows  :  bichloride  of  mercury,  2  parts  ;  sodium  chloride,  1  part ; 
dilute  acetic  acid,  1  part ;  water,  16  parts.  By  adding  water  in  proper 
quantity  a  1  to  1000  or  1  to  2000  solution  may  be  made. 

In  private  practice  the  most  convenient  method  of  making  bichloride 
solution  is  by  the  use  of  bichloride  pellets,  which  contain  a  definite  amount 
of  bichloride  of  mercury,  mixed  with  a  few  grains  of  common  salt.  These 
are  dissolved  in  the  requisite  amount  of  boiled  water  to  make  a  solution  of 
the  strength  desired. 

Carbolic  Acid'. — Carbolic  acid  was  the  first  antiseptic  recommended 
and  used  by  Lister,  and  was  poj)ular  until  it  was  found  that  bichloride  of 
mercury  possessed  more  decided  germicidal  action.  Carbolic  acid  is  a  local 
caustic  and  coagulates  albumin,  and  on  account  of  its  irritating  effects  should 
not  be  emijloyed  in  fresh  wounds.  This  drug  is  employed  in  watery  solu- 
tions 1  to  20  or  1  to  60.  A  1  to  20  solution  is  usually  employed  for  the  ster- 
ilization of  instruments,  the  latter  being  allowed  to  remain  in  the  sohition 
for  thirty  minutes  before  being  used  :  a  solution  of  this  strength  benumbs 
and  cracks  the  skin  of  the  surgeon's  hands,  and  it  should  therefore  be 
diluted  before  the  instruments  are  required  by  adding  an  equal  quantity 
of  hot  water.  A  1  to  60  solution  is  employed  in  the  irrigation  of  wounds 
and  the  washing  of  sponges.  The  rusting  of  steel  instruments  and  the 
blunting  of  the  edges  of  knives  by  exposure  to  carbolic  solution  may  be 
overcome  by  the  addition  of  five  per  cent,  of  sodium  carbonate  to  the  solu- 
tion. A  ready  method  of  making  a  five  per  cent,  carbolic  solution  is  to 
add  one  tablespoonful  of  carbolic  acid  to  one  pint  and  a  half  of  water. 
The  continued  use  of  carbolic  acid  solution  may  give  rise  to  poisoning,  which 
will  show  itself  by  dark-colored  urine,  headache,  dizziness,  vomiting,  and  in 
some  cases  bloody  diarrhoea,  hajmoglobinuria,  collapse,  and  death.  The  use 
of  weak  solutions  of  carbolic  acid  seems  to  involve  more  risk  of  toxic  action 
than  does  the  employment  of  the  pure  drug,  the  superficial  layer  of  tissue 
being  coagulated  by  the  latter,  so  that  the  absorption  of  the  drug  is  pre- 
vented. Gangrene  of  the  skin  and  subjacent  tissues  has  frequently  been 
observed  to  follow  the  long- continued  use  of  quite  dilute  solutions  of  car- 
bolic acid  or  of  ointments  containing  small  quantities  of  the  drug.  Infants 
and  children  seem  especially  susceptible  to  the  poisonous  action  of  carbolic 
acid.  Fatal  poisoning  has  followed  the  application  of  a  1  to  40  solution  to 
small  wounds,  such  as  the  wound  of  circumcision. 

Iodoform. — Iodoform  has  been  shown  by  experimental  research  to  pos- 
sess little  direct  germicidal  action,  but  in  spite  of  this  fact  clinical  experi- 
ence has  ijroved  that  it  possesses  powerful  antiseptic  properties,  due,  as 
shown  by  Behring  and  De  Euyter,  not  to  the  destruction  of  germs,  but 
to  its  undergoing  a  decomposition  in  their  presence  and  thus  rendering 
inert  the  ptomaines  which  have  resulted  from  the  germ-growth.  It  may  be 
rendered  absolutely  sterile  by  exposing   it  to   heat,  and,  as  it  is  easily 


AGENTS  EMPLOYED  TO   SECURE  ASEPSIS.  115 

decomposed,  fractional  sterilization  may  be  employed,  or  by  washing  it  in  a 
1  to  1000  bichloride  solution  ;  it  should  then  be  dried  and  kept  for  use  in 
closely  stoppered  bottles.  Iodoform  is  very  extensively  employed  as  an, 
application  to  wounds.  It  is  frequently  emiiloyed  in  aseptic  wounds  which 
are  liable  from  their  position  to  become  infected,  such  as  wounds  about  the 
mouth,  rectum,  and  vagina,  and  is  especially  useful  as  a  dressing  in  infected 
wounds  and  in  tubercular  or  syphilitic  ulcers,  and  in  bone  cavities.  In  op- 
erations upon  the  mouth,  anus,  rectum,  uterus,  and  abdominal  cavity  iodo- 
form gauze  packing  is  largely  employed,  and  serves  to  keep  the  discharges 
from  becoming  foul,  thus  often  preventing  septic  intoxication  ;  it  must,  how- 
ever, be  used  with  caution  in  the  mouth.  Iodoform  may  be  used  in  the  form 
of  powder.  Iodoform  collodion,  made  by  adding  iodoform,  gr.  xlviii,  to  col- 
lodion, f.li,  is  a  useful  dressing  in  superficial  wounds.  It  may  be  also  em- 
ployed in  the  form  of  an  ethereal  solution,  iodoform,  gr.  xv,  ether,  fli,  as  an 
apjjlication  to  wounds  or  ulcers.  An  emulsion  of  iodoform  in  glycerin,  iodo- 
form, oi,  glycerin,  3x,  or  an  emulsion  of  iodoform  made  by  adding  steril- 
ized iodoform,  .5i,  to  boiled  olive  oil,  ox,  is  much  employed  as  an  injection 
in  the  treatment  of  tubercular  abscesses  and  joints.  For  packing  cavities  a 
five  per  cent,  gauze  is  best ;  a  ten  per  cent,  gauze  is  too  strong  except  in  small 
amounts.  For  large  cavities  a  ''Mikulicz  pack,"  consisting  of  a  bag  of 
iodoform  gauze  stuffed  with  sterilized  gauze,  may  be  employed.  Ifumerous 
cases  have  been  reported  in  which  toxic  symptoms  were  observed,  such  as  urti- 
carial eruptions,  dermatitis,  headache,  depression,  delirium,  mania  becoming 
permanent,  debility,  and  sleeplessness,  and  sometimes  heart  derangements. 
Elderly  persons  and  infants  are  very  prone  to  the  toxic  action  of  iodoform. 

Aristol. — Aristol,  which  is  a  compound  of  iodine  and  thymol,  has  been 
introduced  as  a  substitute  for  iodoform.  It  is  said  to  produce  no  toxic 
effects,  and  is  without  disagreeable  odor,  but  clinically  it  does  not  com- 
pare in  value  with  iodoform.  It  may  be  emjiloyed  for  the  same  purposes  as 
iodoform,  and  is  useful  as  a  dressing  for  chronic  and  specific  ulcers. 

Airol. — This  drug  has  been  recommended  as  a  substitute  for  iodoform 
when  an  antiseptic  and  not  an  antitubercular  action  is  desired.  It  seems  to 
be  free  from  toxic  action  even  when  used  in  large  quantities,  and  to  be  espe- 
cially useful  in  wounds  where  primary  infection  is  i^resent.  It  has  been  used 
with  good  results  in  operations  upon  the  i-ectum  and  bladder. 

Acetate  of  Alumimim. — This  is  employed  in  the  following  solution  : 
Aluminis,  3  vi  (24  grammes)  ;  plumbi  acetatis,  3  ixss  (38  grammes)  ;  aqute, 
Oii  (1000  grammes).  Mix  and  filter  after  standing  twenty-four  hours.  It 
has  decided  germicidal  qualities,  is  employed  for  irrigation  and  moist  dress- 
ings where  carbolic  or  bichloride  solutions  cannot  be  used,  and  is  by  all 
means  the  safest  and  best  antiseptic  substance  for  wet  dressings. 

Beta-Naphtol. — Beta-naphtol  is  employed  for  much  the  same  pur- 
pose as  bichloride  of  mercury,  and  is  used  in  a  1  to  2500  solution,  but  is  not 
so  powerful  a  germicide.  As  it  does  not  possess  marked  toxic  cjualities,  it 
is  employed  in  the  irrigation  of  large  cavities,  and  as  it  does  not  corrode 
instruments,  it  is  especially  useful  as  a  bath  for  them.  It  is  useful  as  a 
dusting  powder  on  sloughing  surfaces,  and  especially  in  wounds  exposed  to 
fseces  and  urine. 


116  AGENTS  EMPLOYED  TO   SECURE  ASEPSIS.  *■ 

Formalin. — This  is  a  forty  per  cent,  solution  of  formic  aldehyde  gas  in 
water  and  has  valuable  antiseiitic  properties.  It  possesses  decided  irritating 
qualities.  It  may  be  used  in  a  two  per  cent,  solution  to  disinfect  instru- 
ments. Brewer  recommends  a  one  per  cent,  solution  applied  for  three  min- 
utes to  disiiifect  the  skin,  a  two  per  cent,  solution  applied  under  anaesthesia, 
to  sterilize  infected  tissues,  and  a  one-third  to  one  per  cent,  solution  for  gauze. 

Chloride  of  Zinc. — Chloride  of  zinc  in  a  solution  of  1.5  to  30  grains  to 
an  ounce  of  water  has  marked  antiseptic  properties.  When  employed  in 
solutions  of  this  strength  upon  raw  surfaces  it  produces  marked  blanching 
of  the  tissues,  and  is  especially  useful  as  an  application  to  infected  wounds. 
We  have  found  it  the  best  application  in  infected  wounds  which  are  re- 
ceived in  the  dissection  of  dead  bodies  and  in  operations.  In  such  cases 
the  whole  surface  of  the  wound  should  be  swabbed  with  a  thirty-grain 
solution  of  chloride  of  zinc,  and  the  wound  then  dressed  with  iodoform  or 
bichloride  gauze. 

Sulpho-Carbolate  of  Zinc. — This  drug  is  less  irritating  than  chlo- 
ride of  zinc,  and  possesses  the  same  antiseptic  properties.  It  is  used  in 
solutions  of  the  same  strength  and  for  the  same  purpose  as  the  chloride. 

Peroxide  of  Hydrogen. — Peroxide  of  hydrogen  is  furnished  in  what 
is  known  as  the  15-volume  solution.  It  may  be  used  in  this  strength  or  may 
be  diluted.  It  seems  to  have  a  direct  action  upon  pus-generation  by  de- 
stroying the  micro-organisms  of  i)us,  and  is  ixequently  employed  in  the 
sterilization  of  sinuses  or  suppurating  cavities  such  as  remain  after  the 
opening  of  abscesses  or  result  from  diseases  of  or  operations  upon  the 
bones.  It  is  injected  into  the  sinuses  and  cavities  by  means  of  a  glass 
syringe,  or  may  be  applied  to  open  wounds  in  the  form  of  a  spray.  Its  use 
is  dangei-ous  in  closed  cavities,  on  account  of  the  pressure  caused  by  the 
formation  of  gas.  Its  action  is  shown  by  the  escape  of  bubbles  of  gas,  which 
cleanse  sux^purating  surfaces  or  sinuses  mechanically,  and  it  should  be  used 
as  long  as  these  continue  to  escape. 

Kreolin. — Kreolin  is  obtained  from  English  coal-tar  by  dry  distillation, 
and  has  been  found  to  possess  marked  germicidal  properties.  It  is  insoluble 
in  water,  but  forms  an  emulsion  with  it.  It  is  used  in  an  emulsion  of  from 
two  to  five  per  cent,  strength  in  the  irrigation  of  large  wounds  or  cavities 
of  the  body,  and  has  been  most  favorably  recommended  in  gynsecological 
practice.  It  is  employed  for  the  same  purpose  as  carbolic  acid,  and  has  the 
advantage  over  the  latter  that  it  does  not  irritate  the  skin  and  is  practically 
non-toxic  ;  it  is  especially  useful  as  a  deodorant  in  offensive  malignant  ulcers. 

Lysol. — This  is  a  soapy  fluid,  closely  resembling  kreolin.  It  is  used  as 
an  antiseptic  in  solutions  of  one  or  two  per  cent.  Its  toxic  effects  are  much 
milder  than  carbolic  acid,  and  it  does  not  irritate  the  skin.  It  may  be 
employed  for  disinfecting  the  hands  and  for  disinfection  of  the  skin  before 
operations. 

Boric  Acid. — Boric  acid  does  not  possess  very  active  antiseptic  qual- 
ities, but  is  non-irritating  even  in  saturated  solutions.  It  is  frequently 
emj)loyed  as  a  powder  and  in  solutions  of  from  five  to  thirty  per  cent,  to 
cleanse  and  disinfect  mucous  surfaces  and  large  cavities.  On  account  of  its 
non-irritating  qualities  it  is  frequently  used  to  wash  out  the  bladder  before 


AGENTS  EMPLOYED  TO  SECURE  ASEPSIS.  H7 

operatious  for  the  removal  of  calculi  or  growths  from  this  organ.  In  the 
dressing  of  wounds  in  which  bichloride  or  carbolic  dressings  produce  irri- 
tation of  the  skin,  or  of  superficial  wounds  or  extensive  burns,  an  ointment 
of  boric  acid  1  part  to  petrolatum  5  parts  will  be  found  very  satisfactory. 
Occasionally  boric  acid  produces  irritation  of  the  skin. 

Salicylic  Acid. — Salicylic  acid  does  not  have  very  marked  antiseptic 
qualities,  but  possesses  much  less  toxic  action  than  carbolic  acid,  and  is  used 
for  somewhat  the  same  purposes.  Its  antiseptic  power  is  said  to  be  increased 
by  the  addition  of  boric  acid,  and  a  boro-salicylic  solution  (Thiersch's  solu- 
tion) is  prepared  by  adding  salicylic  acid  1  part,  boric  acid  6  parts,  to  hot 
water  500  parts,  making  a  very  bland  solution,  which,  reduced  to  twenty-five 
or  fifty  per  cent,  of  the  original  strength,  can  be  used  for  irrigation  of  the 
bladder  or  the  peritoneal  cavity. 

Permanganate  of  Potassium. — Permanganate  of  potassium  acts  as 
an  antiseptic  by  its  rapid  absorption  of  oxygen,  and  is  often  employed  for 
the  disinfection  of  foul  wounds  and  ulcers.  It  is  also  used  in  disinfecting 
the  hands  before  operation  and  for  the  disinfection  of  sponges.  It  is  non- 
irritating,  and  may  be  used  in  quite  concentrated  solutions.  It  is  usually 
employed  in  the  following  solution  :  j^otassii  permanganatis,  3i ;  aquae,  foi. 
One  drachm  of  this  solution  to  a  pint  of  water  makes  a  1  to  1000  solution. 

IcMhyol. — This  substance  possesses  piild  antiseptic  properties.  It  is 
employed  in  inflammatory  conditions  of  the  skin,  in  erysipelas,  and  in  the 
dressing  of  chilblains,  burns,  furuncles,  and  carbuncles.  It  is  usually  used 
as  an  ointment  of  twenty-five  to  fifty  per  cent,  with  lanolin  or  petrolatum. 

Silver. — Crede  has  demonstrated  that  metallic  silver  exerts  an  iuhibitive 
action  upon,  the  growth  of  micro-organisms  and  that  some  of  its  compounds 
possess  valuable  antiseptic  i^roperties.  The  preparations  most  employed  are 
actol,  silver  lactate,  and  itrol,  silver  citrate.  The  latter  is  often  used  as  a 
dusting  powder. 

Sodium  Chloride.— This  salt  has  no  direct  antiseptic  action,  but  is 
used  in  the  preparation  of  normal  salt  or  saline  solution,  the  strength 
of  which  is  six-tenths  of  one  per  cent.  It  is  prepared  by  adding  six  drachms 
of  sterilized  sodium  chloride  to  one  litre  of  distilled  water  which  is  contained 
in  a  sterilized  oval  glass  flask.  The  mouth  of  the  flask  should  be  ]5lugged 
with  sterilized  cotton  and  a  piece  of  gauze  fastened  tightly  over  the  mouth 
and  neck  of  the  bottle.  The  solution  should  be  exposed  to  steam  sterilization 
for  half  an  hour  on  two  successive  days. 

Saline  solution  is  non-irritating  and  is  the  best  irrigating  fluid  that  can 
be  employed,  and  is  frequently  used  in  the  irrigation  of  fresh  wounds,  to 
remove  foreign  bodies  or  blood,  and  for  the  cleansing  of  mucous  and  serous 
surfaces.  Its  utility  by  intravenous  injection  or  infusion  is  well  recognized. 
(See  p.  160.)  It  should  be  used  at  a  temperature  of  100°  to  120°  P.  (37.7°  to 
48.8°  C). 

METHODS   OF   DISINFECTION   OK   STEEILIZATION. 

Sterilization  of  the  wound  or  the  substances  coming  in  contact  with  it 
may  be  accomplished  by  using  either  the  aseptic  method  or  the  antiseptic 
method,  and  at  the  present  time  tliese  two  methods  are  to  a  certain  extent 
combined  ;  that  is,  it  is  impossible  to  be  strictly  aseptic  without  employing 


118  METHODS   OF  DISINFECTION  OE   STERILIZATION. 

means  of  disinfection  by  the  use  of  antiseptics.  Tlie  aseptic  method,  which 
employs  antiseptic  substances  only  for  the  purpose  of  sterilization  of  objects 
coming  in  contact  with  the  wound,  when  their  disinfection  by  heat  is  impos- 
sible, is  the  method  which  has  been  generally  adopted. 

Antiseptic  Method. — In  the  antiseptic  method  the  sterilization  of  the 
field  of  operation,  the  hands  of  the  surgeon  and  assistants,  the  instruments, 
ligatures,  sponges,  and  sutures,  is  accomjilished  by  the  use  of  germicidal 
solutions,  and,  in  addition,  the  wound  is  irrigated  frequently  during  the 
operation  with  germicidal  sokitions,  and  is  afterwards  covered  with  dress- 
ings imi)regnated  with  germicidal  substances.  The  antiseptic  method  was 
that  first  employed,  and,  recognizing  its  value  in  surgical  procedures,  many 
surgeons  still  continue  to  emj)loy  this  method,  but  it  has  certain  disadvan- 
tages. Eecent  investigations  have  shown  that  many  of  the  germicidal  sub- 
stances have  not  the  power  which  was  formerly  attributed  to  them,  as  they 
only  arrest  bacterial  develoi^ment ;  many  chemical  germicides  form  a  dense 
layer  of  coagulated  albumin  around  albuminous  substances,  and  also  fail  to 
destroy  micro-organisms  associated  with  fatty  or  oily  substances.  Chemical 
germicides  may  also  form  combinations  in  the  tissues  with  substances  with 
which  they  come  in  contact,  seriously  impairing  their  germicidal  action. 
Antiseptic  substances  which  are  active  as  germicides  often  cause  irritation 
of  the  surface  of  the  wound,  interfering  with  its  repair.  Halstead  has  shown 
that  irrigation  of  a  fresh  wound  with  a  1  to  10,000  solution  of  bichloride 
of  mercury  is  followed  by  distinct  evidence  of  superficial  necrosis  of  the 
tissues.  Antisei)tic  ir-rigation  of  wounds  is  apt  to  cause  very  free  oozing  of 
serum,  which  necessitates  the  use  of  drainage  and  makes  the  frequent  dress- 
ing of  the  woiind  necessary.  Many  antiseptic  substances  produce  marked 
toxic  effects  upon  the  patient,  and  also  cause  very  severe  irritation  of  the 
skin  with  which  they  come  in  contact. 

Aseptic  Method. — In  employing  the  aseptic  method  in  the  treatment 
of  wounds  the  field  of  operation,  the  hands  of  the  surgeon  and  assistants, 
the  instruments,  ligatures,  sponges,  and  sutures,  are  sterilized  by  the  use  of 
germicidal  solutions  or  heat,  and  after  this  has  been  accomplished,  rely- 
ing upon  the  completeness  of  the  sterilization,  no  antiseptic  substances  are 
brought  in  contact  with  the  wound,  sterilized  water  or  sterilized  salt  solution 
being  used  if  it  is  necessary  to  flush  the  wound,  and  the  dressings  emijloyed 
are  those  which  have  been  sterilized  only  by  moist  or  dry  heat.  The  advan- 
tages of  the  aseptic  method  are  as  follows :  the  method  is  applicable  to  all 
parts  of  the  body  ;  wounds  treated  by  this  method  heal  more  promptly  and 
do  not  require  such  frequent  dressing  ;  there  is  no  risk  of  toxic  effects,  and 
there  is  no  irritation  of  the  skin  by  the  dressings.  Dry  sterilised  dressings 
are  efficient  to  produce  absorption,  and  at  the  same  time  the  dryness  may 
be  a  factor  in  the  destruction  of  germs,  for  exposing  bacteria  to  dryness 
deprives  them  of  one  of  the  conditions  necessary  to  their  existence.  The 
aseptic  method  is,  therefore,  to  be  preferred  to  the  antiseptic  method  in  the 
treatment  of  wounds  wherever  it  is  possible. 

Sterilization  of  the  Hands. — Experimental  investigation  has  shown 
that  the  hands  of  the  surgeon,  unless  properly  sterilized,  may  be  the  most 
active  agents  in  producing  infection  of  the  wound  ;  the  region  of  the  finger- 


STERILIZATION  OF  THE  HANDS.  119 

naiU  and  the  interdigital  folds  are  locations  where  germs  are  particularly 
abundant.  Various  methods  of  sterilizing  the  hands  have  been  employed 
and  a  few  of  the  most  satisfiictory  methods  are  given  below. 

First  Method. — The  hands  and  forearms  of  the  surgeon,  assistants,  and 
nurses  who  are  to  take  part  in  the  operation  may  be  sterilized  by  first  rub- 
bing them  with  spirit  of  turiientine,  and  then  thoroughly  scrubbing  them 
with  Castile  soap  and  water,  using  a  nail-brush  freely.  Care  should  be 
taken  that  the  brush  is  sterilized.  This  scrubbing  should  be  employed  for 
several  minutes ;  the  hauds  are  then  rinsed  to  remove  the  soap,  and  are 
soaked  for  five  minutes  in  a  1  to  1000  bichloride  of  mercury  solution.  If 
turpentine  has  not  been  employed,  strong  alcohol  or  ether  should  be  well 
rubbed  over  the  hands  before  they  are  immersed  in  the  bichloride  solution. 
When  the  hands  have  been  sterilized  they  should  not  be  brought  in  contact 
with  anytliiiig  that  is  not  sterile. 

Second  Method. — This  method  of  sterilizing  the  hands,  which  is  very 
satisfactory,  is  that  employed  by  Kelly,  which  consists  in  washing  the  hands 
and  forearms  with  soap  for  ten  minutes,  and  then  covering  them  with  a 
warm  saturated  solution  of  permanganate  of  potassium,  which  stains  them  a 
deep  mahogany  color  ;  they  are  then  washed  in  a  warm  saturated  solution 
of  oxalic  acid  until  all  the  permanganate  stain  is  removed,  and  should  next 
be  washed  in  sterilized  water  to  remove  the  oxalic  acid  which  may  adhere  to 
the  skin. 

Third  Method. — Weir  and  Stimson  recommend  the  following  method 
of  sterilizing  the  hands.  After  washing  the  hands  with  green  soap,  put  a 
tablespoonful  of  commercial  chloride  of  lime  and  a  i^iece  of  carbonate  of 
soda  (1  X  2  inch)  in  the  hand,  with  enough  water  to  make  a  paste.  Eub 
this  into  a  thick  cream,  ^  hich  should  be  rubbed  into  the  hands  until  the 
grains  of  lime  disappear  and  the  skin  feels  cool.  The  hands  are  then  rinsed 
in  sterile  water  and  may  be  soaked  for  a  short  time  in  a  four  per  cent,  solu- 
tion of  sodium  phosphite  to  remove  the  odor  of  chlorine  if  desired.  We  have 
found  this  one  of  the  simj)lest  and  most  satisfactory  methods  of  sterilizing 
the  hands. 

The  difficulty  of  completely  sterilizing  the  hands  has  been  shown  by  bac- 
teriological tests,  for  it  has  been  demonstrated  that  after  great  care  in  the 
process  complete  sterility  could  only  be  obtained  in  about  ninety-five  per 
cent,  of  the  tests.  To  render  them  completely  sterile  the  use  of  gloves 
has  been  recently  employed.  Mikulicz  recommended  the  use  of  sterilized 
cotton  gloves,  but  their  emj)loymeut  has  been  found  unsatisfactory,  as,  when 
wet,  fluids  from  the  surface  of  the  hands  can  pass  freely  through  the  meshes, 
and  if  the  hands  are  not  perfectly  sterile  infection  of  the  wound  may  occur 
in  this  manner. 

India-Rubber  Gloves. — These  gloves  are  now  extensively  employed  in 
operative  work,  and  the  results  following  their  use  have  been  most  satisfac- 
tory. They  are  made  of  very  thin  rubber,  so  that  there  is  little  interference 
with  tactile  sensation,  and  from  their  elasticity  they  fit  the  hand  accurately. 
They  can  be  rendered  absolutely  sterile,  and  as  they  ai-e  impervious  to 
moisture  there  is  no  risk  of  wound  infection,  even  if  the  hand  is  not  com- 
pletely sterilized,  unless  the  gloves  are  torn  or  punctured.     It  is  most  im- 


120  STERILIZATIOX   OF  IXSTELTMEXTS. 

portaut  that  the  hands  should  be  thoroughly  sterilized  before  the  gloves  are 
applied,  in  view  of  the  possibility  of  this  accident.  They  may  be  sterilized 
by  fii'st  washing  them  with  soap  and  water  and  then  immersing  them  for 
twenty-four  hours  in  a  1  to  1000  bichloride  solution.  A  better  method  of 
sterilization,  however,  consists  in  wrapping  them  in  a  towel  and  boiling 
them  for  ten  minutes  in  plain  water.  They  are  usuallj"  applied  by  filling 
them  with  sterile  water  or  salt  solution  and  then  introducing  the  hand. 
Some  operators  prefer  to  apply  them  dry  (after  sterilization)  by  covering 
the  hand  with  a  dry  sterilized  powder,  such  as  starch  or  soapstone.  If 
properly  cared  for  a  pair  of  gloves  will  withstand  a  number  of  sterilizations. 
A  freshly  sterilized  pair  should  be  used  for  each  operation. 

Sterilization  of  Instruments. — For  ease  of  sterilization  instruments 
should  be  made  entirely  of  metal,  or  have  hard  rubber  handles,  sliould  not 
be  of  complicated  mechanism,  should  have  smooth  surfaces  so  that  they  can 
be  readily  cleansed,  and  should  have  pivot  or  lock  joints  rather  than  screw 
joints.  The  sterilization  of  instruments  can  be  best  accomplished  by  moist  . 
heat.  The  method  suggested  by  Schimmelbusch  is  now  almost  universally 
employed.  This  consists  in  boiling  them  for  fifteen  minutes  in  water  to 
which  a  tablespoonful  of  washing  soda  (carbonate  of  sodium)  has  been  added 
for  each  Cjuart  of  water :  this  prevents  the  rusting  of  the  instruments,  and 
also  maiies  the  water  a  better  solvent  for  any  fatty  matter  which  may  be  upon 
the  instruments.  Delicate  cutting  instruments  and  needles  are  injured  by 
so  prolonged  a  sterilization,  so  that  they  are  usually  boiled  for  only  five 
minutes.  Glass  syringes,  aspirators,  and  glass  drainage-tubes  may  be  steril- 
ized by  boiling.  If  wooden-handled  instruments  are  used,  which  would  be 
injured  by  boiling,  they  should  first  be  thoroughly  scrubbed  with  soap  and 
water  and  a  brush,  and  after  having  been  rinsed  in  sterilized  water  they 
should  be  placed  in  a  tray  and  covered  with  a  1  to  20  watery  solution  of  car- 
bolic acid,  to  which  five  i^er  cent,  of  carbonate  of  sodium  has  been  added,  and 
allowed  to  remain  in  this  solution  for  at  least  half  an  hour  ;  before  being  used 
they  should  be  transferred  to  a  solution  of  sterilized  water,  which  will  pre- 
vent the  benumbing  eifect  of  the  carbolic  solution  upon  the  surgeon's  hands. 

Sterilization  of  Catheters  and  Bougies.— These,  if  made  of 
metal  or  glass,  may  be  sterilized  by  boiling  for  fifteen  minutes  in  a  one  per 
cent,  solution  of  sodium  carbonate.  If  constructed  of  rubber  or  gum  pro- 
longed boiling  destroys  them  ;  theyciiay,  however,  be  sterilized  by  first  wash- 
ing them  with  soap  and  water  and  then  placing  them  in  water  heated  nearly 
to  the  boiling-point  for  fifteen  minutes.  They  are  next  placed  in  a  1  to  1000 
bichloride  solution  until  required.  They  should,  on  being  removed  from  this 
solution  for  use,  be  thoroughly  washed  in  hot  sterile  water  to  remove  all  of 
the  bichloride  solution.  Eubber  catheters  may  also  be  sterilized  by  soaking 
them  for  an  hour  in  a  two  per  cent,  solution  of  formalin,  or  by  placing  them 
in  an  air-tight  metallic  case  or  glass  jar  containing  pastils  of  paraform  for 
twenty-four  hours.  They  can  be  kept  indefinitely  in  such  a  receptacle,  and 
when  removed  for  use  should  be  washed  in  sterilized  water. 

For  lubricating  catheters  and  bougies,  oily  materials  should  be  avoided 
and  sterilized  glycerin  or  lubrichondrin,  both  of  which  are  soluble  in 
water,  should  be  employed. 


STEEILIZATIOX   OF   SPECIAL  PARTS.  121 

Sterilization  of  Special  Parts. — The  Scalp.— Great  care  should 
be  observed  iu  sterilizing  the  scalp  before  operatious  upon  the  scalp,  the 
skull,  or  the  brain,  as  it  is  often  covered  by  dense  masses  of  epidermis.  The 
entire  scalp  should  be  shaved  and  a  soajo  poultice  applied  for  twelve  hours, 
or  the  apijlication  of  sweet  oil  for  twenty-four  hours  before  the  use  of  the 
soap  poultice  may  be  of  service  in  softening  the  epidermis.  It  should  be  thor- 
oughly scrubbed  with  soap  and  water  and  finally  with  a  1  to  1000  bichloride 
solution. 

The  Mouth  and  Nasal  Cavities. — To  render  the  mouth  as  far  as  pos- 
sible sterile  the  teeth  should  be  thoroughly  brushed  with  tooth-powder  and 
the  cavity  of  the  mouth  frecxuently  rinsed  with  a  solution  of  peroxide  of 
hydrogen  one  part  to  six  parts  of  water,  or  with  a  saturated  solution  of 
boric  acid.  The  nasal  cavities  and  i^ost-nasal  region  should  be  sterilized 
by  sprajang  them  with  the  same  solutions. 

The  Bladder  and  Urethra. — The  bladder  should  be  emptied  by  a 
catheter  and  then  filled  with  sterile  water,  boric  acid,  or  normal  salt  solu- 
tion ;  this  pi-ocedure  should  be  repeated  several  times.  In  operations  upon 
the  urethra  the  same  care  should  be  taken  to  render  the  urethra  sterile  by 
free  irrigation  with  normal  salt  solution  or  boric  acid  solution. 

The  Skin. — The  skin  always  contains  micro-organisms  which  develop 
upon  it  and  are  constantly  deposited  upon  it  from  the  air  ;  it  also  contains 
hail'.  We  can  scarcely  hoj^e  to  obtain  absolute  sterilization  of  the  skin 
under  these  circumstances,  but  by  careful  preparation  seek  to  secure  that 
relative  sterility  which  enables  us  to  obtain  primary  union.  The  skin 
is  sterilized  by  scrubbing  it  with  soap  and  water,  and  afterwards  washing  it 
with  alcohol  and  ether,  and  finally  rubbing  it  with  a  1  to  1000  bichloride  solu- 
tion. Care  should  be  taken  that  the  rubbing  is  not  so  hard  or  prolonged  as 
to  cause  a  dermatitis. 

The  Vagina. — The  vagina  and  external  genitals  require  great  care  in 
sterilization.  The  external  genitals  should  be  scrubbed  with  soap  aud  water 
and  the  vagina  fully  dilated  with  a  speculum,  aud  thoroughly  mopped  with 
a  si)onge  or  gauze  pads  saturated  with  green  soap  and  afterwards  with 
Thiersch's  solution.  It  should  finally  be  irrigated  with  a  1  to  2000  bichloride 
solution  or  a  one  per  cent,  solution  of  kreoliu. 

The  Stomach. — The  stomach  may  be  incomjaletely  sterilized  by  thor- 
ough lavage  with  normal  salt  solution  or  boric  acid  solution.  This  is  impor- 
tant uot  only  in  operations  upon  the  stomach  itself,  but  also  in  operations 
upon  the  pharynx,  to  diminish  the  risk  of  infection  by  vomited  matter.  In 
cases  of  intestinal  obstruction  with  vomiting,  lavage  of  the  stomach  should 
always  be  employed  before  the  administration  of  an  anaesthetic. 

The  Rectum. — When  an  operation  is  to  be  performed  ui^on  the  anus 
or  rectum,  the  patient  should  be  given  a  purgative  and  an  enema  some 
hours  before  the  operation,  to  remove  any  fecal  matter  which  may  be  in  the 
rectum.  The  region  of  the  anus  should  be  disinfected  with  soap  and  water 
and  thoroughly  scrubbed,  and  after  the  patient  has  been  anaesthetized  the 
sphincter  should  be  well  stretched  and  the  rectum  carefully  wiped  out  with 
gauze  saturated  with  a  solution  of  green  soajD  and  then  irrigated  with  normal 
salt  or  boric  acid  solution.     A  tampon  of  a  sterilized  sponge  or  gauze,  with 


122  PREPAEATION  OF  PATIENT  FOE   OPERATION. 

a  string  attached,  should  be  packed  into  the  rectum  above  the  seat  of  oper- 
ation, to  prevent  the  wound  from  becoming  soiled  with  fteces  during  the 
operation.  The  tampon  can  be  removed  by  means  of  the  string  after  the 
operation  has  been  completed. 

The  Feet. — There  is  usually  present  upon  the  feet  a  very  large  amount 
of  thickened  epidermis,  which  is  often  a  difficult  matter  to  render  sterile. 
The  feet  should  be  thoroughly  washed  with  soap  and  water  and  scrubbed 
vigorously  with  a  brush  ;  or  a  soap  poultice  sliould  be  applied  to  the  whole 
surface  of  the  feet  for  some  hours  and  held  in  position  by  a  bandage.  A 
moist  dressing  favors  the  separation  of  the  superficial  layers  of  the  epi- 
dermis, and  after  it  has  been  worn  for  a  few  hours  it  is  possible  to  remove  a 
large  portion  of  the  epidermis  by  the  use  of  the  brush.  After  having 
been  thoroughly  washed  with  a  1  to  1000  bichloride  solution  they  should  be 
wrai^xjed  in  a  towel  or  a  few  layei'S  of  gauze  saturated  with  bichloride  of 
mercury  solution  1  to  1000  for  thirty  minutes. 

Preparation  of  the  Patient  for  Aseptic  Operation. — When 
possible  it  is  well  that  the  patient  be  given  a  general  bath  the  night  before 
the  operation,  and  the  skin  surrounding  the  site  of  operation  should  be 
rubbed  over  with  cotton  saturated  with  spirit  of  turpentine,  and  should 
then  be  thoroughly  scrubbed  with  a  brush  and  soap  and  water  ;  or  a  soap 
j)oultice  may  be  applied  to  the  part  for  a  few  hours  before  the  final  steriliza- 
tion with  alcohol  and  bichloride  is  made.  After  this  scrubbing  has  been 
continued  for  a  few  minutes  the  skin  is  washed  with  alcohol,  and  if  turpen- 
tine has  not  been  used  it  is  better  to  rub  the  skin  over  with  ether,  then  wash 
it  with  sterilized  water  and  apply  to  the  surface  a  folded  towel  or  gauze 
dressing  saturated  with  a  1  to  1000  bichloride  solution ;  this  should  be 
replaced  in  thirty  minutes  by  dry  sterilized  gauze  to  avoid  dermatitis.  A 
similar  washing  and  preparation  of  the  seat  of  operation  should  be  made 
the  next  morning,  a  few  hours  before  the  time  fixed  for  operation. 

It  is  well  to  i-emember  that  regions  of  the  body  which  contain  hair  and 
numerous  sweat-glands,  such  as  the  axilla,  navel,  scrotum,  groin,  and  the 
creases  about  the  joints,  are  those  in  which  micro-organisms  grow  with  the 
greatest  activity.  Therefore,  all  hair  in  the  field  of  operation  should  be 
removed  by  shaving. 

Clothing  of  Surgeon  and  Assistants.— It  is  desirable  for  the  sur- 
geon, his  assistants,  and  the  nurses  to  wear  sterilized  linen  or  muslin  suits, 
or  to  be  provided  with  gowns  with  sleeves  reaching  to  the  elbows.  The 
operating-gown  should  be  made  of  muslin  or  linen,  which  can  easily  be  ster- 
ilized by  boiling  or  heat;  a  variety  of  linen  known  as  butcher's  linen  is  very 
serviceable  for  this  purpose.  As  a  matter  of  additional  precaution,  many 
surgeons  and  their  assistants  wear  during  the  operation  closely  fitting  skull- 
caps of  linen  or  sterilized  gauze  turbans.  The  surgeons  and  assistants  will 
often  find  it  convenient  to  wear  under  their  linen  gowns  india-rubber  aprons, 
to  j)revent  the  soiling  of  the  clothing  by  blood  or  solations.  The  nurses 
should  wear  dresses  of  washable  goods.  An  operating-apron  may  be  impro- 
vised from  a  clean  sheet  folded  so  as  to  be  one  and  a  half  yards  in  width  and 
from  five  to  six  feet  in  length,  by  turning  in  about  ten  inches  of  one  end  of 
the  sheet  over  the  ui>per  part  of  the  chest  and  placing  a  strip  of  bandage  in 


DETAILS   OF  ASEPTIC   OPERATION.  123 

this  fold,  which  should  be  secured  around  the  neck,  tying  a  second  strip  of 
bandage  over  the  sheet  at  the  waist.  The  surgeon,  assistants,  and  nurses 
should  wear  rubber  gloves. 

Preparation  of  Room  for  Operation.— In  hospital  practice  suit- 
able operating-rooms  are  j)rovided ;  in  private  practice,  however,  the  sur- 
geon is  ofteu  called  upon  to  select  a  room  and  give  directions  as  to  its  prepa- 
ration. A  well-lighted  room  should  always  be  selected,  and  all  unnecessary 
articles  of  furniture,  such  as  ornaments,  j)ictures,  and  curtains,  should  be 
removed.  The  carpet  should  be  taken  up,  aud  the  floor  scrubbed.  A  few 
small  tables  and  a  large  wooden  table  should  be  placed  in  the  room,  having 
previously  been  dusted  and  wiped  off  with  a  bichloride  solution.  All  prep- 
arations should  be  made,  if  possible,  upon  the  day  before  the  oj)eration,  as 
the  stirring  up  of  dust  incidental  to  the  change  in  furniture  in  cleaning  the 
room  on  the  day  of  ojaeration  immediately  before  the  time  set  is  more  dan- 
gerous than  no  cleauing  of  the  room  whatever,  since  the  principal  contami- 
nation of  the  wound  is  likely  to  come  from  germs  contained  in  the  dust.  In 
case  of  emergency  the  carpet  should  not  be  taken  up,  but  the  floor  may  be 
well  moistened  by  sprinkling  with  water  to  lay  the  dust.  The  preparation 
of  the  room  is  not,  in  our  judgment,  a  matter  that  affects  the  results  of 
operations  as  much  as  does  the  exercise  of  great  care  in  regard  to  aseptic 
details  of  the  operation  itself 

Details  of  an  Aseptic  Operation.— The  patient,  being  prepared 
for  operation  as  described,  and  having  been  anesthetized,  is  placed  upon  the 
operating-table,  the  surgeon,  assistants,  and  nurses  also  being  prepared  for 
the  operation  as  previously  described.  If  the  operation  be  one  upon  the 
face,  neck,  or  chest,  it  is  well  before  the  dressings  covering  the  seat  of  opera- 
tion are  removed  to  cover  the  patient's  hair  with  a  towel  or  handkerchief 
bandage  made  of  several  laj^ers  of  sterilized  or  bichloride  gauze.  The  por- 
tions of  the  patient's  body  which  it  is  not  necessary  to  expose  in  the  opera- 
tion should  be  covered  with  a  sterilized  blanket,  and  this  covered  with  a 
sterilized  sheet.  Some  surgeons  prefer  to  have  the  patient  wear  a  sterilized 
gown,  which  is  ripped  or  cut  to  expose  the  part  to  be  operated  upon.  The 
region  of  the  wound  and  the  operating-table  are  next  protected  with  ster- 
ilized towels  or  cloths.  The  surgeon  having  assigned  the  assistants  and 
nurses  their  duties,  the  dressing  is  removed  from  the  part  to  be  operated 
upon,  and  the  operation  is  begun.  Hemorrhage  is  controlled  during  the 
operation  by  the  use  of  haemostatic  forceps,  and  sterilized  gauze  pledgets  are 
emi^loyed  to  keep  the  wound  free  from  blood.  When  the  operation  is  com- 
pleted, the  vessels  are  ligated,  the  haemostatic  forceps  are  removed,  and  the 
wound  is  dried  with  gauze  pledgets.  If,  for  any  reason,  the  surgeon  deems 
it  advisable  to  irrigate  the  wound,  it  may  be  done  with  hot  water  which  has 
been  boiled,  or  with  hot  sterilized  salt  solution.  If  the  surgeon  decides  that 
drainage  is  not  necessary,  the  deeper  jaarts  of  the  wound  may  then  be 
brought  together  by  buried  sutures  of  catgut  or  silk,  and  the  edges  of  the 
superficial  wound  next  approximated  by  sutures  of  catgut,  silk,  or  silkworm- 
gut.  If  the  surgeon  decides  to  use  drainage,  a  few  strands  of  catgut,  a  strip 
of  sterilized  gauze,  a  tent  of  rubber  tissue,  or  a  rubber  drainage-tube  is  intro-  . 
duced  into  the  deepest  portion  of  the  wound  and  is  brought  out  at  its  most 


124  DETAILS   OF  ANTISEPTIC  OPERATION. 

dependent  part.  The  wound  is  then  dressed  with  a  number  of  loose  masses 
of  sterilized  gauze  placed  so  as  to  cover  the  wound  and  extend  beyond  it  in 
all  directions,  and  these  are  covered  by  a  number  of  layers  of  sterilized 
gauze.  Over  the  gauze  dressing  are  placed  a  few  layers  of  sterilized  cotton, 
extending  on  all  sides  well  beyond  the  gauze,  and  the  dressings  are  held  in 
l^lace  by  a  sterilized  gauze  bandage.  The  bandage  should  be  so  applied  as 
to  cover  the  cotton  at  the  edges  of  the  dressing  and  thus  make  the  occlusion 
of  the  air  from  the  wound  as  complete  as  possible.  The  dressings  should  be 
voluminous  ;  it  is  always  a  mistake  to  apply  scanty  dressings.  In  redressing 
the  -o'ound  the  same  care  should  be  exercised  as  regards  asepsis  as  was 
observed  at  the  primary  dressing. 

Details  of  an  Antiseptic  Operation. — If  the  surgeon  is  about  to 
operate  upon  a  i^atient  in  whom  a  wound  exists  which  is  already  suppu- 
rating, as,  for  instance,  the  removal  of  suppurating  glands  from  the  groin, 
and  desires  to  employ  the  antiseptic  method,  the  procedure  will  be  as  fol- 
lows. The  region  of  the  wound  being  sterilized,  and  the  sui-geon,  assistants 
and  nurses  having  prepared  themselves  as  before  described,  the  wound  is 
exposed,  and  if  suppurating  sinuses  exist  these  are  washed  out  with  per- 
oxide of  hydrogen,  and  this  application  should  be  followed  by  a  douche 
of  a  1  to  2000  bichloride  solution.  The  surgeon  next  enlarges  the  wound 
and  removes  the  glands  as  completelj^  as  possible,  and  may  during  the  oper- 
ation have  the  wound  douched  at  intervals  with  bichloride  solution,  the 
curette  and  scissors  being  used  freely  to  remove  diseased  tissues.  Hemor- 
rhage is  controlled  bj"  the  use  of  haemostatic  forceps,  which  are  removed 
later,  and  bleeding  vessels  are  tied  with  catgut.  The  wound  is  finally 
irrigated  with  a  warm  bichloride  solution,  is  dried  with  sf)onges  or  gauze 
pledgets,  and  may  be  dusted  freely  with  powdered  iodoform  ;  a  rubber  drain- 
age-tube or  strips  of  iodoform  gauze  are  next  introduced  to  the  bottom  of  the 
wound,  and  the  edges  are  brought  together  by  sutures ;  pads  of  iodoform 
gauze  or  bichloride  gauze  are  jilaced  over  the  wound,  and  over  these  a  num- 
ber of  layers  of  bichloride  cotton,  and  the  dressings  are  held  in  position  by 
a  gauze  bandage.  In  redressing  siich  a  wound  the  same  antiseptic  details 
should  be  employed. 

Aseptic  or  Antiseptic  Treatment  of  Infected  Wounds. — It 

often  happens  that  the  surgeon  is  called  upon  to  treat  a  wound  which  is 
septic  when  it  comes  under  his  care,  as  evidenced  by  the  inflamed  state  of 
the  wound,  inflammation  of  the  lymphatic  vessels  and  skin,  foul  discharges 
and  sloughing  of  the  tissues,  and  the  coexistent  constitutional  sym^jtoms 
of  sepsis.  In  such  a  case  it  would  at  first  sight  appear  that  the  surgeon  or 
his  assistants  could  not  introduce  any  material  of  infection  worse  than  that 
which  already  existed  in  the  wound,  but  he  should  bear  in  mind  the  fact  that 
it  is  possible  to  introduce  an  additional  form  of  infection.  With  this  possi- 
bility in  view  he  should  observe  the  same  j)recautions  as  regards  the  steril- 
ization of  his  hands,  the  skin  of  the  patient,  the  instruments,  and  dressings 
as  he  would  employ  in  treating  a  perfectly  fresh  wound. 

It  was  formerly  the  rule  to  apply  the  antiseptic  method  very  generally 
in  the  treatment  of  infected  wounds.  Recent  investigations,  however,  have 
shown  that  the  aerms  in  abscesses  are  to  a  great  extent  dead,  and  that  the 


MATERIAXS  USED   IN   ASEPTIC  OPERATIONS.  125 

pus-formation  is  largely  due  to  the  irritation  caused  by  their  products.  In 
view  of  these  facts,  it  would  seem  that  the  most  important  part  of  the  treat- 
ment of  infected  wounds  is  thorough  drainage.  It  is  a  question  whether  the 
micro-organisms  in  the  walls  of  infected  cavities  or  sinuses  can  be  destroyed 
by  antiseptic  irrigation.  Some  surgeons  recommend  active  treatment,  both 
mechanically  and  by  the  use  of  germicidal  solutions,  while  others  are  satis- 
fled  sim]3ly  to  secure  free  drainage,  and  if  irrigation  is  necessary  they  do  not 
employ  strong  germicidal  fluids,  but  use  simply  sterilized  water  or  sterilized 
salt  solution.  For  our  own  part  we  are  inclined  to  employ  the  antiseptic 
method  in  dealing  with  infected  wounds,  and  can  recommend  the  follow- 
ing plan.  The  skin  surrounding  the  wound  for  some  distance  should  be 
wiped  over  with  spirit  of  turpentine  and  carefully  scrubbed  with  soap  and 
water,  and  should  next  be  washed  with  a  1  to  1000  bichloride  solution  ;  the 
wound  itself  should  next  be  washed  with  peroxide  of  hydrogen  and  a  1 
to  2000  bichloride  solution.  "With  forceps  and  curette  any  dirt  or  slough- 
ing tissue  should  be  removed ;  then  the  wound  again  washed  with  per- 
oxide of  hydi-ogen  and  douched  with  a  1  to  2000  bichloride  solution.  The 
wound  should  then  be  dried  with  gauze  pledgets  and  dusted  with  iodoform 
and  loosely  jjacked  with  strips  of  iodoform  gauze.  If  from  the  appearance 
of  the  tissues  the  surgeon  has  reason  to  think  that  the  infection  has  passed 
beyond  the  reach  of  the  curette  or  scissors,  he  may  swab  the  surface  of  the 
woiind  over  with  a  solution  of  chloride  of  zinc,  thirty  grains  to  the  ounce 
of  water.  Pm-e  carbolic  acid  may  be  used,  and  is  recommended  by  some 
surgeons,  for  the  same  purpose  as  chloride  of  zinc,  but  the  toxic  action  of 
carbolic  acid  causes  its  employment  to  be  attended  with  some  danger.  Toxic 
effects  and  too  extensive  cauterization  may  be  prevented  by  immediately 
washing  the  part  with  absolute  alcohol.  Free  di-ainage  being  secured  by 
the  introduction  of  a  few  strips  of  iodoform  gauze,  the  wound  is  dressed 
with  a  voluminous  dressing  of  bichloride  gauze  and  bichloride  cotton.  No 
attempt,  as  a  rule,  should  be  made  to  bring  together  the  edges  of  such  a  wound 
by  the  introduction  of  sutures.  In  the  dressing  of  infected  wounds,  when 
the  discharges  are  ropy  or  viscid  they  are  not  well  absorbed  by  dry  dressings, 
and  in  this  class  of  wounds  it  is  therefore  of  advantage  to  employ  moist  anti- 
septic dressings.  By  this  method  of  treatment  it  is  often  possible  to  convert 
a  septic  wound  into  an  aseptic  one,  and  have  rapid  improvement  follow  both 
in  the  local  condition  of  the  wound  and  in  the  constitutional  condition  of 
the  patient. 

PPvEPAPvATION    OP    MATERIALS    USED    IN   ASEPTIC    OPERATIONS. 

Sterilization  of  Water. — Water  may  be  rendered  absolutely  sterile  by 
boiling  for  from  fifteen  to  thirty  minutes.  It  should  be  distilled  or  filtered 
before  being  boiled  to  remove  any  inert  matter  which  is  not  desirable  in 
wounds.  After  being  boiled  it  should  be  i^laced  in  sterilized  glass  flasks 
corked  with  sterilized  cotton,  the  mouths  of  the  flasks  also  being  covered 
with  several  layers  of  gauze.  It  is  employed  for  the  irrigation  of  wounds 
and  of  mucous  and  serous  surfaces. 

Sponges. — Marine  sponges  are  the  best  materials  for  the  purpose  of 
sponging,  but  their  satisfactory  sterilization  is  often  a  matter  of  difficulty. 


126  MATERIALS  USED  IN  ASEPTIC  OPERATIONS. 

It  is  better  to  use  a  cheap  grade  of  sponges  and  iise  them  only  once.  The 
sterilization  of  sponges  by  boiling  destroys  to  a  certain  extent  their  elasticity 
and  their  absorbent  power.  Elsberg  claims  that  sponges  can  be  boiled  in  a 
solution  of  caustic  potash  one  per  cent.,  tannic  acid  two  jjer  cent.,  water 
ninety-seven  per  cent.,  without  losing  these  properties.  Schimmelbusch 
recommends  the  following  method.  The  dried  sijonges  are  freed  from  dirt 
or  sand  by  beating,  and  are  then  soaked  for  several  days  in  cold  water 
slightly  acidulated  with  hydrochloric  acid,  being  kneaded  from  time  to 
time.  They  are  next  thoroughly  washed  in  cold  and  in  warm  water, 
wrapped  up  in  a  linen  sheet,  and  x^laced  iu  a  boiling  one  iier  cent,  soda 
solution ;  the  solution  should  not  be  allowed  to  boil  after  the  sponges  are 
placed  iu  it.  They  are  allowed  to  remain  in  this  hot  solution  for  thirty 
minutes,  are  then  washed  in  boiled  water  to  remove  the  soda,  and  are  placed 
in  a  half  per  cent,  bichloride  solution  for  use.  Another  method  of  pre- 
paring the  sponges  consists  in  beating  them  to  remove  any  sandy  matter 
which  they  may  contain,  and  placing  them  for  twenty-four  hours  in  a  solu- 
tion of  hydrochloric  acid,  4  ounces ;  water,  4  pints ;  upon  removing  them 
from  this  solution,  they  are  washed  until  free  from  acid ;  they  are  then 
placed  for  ten  minutes  in  the  following  solution  :  potassium  permanganate, 
5  ii ;  sodium  sulphite,  3  i ;  acid,  hydrochlor. ,  .5  ii ;  aqute,  Oii.  Remove 
and  wash  in  several  changes  of  sterilized  water,  to  the  last  of  which  a  few 
drops  of  aqua  ammonife  have  been  added,  then  transfer  to  sterile  jars  and 
cover  with  a  live  per  cent,  carbolic  acid  solution. 

Gauze  Pledgets  or  Pads. — Ou  account  of  the  ditficulty  of  the  satis- 
factory sterilization  of  sponges,  as  well  as  of  their  expense,  folded  gauze 
pledgets  have  largely  superseded  them.  Gauze  pledgets  are  prepared  by 
cutting  a  piece  of  gauze  composed  of  from  twelve  to  sixteen  layers  in 
pieces  six  inches  square ;  the  four  angles  of  these  j)ieces  are  then  tied  to- 
gether or  secured  by  a  few  stitches.  Gauze  pads  are  made  from  a  piece 
of  gauze  composed  of  from  sixteen  to  twenty  layers  cut  the  desired  size, 
the  different  layers  in  each  -paA  being  quilted  together  by  a  few  stitches, 
and  the  edges  loosely  whipped  with  a  thread  to  prevent  them  from  fraying. 
Gauze  f)ads  are  used  as  a  substitute  for  the  tiat  sponges  formerly  emjjloyed 
in  abdominal  surgery,  and  for  the  drying  of  wounds.  The  i^ads  or  pledgets 
may  be  sterilized  by  boiling  or  by  exi^osure  to  steam  or  dry  heat  in  a  steril- 
izer, or  may  be  sterilized  and  preserved  at  the  same  time  in  a  1  to  2000 
bichloride  solution.  When  so  preserved,  before  being  emploj^ed  the  moist- 
ure should  be  squeezed  from  them,  or  they  shoxdd  be  washed  iu  sterilized 
water  before  being  brought  in  contact  with  the  wound. 

Silk. — Silk  for  sutures  or  ligatui'es  should  be  sterilized  by  boiling  it 
for  thirty  minutes,  after  which  it  is  to  be  placed  in  stof)pered  bottles 
and  covered  with  a  five  per  cent,  solution  of  carbolic  acid  in  alcohol,  or 
in  ninety-five  per  cent,  alcohol,  or  in  a  1  to  1000  bichloride  and  alcohol 
solution. 

Silkworm- Gut. — Silkworm -gut  is  an  excellent  material  for  sutures, 
and  may  be  sterilized  by  boiling  it  for  fifteen  minutes,  or  by  exposure  to  dry 
heat  for  an  hour  :  after  being  sterilized  it  should  be  kei^t  in  ninety-five  per 
cent,  alcohol.     There  has  recently  been  introduced  an  iron-dyed  black  silk- 


MATERIALS  USED   IN  ASEPTIC  OPERATIONS.  127 

worra-gnt,  wliich  makes  the  sutures  more  prominent  and  thus  facilitates 
their  removal. 

Catgut  Ligatures  and  Sutures. — Catgut  is  the  ideal  material  for 
ligatures  and  sutures,  but  lias  the  disadvantages  of  difficulty  and  iiucertainty 
in  its  sterilization.  Eaw  catgut  is  often  infected  with  micro-organisms,  and 
therefore  thorough  sterilization  alone  can  i-ender  it  a  safe  material  for  liga- 
tures and  sutures.  Catgut  may  be  sterilized  by  dry  heat  or  by  some  of  the 
following  methods. 

Von  Bergmann's  Method. — This  consists  of  winding  the  catgut 
loosely  upon  glass  rods  or  spools  ;  these  spools  are  i^laced  in  ether  for  twenty- 
four  hours  ;  the  ether  is  then  poured  off,  and  the  catgut  is  placed  in  the  fol- 
lowing solution :  bichloride  of  mercury,  10  parts ;  absolute  alcohol,  800 
parts  ;  distilled  water,  200  parts.  Eemove  from  this  solution  in  twenty-four 
hours,  and  place  it  in  a  similar  solution  for  forty-eight  hours  ;  then  place  it 
in  absolute  alcohol.  If  you  desire  the  gut  to  be  soft,  add  twenty  per  cent. 
of  glycerin  to  the  absolute  alcohol.  To  make  the  sterilization  absolutely  cer- 
tain it  has  been  found  advantageous  to  soak  the  catgut  for  thirty  minutes  in 
a  1  to  1000  aqueous  bichloride  solution  before  placing  it  in  the  alcoholic 
solution  of  bichloride. 

The  Cumol  Method. — The  catgut  is  rolled  loosely  upon  glass  spools 
which  are  placed  in  a  glass  beaker  having  a  layer  of  cotton  in  the  bottom. 
The  beaker  is  covered  by  a  piece  of  cardboard  having  a  hole  in  the  centre 
through  which  a  thermometer  is  introduced,  and  is  placed  in  a  sand-bath 
heated  by  a  Bunsen  burner.  Heat  is  applied  to  the  sand-bath  until  the 
temperature  of  the  catgut  is  raised  to  80°  C.  This  is  maintained  for  one 
hour  and  removes  all  moisture  from  the  catgut.  Cumol  at  a  temperature  of 
100°  C.  is  next  poured  into  the  beaker,  comjaletely  covering  the  catgut,  and 
the  temperature  is  then  raised  to  165°  C.  and  maintained  for  one  hour.  The 
cumol  is  next  poured  off  and  the  catgut  is  allowed  to  dry  in  the  beaker 
on  the  sand-bath  at  a  temperature  of  100°  C.  for  two  hours.  It  is  then 
transferred  to  sterile  jars  or  tiibes,  which  should  be  air-tight  or  plugged  with 
sterilized  cotton. 

The  Alcohol  Method. — Catgut  may  also  be  sterilized  by  boiling  in 
alcohol  under  pressure.  Catgut  is  loosely  wound  upon  glass  rods  or  spools 
and  i^laced  in  a  metallic  cylinder  or  jar  having  an  accurately  fitting  screw 
top.  The  catgut  is  then  covered  with  absolute  alcohol,  the  top  is  screwed 
down,  and  the  cylinder  or  jar  is  immersed  in  boiling  water  for  an  hour. 

Formalin  Catgut. — This  is  prepared  by  winding  catgut  loosely  on  glass 
spools  and  keeping  them  for  forty-eight  hours  in  a  vessel  containing  benzine 
or  ether.  They  should  then  be  removed  from  the  ether,  washed  for  a  few 
minutes  in  alcohol,  and  placed  in  ajar  containing  a  five  per  cent,  solution  of 
formalin  and  allowed  to  remain  for  several  days.  The  excess  of  formalin 
should  then  be  washed  away  with  alcohol,  and  the  catgut  kept  for  use  in 
ninety-five  per  cent,  alcohol  or  placed  in  an  air-tight  metal  tube  and  covered 
by  a  five  per  cent,  glycerin  sohition  in  absolute  alcohol. 

Ammonium  Sulphate  Catgut.— Elsberg's  method  of  sterilizing  catgut 
consists  in  immersing  it  for  forty-eight  hoiu's  ii]  a  mixture  of  one  part  of 
chloroform  to  two  i^ai-ts  of  alcohol.     It  is  then  wound  loosely  upon  glass 


128 


MATERIALS  USED  IN  ASEPTIC  OPERATIONS. 


Fig.  47. 


spools  and  boiled  for  thirty  minutes  in  a  saturated  solution  of  ammonium 
sulphate,  and  upon  its  removal  from  this  solution  it  should  be  immersed  in 
sterilized  water  to  remove  the  crystals  of  ammonium  suljjhate.  It  may  be 
preserved  in  absolute  alcohol. 

Bichloride  of  Palladium  Catgut. — Catgut  should  be  soaked  in  ether 
from  twenty-four  to  forty-eight  hours,  according  to  the  size  of  the  gut.  It 
is  then  placed  in  a  mixture  of  mercuric  bichloride,  40  grains  ;  tartaric  acid, 
200  grains;  alcohol  (ninety -iive  per  cent.),  12  fluidounces,  and  allowed  to 
remain  from  five  to  twenty-five  minutes,  according  to  the  size  of  the  gut. 
Then  place  it  in  a  sterilized  jar  containing  ijalladium  bichloride  grain  xV  to 
alcohol  1  pint,  in  which  it  may  be  kept  indefinitely. 

Chromic  Acid  Catgut. — This  may  be  prepared  by  placing  catgut,  which 
has  been  sterilized,  in  one  quart  of  a  five  per  cent,  carbolic  acid  solution 
which  contains  thirty  grains  of  bichromate  of  potassium,  allowing  it  to 
remain  for  forty-eight  hours.  Or  the  catgut  after  being  soaked  in  ether  for 
twenty-four  hours  and  washed  in  alcohol  is  placed  for  twenty-foiir  hours  in  a 
four  per  cent,  aqueous  solution  of  chromic  acid  ;  it  is  then  removed  and  dried 
in  a  hot  oven.  It  is  nest  sterilized  by  the  cumol,  alcohol,  or  formalin  method. 
This  immersion  shoiild  be  longer  when  the  larger  sizes  of  catgut  are  used, 
but  for  the  sizes  of  catgut  which  are  ordinarily  emj)loyed  this  length  of  im- 
mersion will  prepare  the  gut  to  resist  the  action  of  the  living 
tissues  for  a  week  or  more.  Chromic  acid  catgut  thus  prepared 
may  be  placed  in  sterile  tubes  or  jars  with  pledgets  of  cotton 
between  each  roll  of  the  gut,  or  may  be  kept  in  absolute  alcohol. 
Before  being  used  it  may  be  soaked  for  thirty  minutes  in  a  five 
per  cent,  carbolic  solution  or  a  1  to  2000  bichloride  solution. 
Owing  to  the  fact  that  it  undergoes  very  slow  solution  in  the 
tissues,  chromic  acid  catgut  is  often  of  service  for  sutures  or 
for  the  ligation  of  the  larger  vessels  in  their  continuity. 

A  very  simi^le  method  of  carrying  catgut  and  keeping  it 
sterile  consists  in  using  a  strong  glass  tube,  about  an  inch  in 
diameter  and  six  inches  in  length,  into  each  end  of  which  is 
fastened  a  rubber  cork.  A  number  of  glass  spools  wound  with 
sterilized  catgut  of  various  sizes  are  fitted  into  this  glass  tube  ; 
one  cork  is  introduced  ;  the  tube  is  then  filled  with  alcohol  or 
a  1  to  2000  bichloride  solution  in  alcohol,  and  the  other  cork 
is  introduced,  or  a  test-tiibe  and  a  rubber  stopper  may  be  used.     (Fig.  47.) 

Kangaroo  Tendon. — This  material  is  frequently  used  for  sutures  when 
a  suture  is  desired  which  will  resist  absorption  in  the  tissues  for  from  four  to 
six  weeks.  The  same  method  is  used  in  chromicizing  this  material  as  in  the 
case  of  catgut,  and  afterwards  similar  methods  of  sterilization  are  employed. 
Horse-Hair. — This  material  makes  an  excellent  suture,  but  the  greatest 
care  should  be  observed  in  its  sterilization.  It  should  be  cut  in  pieces  a  foot 
in  length  and  washed  with  soap  and  water,  and  should  then  be  sterilized 
by  boiling  for  half  an  hour,  or  by  steam  under  pressui'e. 

Drainage-Tubes. — The  drainage-tubes  usually  employed  are  prepared 
of  rubber  tubing  of  different  sizes,  perforated  at  short  intervals.  (Fig.  48.) 
Drainage-tubes  are  also  made  of  glass :  these  are  almost  exclusively  used  in 


GAUZE  DEESSINGS. 


129 


Glass 
drainage-tube. 


abdominal  surgery.     (Fig.   49.)     Glass  drainage-tubes  may  be  sterilized  by 

boiling.     Eubber  drainage-tubes  may  also  be  sterilized  by  boiling  foi-  ten 

minutes,  but  if  kept   in   boiling  water  for  any 

greater  length  of  time  they  are  ruined.     Capillary     Fig.  48.  Tu.  40 

drainage  is  often  employed  in  wounds,   and  is 

obtained  by  the  use  of  a  number  of  strands  of 

catgut   or  of  horse-hair.      When   used  for  this 

purpose,    great  care  should   be  taken  that   the 

sterilization  of  the  material  is  complete. 

Protective. — This  is  a  material  resembling 
oiled  silk,  which  is  employed  if  antiseptic  gauze 
is  used  to  prevent  the  wound  from  being  irritated 
by  the  antiseptic  substances  with  which  the  gauze 
is  impregnated,  or  to  keep  the  wound  in  a  moist 
condition.  Various  materials  may  be  employed 
as  protectives,  the  particular  requirement  being 
that  they  can  be  readily  rendered  aseptic. 

Silver-Foil. — The  inhibitive  action  of  me- 
tallic silver  on  the  growth  of  micro-organisms  is 
utilized  in  the  emi^loyment  of  silver-foil  to  cover 
the  surface  of  wounds.  The  sheets  of  foil  are 
sterilized  by  dry  heat  and  are  placed  directly  over 
the  wound  and  covered  by  a  gauze  dressing.  Rubber 

Rubber  Dam. — Eubber  dam  is  a  thin,  pure  drainage-tube. 
rubber  tissue,  which  is  cleansed  and  sterilized 

with  great  ease.  It  is  sterilized  by  washing  it  with  soap  and  water  and 
then  placing  it  in  a  bichloride  or  carbolic  solution  for  a  short  time.  It  may 
be  used  in  the  moist  method  of  dressing  to  cover  the  gauze  dressings,  and 
is  also  attached  to  the  drainage-tube  in  abdominal  wounds  to  shut  off  the 
opening  of  the  tube  from  the  abdominal  wound. 

Rubber  Tissue. — Eubber  tissue  consists  of  a  very  thin  sheet  of  india- 
rubber  with  glazed  surface.  It  is  employed  for  the  same  purposes  as  mack- 
intosh, is  much  less  expensive,  and  may  be  used  instead  of  protective  for 
covering  the  wound.  It  is  sterilized  by  soaking  it  in  a  carbolic  or  bichloride 
solution. 

GAUZE   DRESSINGS. 

The  most  convenient  and  cheapest  material  for  wound  dressing  is  a 
material  known  to  the  trade  as  cheese-cloth  or  tobacco-cloth,  and  for  surgical 
use  should  contain  no  sizing.  Prom  the  fact  that  it  has  a  very  oijen  mesh, 
it  absorbs  well  either  the  materials  with  which  it  is  prepared  or  the  dis- 
charges from  the  wound,  and  is  soft  and  pliable,  so  that  it  is  a  comfortable 
form  of  dressing  to  the  patient.  Gauze  containing  various  antiseptic  sub- 
stances was  foi-merly  much  employed,  but  at  the  present  time  its  use  has 
been  largely  superseded  by  sterilized  gauze. 

Sterilized  Gauze. — This  is  prepared  by  cutting  the  gauze  in  pieces 
of  the  desired  size,  wrapping  them  in  a  towel,  and  placing  them  in  wire 
baskets,  or  the  gauze  may  be  placed  in  cylindrical  tin  boxes,  three  inches 
in  diameter  and  eight  inches  in  height  with  perforated  metal  covers,  and 

9 


130 


GAUZE  DRESSINGS. 


covering  the  gauze  at  each  end  of  the  cylinder  with  a  layer  of  cotton  before 
]3uttiug  on  the  covers.  The  gauze  is  next  placed  in  a  steam  sterilizer  and 
subjected  to  ten  pounds  iiressnre  of  live  st«am  for  half  an  hour.  The  steam 
is  then  shut  off  from  the  sterilizer  and  allowed  to  circulate  in  the  jacket  of 
the  instrument  without  pressure  for  half  an  hour  to  dry  the  dressings.  If 
the  gauze  has  been  sterilized  in  metal  cases  it  may  be  kept  for  some  time  and 
still  remain  sterile.     Cotton  may  be  sterilized  in  the  same  manner. 

Dry  Sterilized  Gauze. — Dry  sterilized  gauze  is  prepared  by  cutting 
gauze  into  proper  lengths  and  packing  it  looselj^  in  wii-e  cages  or  perforated 
metal  cans,  which  are  next  placed  in  a  dry  sterilizing-oven  for  several  hours, 
and  upon  removal  it  is  placed  in  air-tight  jars  or  metal  boxes.  In  using 
dry  sterilized  gauze  dressings  it  is  safer  to  have  the  dressings  freshly  ster- 
ilized immediately  before  each  operation. 
Fig.  50.  A  convenient  form  of  sterilizing-oven  is 

shown  in  Fig.  50.  Towels  and  oj)er- 
ating-gowns  can  be  sterilized  in  the  same 
oven. 

Bichloride  or  Corrosive  Sub- 
limate Gauze. — Bichloride  or  corro- 
sive sublimate  gauze  is  prepared  by 
placing  cheese-cloth  in  a  washing- kettle 
and  covering  it  with  water  to  which  is 
added  two  pounds  of  washing-soda  or  a 
pint  of  lye  ;  the  latter  is  added  to  remove 
any  oily  matter  which  the  cheese-cloth 
contains,  thus  making  it  more  absorbent. 
The  gauze  is  boiled  in  this  solution  for 
an  hour,  and  is  then  removed  and  washed 
in  boiled  water  and  passed  through  a 
sterilized  clothes- wringer  ;  it  is  then  im- 
mersed in  a  1  to  1000  bichloride  solution 
for  twenty-four  hours ;  the  excess  of 
fluid  is  then  squeezed  out  of  it,  and  it 
may  be  packed  in  air-tight  jars  and  pre- 
served as  a  moist  gauze,  or  may  be  dried 
in  a  warm  oven  and  packed  in  sterilized  jars  and  kept  as  a  dry  gauze.  Dry 
bichloride  gauze  possesses  little  antiseptic  properties. 

Iodoform  Gauze. — Iodoform  ga,uze  may  be  i^repared  by  soaking  ster- 
ilized gauze  in  a  mixture  containing  iodoform,  5  j)arts  ;  glycerin,  20  parts  ; 
alcohol,  75  parts.  After  thorough  saturation,  it  shovild  be  wrung  out  with 
sterilized  hands,  to  remove  the  alcohol.  It  may  also  be  prepared  by  satu- 
rating sterilized  gauze  with  a  solution  of  iodoform  in  ether,  then  allowing 
the  ether  to  evaporate  rapidly,  the  iodoform  thus  being  evenly  distributed 
through  the  tissue  of  the  gauze ;  this  should  be  dried  and  kept  in  jars  for 
use.  The  iodoform  gauze  in  general  use  contains  from  five  to  ten  ])er  cent, 
of  iodoform  by  weight. 

Carbolized  Gauze. — In  preparing  carbolized  gauze,  cheese-cloth 
which  has  been  previously  boiled  and  dried  is  soaked  for  a  few  hours  in 


GAUZE  DRESSINGS.  131 

the  following  solution:  resin,  1  pint ;  alcohol,  5  pints  ;  castor  oil,  24  ounces  ; 
carbolic  acid,  12  ounces.  The  gauze  is  removed  from  this  solution  and 
passed  through  a  clothes- wringer,  and  is  then  cut  into  pieces  from  four  to 
six  yards  in  length,  which  are  folded  and  packed  in  air-tight  jars  for  use. 

Improvised  Aseptic  and  Antiseptic  Dressings. — Aseptic  dress- 
ings in  cases  of  emergency  may  be  improvised,  where  the  ordinary  gauze 
dressings  cannot  be  obtained,  by  tearing  a  piece  of  muslin  or  mosquito 
netting  into  pieces  half  a  yard  square  and  throwing  them  into  boiling  water 
for  a  few  minutes  ;  they  are  then  removed,  the  excess  of  moisture  is  wrung 
out  of  them,  and  they  are  applied  to  cover  the  wound. 

If  it  is  desirable,  they  may  be  used  as  antiseptic  dressings  by  soaking 
them  for  a  few  minutes  in  a  1  to  1000  or  1  to  2000  bichloride  solution,  or  in 
a  five  per  cent,  carbolic  solution.  This  dressing  will  keep  the  wound  aseptic 
until  a  more  elaborate  dressing  cau  be  obtained. 

Sterilized  Bandages. — Sterilized  bandages  are  prepared  by  tearing 
or  cutting  gauze  into  strips  from  two  and  a  half  to  three  inches  in  width  and 
forming  these  strii)s  into  rollers,  ;ivhich  are  sterilized  by  steam  or  dry  heat. 
They  should  be  used  soon  after  being  prepared,  or,  if  kept  for  any  time, 
should  be  resterilized  before  being  used. 

Bichloride  Cotton. — This  material  is  prepared  by  soaking  absorbent 
cotton  in  a  1  to  1000  bichloride  solution  for  twenty-four  hours,  and  allowing 
it  to  dry,  or  it  may  be  dried  in  a  hot  oven  ;  when  dry  it  is  packed  in  jars 
or  in  air-tight  boxes.  Several  layers  of  bichloride  cotton  are  usually  ap- 
plied over  the  gauze  dressing,  as  its  great  absorbing  power  and  elasticity 
make  it,  -when  properly  i^repared,  a  most  valuable  dressing. 

Sterilized  Cotton. — Sterilized  cotton  is  prepared  by  placing  absorbent 
cotton,  enclosed  in  perforated  metal  cans,  in  a  steam  sterilizer  and  allowing 
it  to  remain  for  half  an  hour  under  ten  pounds  pressui'C.  It  is  used  for  the 
same  purposes  in  dressings  as  the  bichloride  cotton. 

Surgical  Operating-Bag. — For  operations  in  private  practice  the 
surgeon  will  find  it  convenient  to  have  a  bag  containing  gauze  dressings, 
bichloride  pellets,  carbolic  acid,  alcohol,  turpentine,  ligatm-es,  sutures, 
needles,  syringes,  a  metal  tray  in  which  instruments  can  be  boiled,  a  nest  of 
small  agate-ware  basins,  sponges,  gauze  pads,  a  sheet  of  rubber  cloth,  drain- 
age-tubes, and  operating-gown.  These  can  all  be  packed  in  a  comparatively 
small  space,  and  when  the  surgeon  is  called  upon  to  perform  any  special 
operation  at  short  notice  the  instruments  required  may  be  selected,  wrapped 
in  a  Canton  flannel  scroll,  and  placed  in  the  bag.  Much  time  will  be  saved 
by  having  the  materials  required  in  operations  always  in  readiness  in  such 
a  bag. 


CHAPTER    XIII. 


MINOR  SURGERY. 


By  Heney  E.  Whaeton,  M.D. 


BANDAGING. 

Bandages  are  usually  prepared  from  strips  of  muslin,  flannel,-  crinoline, 
or  cheese-cloth,  which  are  rolled  into  the  form  of  a  cylinder,  and  are  em- 
ployed to  hold  dressings  in  contact  with  the  surface  of  the  body,  to  make 
pressure,  or  to  retain  splints  in  place  in  the  treatment  of  fractures  or  dislo- 
cations. The  ordinary  roller  bandage  consists  of  a  strip  of  woven  material, 
usually  unbleached  muslin,  but  cheese-cloth  may  also  be  employed,  which 
varies  in  length  from  one  to  nine  yards  and  in  width  from  one  inch  to  four 
inches;  this,  for  convenience  of  application,  is  rolled  into  a  cylindrical  form. 
In  preparing  the  roller  bandages  it  is  imj)ortant  that  they  should  be  free  from 

seams  and  selvage,  for  if  made 
of  a  number  of  j)ieces  sewed 
together,  or  if  they  contain  sel- 
vage, they  cannot  be  so  neatly 
applied  and  are  apt  to  leave 
creases  upon  the  skin  of  the  pa- 
tient. In  preparing  the  ordi- 
nary roller  bandage,  muslin  or 
cheese-cloth  is  torn  into  strips, 
and  is  then  rolled  into  a  cylin- 
der, either  by  the  hand  or  by  a 
machine  constructed  for  the  pur- 
pose. To  roll  a  bandage  by 
hand,  the  strip  should  be  folded 
at  one  extremity  several  times 
until  a  small  cylinder  is  formed  ; 
this  is  then  grasped  by  the  ex- 
tremities between  the  thumb  and  finger  of  the  left  hand  ;  the  free  extremity 
of  the  strij)  is  then  grasped  by  the  thumb  and  index  finger  of  the  right  hand, 
and  by  alternating  pronation  and  snxjination  of  the  right  hand  the  cj'linder 
is  revolved  and  the  roller  is  formed.     (Fig.  51.) 

Dimensions  of  Bandages. — Bandages  vary  in  length  and  width 
according  to  the  purposes  for  which  they  are  employed. 

Bandage  one  inch  wide,  three  yards  in  length,  for  bandages  for  the  hand, 
fingers,  and  toes. 

Bandage  two  inches  wide,  six  yards  in  length,  for  head  bandages  and  for ' 
the  extremities  in  children. 

Bandage  two  and  a  half  inches  wide,  seven  yards  in  length,  for  bandages 
132 


Rolling  bandage  by  hand. 


SPECIAL  BAJSfDAGES.  133 

of  the  extremities  in  adults ;  a  bandage  of  this  size  is  the  one  usually 
employed  in  general  surgical  work. 

Bandage  three  inches  wide,  nine  yards  in  length,  for  bandages  of  the 
thigh,  groin,  and  trunk. 

Bandage  four  inches  wide,  ten  yards  in  length,  for  bandages  of  the 
trunk. 

Rules  for  Bandaging. — In  applying  a  roller  bandage  the  oj^erator 
should  place  the  external  surface  of  the  free  extremity  of  the  roller  upon 
the  part  and  hold  it  in  position  with  the  fingers  of  the  left  hand  until  the 
end  is  iixed  by  a  few  turns  of  the  roller ;  it  should  be  held  in  the  right 
hand  by  the  thumb  and  fingers,  and  as  the  bandage  is  unwound  it  rolls  into 
the  operator's  hands ;  the  turns  should  be  applied  smoothly  to  the  surface, 
the  pressure  exerted  by  each  turn  being  uniform.  In  applying  a  bandage 
over  the  region  of  a  joint  the  surgeon  shoiild  see  that  the  part  is  in  the 
position  it  is  to  occupy  as  regards  flexion  and  extension  when  the  dressing 
is  completed,  for  a  bandage  applied  when  the  limb  is  flexed  will  exert  too 
much  pressure  when  the  limb  is  extended  ;  if  applied  when  the  limb  is 
extended  it  will  be  found  uncomfortable  upon  flexion,  and  may  even  exert 
dangerous  compression  of  the  part.  Those  who  have  had  little  experience 
with  the  application  of  the  roller  bandage  are  apt  to  apply  their  bandages 
too  tightly,  which  may  lead  to  dangerous  consequences,  especially  in  the 
dressing  of  fractures.  When  the  bandage  has  been  applied  to  a  part,  the 
extremity  should  be  secured  by  a  pin  or  safety-pin.  The  bandage  may  be 
removed  by  cutting  its  folds  with  scissors  made  for  this  purpose,  or  it  may 
be  removed  by  unpinning  the  terminal  extremity  and  gathering  the  folds 
carefully  into  a  loose  mass  as  the  bandage  is  unwound,  the  mass  being  trans- 
ferred rapidly  from  one  hand  to  the  other,  thus  facilitating  its  removal  and 
preventing  the  j)art  from  becoming  entangled  in  its  loops. 

SPECIAL   BANDAGES. 

Spiral  Reversed  Bandage. — This  bandage  is  a  spiral  bandage, 
but  diflers  from  the  ordinary  spiral  bandage  in  that  its  turns  are  folded 
back  or  reversed  as  it  ascends  a  part  the  diameter  of  which  gi-adually  in- 
creases. It  is  possible  by  the  use  of  this  bandage  to  cover  by  spii-al  reversed 
turns  a  part  conical  in  shape,  and  so  make  ec[uable  pressure  upon  all  parts 
of  the  surface.  It  rec[uires  skill  and  practice  to  ai>ply  this  bandage  neatly  ; 
a  well-apijlied  spiral  reversed  bandage  is  a  test  of  a  competent  bandager. 
Eeverses  are  made  as  follows  :  the  initial  extremity  of  the  roller  is  fixed,  and 
as  the  part  increases  in  diameter  the  bandage  is  carried  oif  a  little  obliquely 
to  the  axis  of  the  limb  for  from  four  to  six  inches  ;  the  index  finger  or  thumb 
of  the  disengaged  hand  is  placed  irpon  the  body  of  the  bandage  to  keep 
it  securely  in  place  upon  the  limb,  while  the  hand  holding  the  roller  is 
carried  a  little  towards  the  limb,  to  slacken  the  unwound  portion  of  the 
bandage,  and  by  changing  the  x^ositiou  of  the  hand  holding  the  bandage 
from  extreme  supination  to  pronation  the  reverse  is  made.  (Fig.  52.)  The 
reverse  should  not  be  made  while  the  bandage  is  tense,  for  by  so  doing 
the  bandage  is  twisted  into  a  cord,  which  is  unsightly  and  uncomfortable 
to  the  patient ;  the  reverse  should  be  completely  made  before  the  bandage 


134 


COMPOUND   BANDAGES. 


is  carried  around  the  limb,  and  when  it  has  been  completed  it  should  be 
slightly  tightened,  so  as  to  conform  accurately  to  the  part.     The  reverses 


Fig.  52. 


Halving  reverses. 

should  not  be  made  over  salient  parts  of  the  skeleton,  and  should  be  kept 
in  line. 

Compound  Bandages. — Compound  bandages  are  usually  formed  of 
several  pieces  of  muslin  or  other  material  three  or  four  inches  in  width, 
sewed  or  pinned  together,  and  are  employed  to  fulfil  some  special  indica- 
tion in  the  application  of  dressings  to  particular  parts  of  the  body.  The 
most  useful  of  the  comjiouud  bandages  are  the  T-bandages  and  many-tailed 
bandages. 

Single  T-Bandage. — A  single  T-bandage  consists  of  a  horizontal  band, 
to  which  is  attached,  about  its  middle,  another  having  a  vertical  direction  ; 
the  horizontal  piece  should  be  about  twice  the  length  of  the  vertical  piece. 

(Fig.    53.)      A   single   T- 
^'"-  ■''•"■  YiG  54  bandage  is  often  employed 

in  applying  dressings  to 
the  anal  region  or  the  peri- 
neum and  anu,s. 

Double  T-Bandage. 
— A  double  T-bandage  has 
two  vertical  strips  attached 
to  the  horizontal  strip 
(Fig.  54),  and  may  be  used 
for  much  the  same  purpose 
as  the  single  T-bandage ; 
it  may  be  used  for  retaining  dressings  to  the  chest,  back,  or  abdomen  ;  when 
employed  for  this  purpose  the  horizontal  portion  should  be  from  eight  to 


Single  T-bandage. 


Double  T-bandage. 


MANY-TAILED  BANDAGES. 


135 


Fig.  5.5. 


Four-tailed  sling. 


Fig.  56. 


twelve  inches  wide,  and  long  enough  to  pass  one  and  a  quarter  times  about 
the  chest ;  two  A^ertical  strips,  each  two  inches  wide  and  twenty  inches  long, 
should  be  attached  to  the  horizontal  strip  a  short  distance  apart,  near  its 
middle.  In  applying  this  bandage  to  the  chest  the  horizontal  strip  is  placed 
around  the  chest  so  that  the  vertical  strips  occupy  a  position  on  either  side 
of  the  spine  ;  the  o\'erlapping  end  of  the  horizontal  portion  is  secured  by  pins 
or  safety-pins,  and  thevertical  strips  are  next  carried  one  over  either  shoulder 
and  secured  to  the  other  portion  of  the  bandage  in  front  of  the  chest. 

Many-Tailed  Bandages  or  Slings. — Many-tailed  bandages  are  pre- 
pared from  i^ieces  of  muslin  of  various  lengths  and  breadths,  which  are  split 
at  each  extremity  into  two  or  three  or  more 
tails  up  to  within  a  few  inches  of  the  cen- 
tre, their  width  and  length  being  regulated 
by  the  part  of  the  body  to  which  they  are 
to  be  applied.  (Fig.  55.)  Four- tailed 
bandages  may  be  found  useful  as  temporary 
dressings  in  cases  of  fracture  of  the  jaw  or 
clavicle  or  in  retaining  dressings  to  the 

scalp.  The  many-tailed  bandage  may  also  be  used  in  holding  dressings  in 
contact  with  the  abdomen  or  trunk,  and  is  the  bandage  which  most  surgeons 
emjjloy  to  hold  dressings  to  the  laparotomy  wound  and  to  give  svipport  to 

the  abdominal  walls  after  this  oper- 
ation. In  preparing  this  bandage 
for  the  abdomen,  a  strip  of  muslin 
or  flannel,  one  and  a  half  yards  in 
length  and  from  eighteen  to  twenty 
inches  in  width,  has  the  extremi- 
ties split  so  as  to  form  a  six-tailed 
bandage ;  or  a  modified  bandage 
of  Scultetus,  which  is  made  by 
stitching  together  in  their  centre  a 
number  of  overlapping  strips  of 
flannel  aljout  three  or  four  inches 
in  width,  may  be  employed.  (Fig. 
56. )  In  applying  this  bandage  to 
the  abdomen  the  body  of  the  band- 
age is  placed  under  the  patient's 
back,  and  the  tails  are  brought 
around  the  abdomen  and  made  to 
overlap  each  other,  and  when  firmly 
di-awn  to  make  the  desired  amount  of  pressure  they  are  secured  by  means 
of  safety-pins. 

Handkerchief  Bandages. — Bandages  may  be  applied  by  means  of 
handkerchiefs  or  square  pieces  of  muslin  for  a  temporary  or  permanent 
di-essing  in  wounds  or  fractures.  Many  handkerchief  bandages  have  been 
devised  and  employed,  and  for  the  application  of  temporary  dressings, 
where  the  ordinary  roller  bandages  cannot  be  obtained,  their  use  will  often 
prove  satisfactory.     Handkerchiefs  may  be  folded  so  as  to  form  an  oblong  or 


Modified  bandage  of  Scultetus. 


136 


HANDKERCHIEF  BANDAGES. 


a  triangle,  or  a  cravat,  or  a  cord.  The  names  of  the  various  handkerchief 
bandages  are  derived  from  the  shape  of  the  handkerchief  used  and  the  parts 
to  which  they  are  to  be  applied.  The  names  serve  as  guides  to  their  api^li- 
cation.  The  handkerchief  bandages  may  be  used  to  take  the  place  of  the 
ordinary  roller  bandage ;  for  instance,  the  bis-axillary  cravat  may  be  used 
as  a  substitute  for  the  spica  bandage  of  the  shoulder,  and  the  mento-vertico- 
occipital  cravat  modified  may  be  used  to  take  the  place  of  the  Barton's 
bandage  of  the  head. 

Bis-axillary  Cravat.— This  handkerchief  is  applied  by  placing  the 
body  of  the  cravat  in  the  axilla  and  bringing  the  ends  up,  one  in  front  of 
the  axilla,  the  other  behind  it,  and  making  them  cross  over  the  top  of  the 

shoulder,  then  carrying  the  extremities  across 
^ic^.  57.  tj^e  back  and  chest  respectively  to  the  opi^o- 

site  axilla,  where  they  are  secured  by  tying 


Mento-vertico-occipital  cravat. 


or  by  a  safety-xsin.  (Fig.  57. )  This  handkerchief  may  be  employed  to  secure 
dressings  in  the  axilla  or  to  hold  dressings  in  contact  with  the  shoulder. 

The  Mento-Vertico-Occipital  Cravat. — This  handkerchief  is  applied 
by  placing  the  base  of  the  cravat  under  the  chin  and  carrying  the  extremi- 
ties over  the  A^ertex  of  the  skull,  crossing  them  at  that  point,  then  carrying 
them  downward  to  the  occiput  and  crossing  them  again  here,  passing  them 
forward  around  the  chin,  and  finally  securing  the  ends  by  a  knot  or  pin. 
The  turns  of  this  handkerchief  correspond  exactly  to  the  turns  of  the  Bar- 
ton's bandage  of  the  head,  and  may  be  used  to  secure  dressings  to  the  chin 
or  scalp,  or  may  be  employed  as  a  temporary  dressing  in  cases  of  fracture  or 
dislocation  of  the  jaw.     (Fig.  58.) 

Barton's  Bandage. — The  initial  extremity  of  the  roller  should  be 
placed  just  below  the  occii^ital  protuberance,  and  the  roller  should  be  car- 
ried obliquely  upward,  under  and  in  front  of  the  iiarietal  eminence,  across 
the  vertex  of  the  skull,  then  downward  over  the  zygomatic  arch,  under  the 
chin,  and  upward  over  the  oj)posite  zygomatic  arch  and  over  the  top  of  the 


BANDAGES   OF  THE  HEAD. 


137 


Fig.  .59. 


\ 


Barton's  bandage. 


head,  crossing  the  first  turn  as  nearly  as  possible  in  the  median  line  of  the 
skull ;  the  turns  of  the  roller  should  next  be  carried  under  the  parietal  emi- 
nence to  the  point  of  starting.  The  bandage 
is  next  carried  obliquely  around  under  the  oc- 
ciiJital  protuberance,  and  forward  under  the 
ear  to  the  front  of  the  chin,  then  back  to  the 
point  from  which  the  roller  started.  These 
figure-of-eight  turns  over  the  head  and  the  cir- 
cular turns  from  the  occiput  to  the  chin  should 
be  repeated,  each  turn  exactly  overlapping  the 
preceding  one,  until  the  bandage  is  exhausted. 
(Fig.  59. )  The  extremity  of  the  bandage  should 
be  secured  by  a  pin,  and  pins  should  be  intro- 
duced at  the  points  where  the  turns  cross  each 
other,  to  give  additional  fixation  to  the  bandage. 
To  obtain  additional  security  in  the  aijplication 
of  Barton's  bandage,  a  turn  of  the  bandage 
Ijassing  from  the  occii^ut  to  the  forehead  may 
be  made,  this  turn  being  interposed  between 
the  turns  of  the  bandage  ordinarily  applied. 

The  Oblique  Bandage  of  the  Jaw.— This  bandage  is  applied  by 
placing  the  initial  extremity  of  the  roller  in  front  of  and  above  the  left  ear, 
if  the  left  angle  of  the  lower  jaw  is  to  be  covered  in.  The  bandage  is  then 
carried  from  left  to  right,  ]naking  two  complete  turns  around  the  head  from 
the  occiput  to  the  forehead.  When  two  turns 
have  been  made  from  the  occiput  to  the  forehead, 
the  bandage  is  allowed  to  drop  down  upon  the 
neck,  and  is  carried  forward  under  the  right  ear 
and  under  the  chin  to  the  angle  of  the  left  side 
of  the  jaw  ;  it  is  next  carried  upward  close  to  the 
edge  of  the  orbit  and  obliquely  over  the  vertex 
of  the  skull,  then  down  behind  the  right  ear,  con- 
tinuing this  oblique  turn  under  the  chin  to  the 
leftaugie  of  the  jaw,  where  it  ascends  in  the  same 
direction  as  the  previous  turns.  Three  or  four 
of  these  oblique  turns  are  made,  each  turn  over- 
lapping the  preceding  one,  and  xsassing  from  the 
edge  of  the  orbit  towards  the  eai',  until  the  space 
is  covered  in  ;  the  bandage  is  then  carried  to  a 
point  just  above  the  ear  on  the  opposite  side, 
and  is  reversed  and  finished  with  one  or  two 
circular  turns  from  the  occiput  to  the  forehead.  (Fig.  60.)  If  the  right 
angle  of  the  lower  jaw  is  to  be  covered  in,  the  turns  should  be  made  in  the 
opposite  direction. 

Recurrent  Bandage  of  the  Head.— To  apply  this  bandage  the 
initial  extremity  of  the  roller  is  i)laeed  ui)ou  the  lower  j)art  of  the  forehead, 
and  the  bandage  is  carried  twice  around  the  head  over  the  forehead  to  the 
occiput ;  when  the  bandage  is  brought  back  to  the  median  line  of  the  forehead 


Fig.  60. 


Oblique  bandage  of  the  ia\\ 


138  BANDAGES   OF  THE  FINGERS. 

it  is  reversed,  and  the  reversed  turn  is  held  by  the  finger  of  the  left  hand 
while  the  roller  is  carried  from  the  top  of  the  head  along  the  sagittal  suture 

to  a  point  just  below  the  occipital  pro- 
■^''^  ^^  ■  tuberance  ;   it  is  here  reversed,  and  the 

reverse  is  held  by  an  assistant  while  the 
roller  is  carried  back  to  the  forehead  in 
an  elliptical  course  ;  these  turns,  each  cov- 
ering in  two-thirds  of  the  preceding  turn, 
are  repeated  with  successive  reverses  at 
the  forehead  and  occiput  until  one  side  of 
the  head  is  completely  covered  in,  when 
a  circular  turn  is  made  over  the  forehead 
and  the  occiput  to  hold  the  reverses  in 
place.     The  opposite  side  of  the  head  is 
next  covered  in  by  elliptical    reversed 
turns   made  in  the  same   manner,   turns 
being  carried  around  the  head  from  the 
'  Kecurrent  bandage'^Xt^ad':  ' '  ~     forehead  to  the  occiput  to  fix  the  preceding 
turns.    Pins  should  be  applied  at  the  fore- 
head and  the  occijiut  at  the  points  where  the  reversed  turns  concentrate. 
(Fig.  61.)     The  recurrent  bandage  of  the  head  may  be  applied  by  making 
transverse  turns,  forming  a  transverse  recurrent  bandage. 

Spiral  Bandage  of  the  Finger.— In  applying  this  bandage  the 
initial  extremity  of  the  roller  is  secured  by  two  or  three  turns  around  the 
wrist,  and  the  bandage  is  carried  obliquely  across  the  back  of  the  hand 
to  the  base  of  the  finger  to  be  covered  in,  and  next  to  its  tip  by  oblique 
turns ;  a  circular  turn  is  then  made,  and  the  finger  is  covered  by  ascend- 
ing spiral  01  spiral  reversed  turns  until  its  base  is  reached,  from  which 
point  the  bandage  is  carried  obliquely  across  the  back  of  the  hand,  and 
finished  by  one  or  two  circular  turns  around  the  wrist.  The  extremity 
may  be  secui-ed  by  a  pin,  or  may  be  split  into  two  tails,  which  are  secured 
by  tying.     (Fig.  62.) 

Spiea  Bandage  of  the  Thumb. — This  bandage  is  applied  by  placing 
the  initial  extremity  of  the  roller  upon  the  wrist  and  fixing  it  by  two  circu- 
lar turns  ;  the  roller  is  then  carried  obliquely  over  the  dorsal  surface  of  the 
thumb  to  its  distal  extremity  ;  a  circular  turn  is  next  made,  and  the  bandage 
is  carried  upward  over  the  back  of  the  thumb  to  the  wrist,  around  which  a 
cii-cular  turn  should  be  made.  Ascending  figure-of-eight  turns  are  then 
made  around  the  thumb  and  wrist,  each  turn  overlapping  the  preceding  one 
two-thirds,  and  each  figure-of-eight  turn  should  alternate  witli  the  circular 
turn  about  the  wrist.  These  turns  are  repeated  until  the  thumb  is  com- 
pletely covered  in  with  spica  turns,  and  the  bandage  is  completed  by  cir- 
cular turns  around  the  wrist.     (Fig.  63.) 

Spiral  Reversed  Bandage  of  the  Arm. — To  apply  this  band- 
age the  initial  extremity  of  the  roller  is  placed  upon  the  wrist  and  secured 
by  two  circular  turns  around  the  wrist ;  the  bandage  is  then  carried 
obliquely  across  the  back  of  the  hand  to  the  second  joint  of  the  fingers, 
where  a  circular  turn  should  be  made ;   the  hand  is  next  covered  in  by 


SPIRAL  BEVERSED  BANDAGE   OF  THE  ARM. 


139 


two  or  three  ascending  spiral  or  spiral  reversed  turns ;  wlien  tlie  thumb  has 
been  reached,  its  base  and  the  wrist  should  be  covered  in  by  two  figure-of- 


FiG.  63. 


Spiral  bandage  of  the  finger. 


Spica  bandage  ot  the  thumb. 


eight  turns ;  the  roller  is  then  carried  up  the  forearm  by  spiral  or  spiral 
reversed  'turns  until  the  elbow  is  reached,  which  may  be  covered  in  with 
spiral  reversed   turns  or  with  figure-of-eight  turns  of  the  elbow.     After 


Spiral  reversed  bandage  o£  the  arm. 


covering  in  the  elbow,  the  bandage  is  continued  up  the  arm  with  spiral 
reversed  tm-us.     (Fig.  01.) 

Figure-of-Eight  Bandage  of  the  Elbow.— In  applying  this  band- 
age the  initial  extremity  of  the  roller  is  placed  upon  the  elbow,  and  two  or 
three  circular  turns  are  made  around  the  joint.  The  bandage  is  next  carried 
to  a  point  a  little  above  the  joint,  and  a  circular  turn  is  made-  around  the 
arm.     It  is  then  conducted  obliquely  across  the  flexiire  of  the  joint  to  the 


140 


spiCA  baj^dage  of  the  shoulder. 


Figure-of-eight  bandage  of  tlie  elbow. 


upper  part  of  the  forearm,  where  a  circular  turn  is  made.     It  is  next  car- 
ried across  the  flexure  of  the  joint,  crossing  the  previous  turn  to  the  arm. 

These  oblique  and  circular  turns 
Fig.  65.  are  repeated,  descending  from  the 

arm  and  ascending  from  the  fore- 
arm, until  the  joint  is  covered 
in.  The  method  of  applying  the 
ascending  and  descending  turns, 
with  the  final  turns  around  the 
elbow,  is  shown  in  Fig.  65. 

Spica  Bandage  of  the 
Shoulder. — This  may  be  applied 
as  an  ascending  or  a  descending 
spica  bandage.  The  ascending 
spica  bandage  is  applied  by  placing 
the  initial  extremity  of  the  roller 
obliquely  upon  the  outer  surface 
of  the  arm  oijposite  the  axillary 
fold  and  fixing  it  by  one  or  two 
circular  turns :  if  applied  to  the 
right  shoulder-joint  the  bandage  is  carried  across  the  front  of  the  chest  to 
the  axilla  of  the  opposite  side,  and  is  conducted  around  the  back  of  the 
chest  to  the  point  of  starting  upon  the  arm  ;  the  roller  should  then  be  carried 
around  the  arm  and  up  over  the  shoulder,  across  the  front  of  the  chest, 
through  the  opposite  axilla,  over  the  posterior  sur- 
face of  the  chest  to  the  point  of  starting.  These 
ascending  turns,  each  overlapping  the  preceding  one 
about  two-thirds,  should  be  applied  until  the  shoulder 
is  covered  in,  when  the  extremity  of  the  bandage 
should  be  secured  by  a  pin  at  the  point  of  ending. 
The  turns  should  be  made  in  such  a  manner  that  the 
spica  turns  shall  keep  as  nearly  as  possible  in  the 
median  line  of  the  shoulder.     (Fig.  66. ) 

Velpeau's  Bandage.— Before  applying  this 
bandage  the  patient  should  place  the  fingers  of  the 
hand  of  the  affected  side  upon  the  opposite  shoulder, 
the  arm  resting  against  the  chest ;  the  initial  ex- 
tremity of  the  bandage  should  be  placed  on  the  body 
of  the  scai^ula  of  the  sound  side,  and  be  secured 
by  a  turn  made  by  carrying  the  bandage  over  the  shoulder  of  the  affected 
side,  near  its  outer  portion ;  it  should  then  be  continued  downward  over 
the  outer  and  posterior  surface  of  the  arm  of  the  same  side  behind  the 
bend  of  the  elbow,  and  obliquely  across  the  front  of  the  chest  to  the  axilla 
of  the  opposite  side,  thence  to  the  point  of  starting.  This  turn  should  be 
repeated  to  fix  the  initial  extremity  of  the  bandage ;  the  second  turn  being- 
completed,  the  roller  should  be  carried  transversely  around  the  thorax, 
passing  over  the  flexed  elbow,  and  from  this  point  to  the  axilla,  and  through 
this  to  the  back ;  froDi  this  point  the  roller  should  be  carried  over  the 


* 


Spica  bandage  of  tiie  sliouider. 


DESAULT'S   BANDAGiE. 


141 


Velpeau's  bandage. 


shoulder  and  down  the  outer  and  jjosterior  surface  of  the  arm  behind  the 
elbow,  and  obliquely  across  the  front  of  the  cliest,  through  the  axilla  to 
the   back,    and    continuing    should    pass 
transversely  across  the  back  of  the  chest  Fig.  67. 

to  the  elbow,  which  it  encircles,  and  then 
be  passed  to  the  axilla.  These  alternating 
turns  are  repeated  until  the  arm  and  fore- 
arm are  bound  firmly  to  the  side  and 
chest.  The  vertical  turns  over  the  shoul- 
der, each  turn  covering  two-thirds  of  the 
previous  turn,  and  ascending  from  the 
point  of  the  shoulder  towards  the  neck, 
and  from  the  posterior  surface  of  the  arm 
towards  the  elbow,  are  applied  until  the 
point  of  the  elbow  is  reached.  The  trans- 
verse turns  passing  around  the  chest  and 
arm  are  so  applied  that  they  ascend  from 
the  point  of  the  elbow  towards  the  shoul- 
der, each  turn  covering  in  one-third  of 
the  previous  one,  and  the  last  turn  should 
pass  transversely  around  the  shoulder  and 
chest,  covering  the  wrist.     (Fig-  67.) 

Desault's  Bandage. — To  apply  this  bandage  three  rollers  are  required, 
as  well  as  a  wedge-shaped  pad  which  hts  in  the  axilla.     The ^rsi  roller  of 
Desault's  bandage  secures  the  pad  in  the  axilla  by  circular  turns  of  the 
bandage  around  the  pad  and  chest ;  the  second  roller  holds  the  arm  iu  con- 
tact with  the  pad  and  the  side  of  the  chest 
^^^-  *^^-  by  circular  turns  of  the  bandage  around 

the  arm  and  chest ;  the  ajaplicatiou  of  the 
third  roller  will  be  described. 

Third  Roller  of  Desault's  Band- 
age.—In  applying  this  roller  the  initial 
extremity  of  the  bandage  should  be  i^laced 
in  the  axilla  of  the  sound  side,  and  the 
bandage  carried  obliquely  over  the  front 
of  the  chest  to  the  shoulder  of  the  injured 
side,  and  then  jpass  over  this  and  be  con- 
ducted down  the  back  of  the  arm  to  the 
elbow  ;  thence  obliquely  upward,  over  the 
upiser  fifth  of  the  forearm,  to  the  axilla  of 
the  sound  side  ;  from  this  point  it  should 
Thir.iK.iiLi  otiii'vaiiifsbandai;..  ^e  Carried  backward  obliquely  over  the 

back  of  the  chest  and  the  shoulder,  cross- 
ing the  previous  shoulder  turn,  and  then  be  conducted  down  iu  front  of  the 
arm  to  the  elbow,  then  carried  around  this,  and  backward  obliquely  over 
the  back  of  the  chest  to  the  axilla  of  the  sound  side  ;  these  turns,  overlyino- 
one  another  exactly,  should  be  repeated  until  three  sets  of  turns  have  beeu 
made.     (Pig.  68.)    After  applying  the  three  rollers,  as  before  described,  the 


142 


SPICA  BANDAGE   OF  THE   GROIN. 


Arm  and  chest  bandage. 


hand  and  tlie  uncovered  portion  of  the  forearm  should  be  supported  in  a 

sling  suspended  from  the  neck. 

Arm  and  Chest  Bandage.— To  apply  this  bandage,  the  arm  having 

been  placed  against  the  side,  with  a  folded  towel  between  the  arm  and  the 

chest,  the  initial  extremity  of  the  bandage 
is  placed  uiaon  the  spine  at  a  point  opposite 
the  elbow -joint,  and  is  fixed  by  a  turn  or 
two  passing  around  the  arm  and  chest.  The 
bandage  is  then  continued  by  making  as- 
cending spiral  turns  covering  the  arm  and 
chest  until  the  axilla  is  reached.  At  this 
point  the  bandage  is  carried  through  the 
axilla  and  over  the  back  of  the  chest  to  the 
opposite  shoulder,  then  conducted  down  the 
front  of  the  arm  to  the  elbow,  passed  be- 
tween the  elbow  and  the  body,  and  carried 
up  the  back  of  the  arm  to  the  shoulder, 
then  conducted  obliquely  across  the  front 
of  the  chest  and  seem-ed  upon  the  back. 
(Fig.  69.) 

Ascending  Spica  Bandage  of  the 
Groin. — In  applying  this  bandage  the  ini- 
tial extremity  of  the  roller  should  be  placed 
obliquely  upon  the  upper  part  of  the  thigh, 
and  the  bandage  should  be  carried  around 

and  behind  the  limb  and  forward  around  the  outer  side  of  the  thigh  to  the 

abdomen  ;  it  should  then  be  carried  obliquely  across  the  lower  part  of  the 

abdomen  to  a  point  just  below  the  crest  of  the 

ilium,  conducted  transversely  around  the  back 

of  the  pelvis  to  a  corresponding  point  upon 

the  opposite  side,  and  then  brought  obliquely 

downward  to  the  groin,  over  the  inner  portion 

of  the  thigh,  and  carried  around  the  limb, 

crossing  the  starting-turn  in  the  middle  line 

of  the  thigh.    These  turns  should  be  repeated, 

each  turn  ascending  and  covering   in   two- 
thirds  of  the  previous  turn,  until  five  or  six 

comj)lete  turns  have  been  made,  and  the  ex- 
tremity should  be  secured  at  the  point  where 

it  ends.     (Fig.  70.)     This  bandage  may  also 

be  applied  by  making  one  or  two  circular 

turns  of  the  bandage  around  the  body  just 

below  the  iliac  crests,  then  carrying  the  band- 
age obliquely  to  the  inner  side  of  the  thigh  and  making  the  spica  turns  as 

described  above.     (Fig.  71.) 

Double  Spica  Bandage  of  the  Groins. — To  apply  this  bandage 

the  roller  should  be  placed  on  the  abdomen  just  above  the  iliac  crest,  and 

secured  by  one  or  two  circular  turns ;  the  bandage  is  then  carried  from  a 


Fig.  70. 


Spica  bandage  of  the  groin. 


SPICA   BANDAGE   OF  THE   GROIN. 


143 


point  just  below  the  crest  of  the  right  ilium  obliquely  across  the  lower  por- 
tion of  the  abdomen  to  the  outer  portion  of  the  left  thigh,  passed  around 


Fig.  71. 


Fig.  72. 


Spioa  bandage  of  the  groin. 


Double  spica  of  I 


Fig.  73. 


this  and  brought  up  between  the  scrotum  and  the  thigh,  and  carried 
obliquely  over  the  groin,  crossing  the  previous  turn  in  the  median  line  ;  it 
should  then  be  conducted  to  a  point  just  below  the  crest  of  the  ilium  of  the 
same  side,  and  carried  around  the  pelvis  to  the  same  point  on  the  opposite 
side,  and  from  this  point  it  should  be  made  to  pass  obliquely  over  the  groin 
to  the  inner  side  of  the  right  thigh,  x^assing  around  this  and  coming  uj)  on 
its  outer  side,  crossing  the  previous  turn  at  the  middle  line  of  the  groin, 
and  be  carried  obliquely  across  the  groin  and  the  lower  part  of  the  abdomen 
to  the  crest  of  the  ilium  on  the  opposite 
side.  These  turns  should  be  repeated, 
each  turn  covering  in  two-thirds  of  the 
previous  one,  until  both  groins  have 
been  covered.     (Fig.  72.) 

Figure-of-Eight  Bandage  of 
the  Knee. — In  applying  this  bandage 
the  initial  extremity  of  the  roller  should 
be  placed  upon  the  thigh  three  inches 
above  the  patella,  and  secured  by  two 
or  three  circular  turns ;  the  bandage 
should  then  be  conducted  over  the  outei' 
condyle  of  the  femur,  crossing  the  pop- 
liteal space,  to  the  inner  border  of  the 
tibia,  and  •  around  its  anterior  surface 
below  the  tubercle  and  the  head  of  the 
fibula,  where  a  circular  turn  should  be  made ;  the  roller  should  then  be 
carried  obliquely  across  the  popliteal  space  to  the  inner  condyle  of  the  femur, 
crossing  the  previous  turn,  and  be  conducted  around  the  front  of  the  thigh  to 
the  outer  condyle.   These  turns  should  be  repeated,  ascending  fiom  the  leg  to 


Figure-of-eight  bandage  of  the  knee. 


144  BANDAGES   OF  THE  FOOT. 

the  tliigli,  and  descending  fi-om  the  thigh  to  the  leg,  and  the  bandage  should 
Toe  finished  by  a  circular  turn  over  the  patella.  (Fig.  73. )  This  bandage  may 
also  be  applied  by  tirst  making  two  or  three  circular  turns  around  the  knee, 
and  afterwards  applying  figure-of-eight  turns  as  described  above,  descending 
fi-om  the  thigh  and  ascending  from  the  leg  to  the  knee.  A  figure-of-eight 
handage  of  both  knees  may  be  applied  in  the  same  manner. 

French  Bandage  of  the  Foot. — In  applying  this  bandage  the  initial 
extremity  of  the  roller  shoiild  be  fixed  on  the  leg  just  above  the  ankle  and 
secured  by  two  circular  turns  around  the  leg ;  the  bandage  should  be  carried 
obliquely  across  the  dorsum  of  the  foot  to  the  metatarso-phalangeal  articu- 
lation, at  which  point  a  circular  turn  should  be  made  around  the  foot ;  the 
roller  should  then  be  carried  up  the  foot,  covering  it  with  two  or  three  spiral 
reversed  turns,  and  after  this  a  figure-of-eight  turn  should  be  made  around 
the  ankle  and  instep  ;  this  should  be  repeated  once  to  cover  the  foot,  with 
the  exception  of  the  heel,  and  the  bandage  continued  up  the  leg  with  spiral 
reversed  turns.     (Fig.  74.) 

Fig.  74.  Fig.  75. 


French  bandage  of  the  fool.  Spica  bandage  of  the  foot. 


Spiea  Bandage  of  the  Foot. — To  apply  this  bandage  the  initial 
extremity  of  the  roller  should  be  fixed  just  above  the  ankle  and  secured  by 
two  circular  turns  ;  the  bandage  should  then  be  carried  obliquely  over  the 
dorsum  of  the  foot  to  the  metatarso-phalangeal  articulation  ;  a  cii'cular  turn 
around  the  foot  should  be  made  at  this  point,  and  the  bandage  continued 
upward  over  the  metatarsus  by  making  two  or  three  spii'al  reversed  turns ; 
it  should  then  be  carried  parallel  with  the  inner  or  the  outer  margin  of  the 
sole  of  the  foot,  according  as  it  is  aijplied  to  the  right  or  the  left  foot, 
directly  across  the  posterior  surface  of  the  heel,  and  from  this  point  it  should 
be  conducted  around  the  outer  border  of  the  foot  and  over  the  dorsum, 
crossing  the  original  turn  in  the  median  line  of  the  foot,  thus  completing 
the  first  spica  turn.  These  spica  tiarns  should  be  repeated,  gradually  as- 
cending, by  allowing  each  turn  to  cover  in  three-fourths  of  the  preceding 
one,  until  the  foot  is  covered,  with  the  exception  of  the  posterior  portion  of 
the  sole  of  the  heel ;  the  turns  should  cross  one  another  in  the  median  line  of 
the  foot,  and  should  be  kept  parallel  throughout  their  coui'se.     (Fig.  75.) 


SPIRAL   REVERSED   BANDAGE  OF  THE  LEG. 


145 


Bandage  of  the  Heel. — To  cover  in  the  heel  two  circular  turns  of  the 
bandage  are  made  around  the  ankle  and  heel ;  it  is  then  carried  under  the 
foot  and  around  the  inner  side 

of  the  ankle  below  the  malle-  Fig.  76 

olus  and  behind  the  ankle, 
then  over  the  dorsum  of  the 
foot  and  around  the  outer 
side  of  the  heel ;  these  turns 
should  be  repeated  several 
times.     (Fig.  76.) 

Spiral  Reversed 
Bandage  of  the  Leg. — 

In  applying  this  bandage  the 
roller  should  be  placed  on  the 
leg  just  above  the  ankle  and 
secured  by  two  circular  turns ; 
it  should  then  be  carried  ob- 
liquely over  the  foot  to  the 
metatarsophalangeal  articu- 
lation, where  a  circular  turn 

should  be  made  around  the  foot ;  the  foot  should  next  be  covered  in  with 
two  or  three  spiral  reversed  turns,  and  two  figure-of-eight  turns  made  around 
the  ankle  and  instep,  and  just  above  the  ankle  one  or  two  circular  or  spiral 
turns  around  the  leg  ;  as  the  bandage  is  carried  iip  the  leg,  spiral  reversed 
turns  are  made  iiutil  it  approaches  the  knee.  At  this  point,  if  the  limb  is 
to  be  kept  straight,  spiral  reversed  turns  may  be  continued  over  this  region 
up  the  thigh.  If  the  knee  is  to  be  bent,  figure-of-eight  turns  should  be 
applied  around  the  knee  until  it  is  covered  ;  then  the  thigh  can  be  covered 
in  with  spiral  reversed  turns.     (Fig.  77.) 


Bandage  of  the  heel. 


Fig. 


versed  bandage  of  the  leg 


Recurrent  Bandage  of  the  Stump. — To  apply  this  bandage  the 
initial  extremity  of  the  roller  should  be  placed  upon  the  anterior  or  the 
posterior  surface  of -the  limb  a  few  inches  above  the  extremity  of  the  stump, 
and  the  bandage  carried  over  the  end  of  the  stump,  and  then  conducted 

10 


146 


THE  RUBBER  BAis"DAC4E. 


Recurrent  bandage  of  the  stump. 


upward  on  the  stump  to  a  point  directly  opposite  tlie  point  of  starting ;  the 
bandage  should  then  be  brought  back  over  the  face  of  the  stump  to  the  point 
of  starting,  a  sufficient  number  of  these  recurrent  turns  being  made,  each 
turn  overlapping  two-thirds  of  the  preceding  one,  until  the  face  of  the  stump 
is  covered  in  ;  the  bandage  should  then  be  reversed,  and  the  recurrent  turns 

should  be  secured  at  their 
^iG.  78.  points  of  origin   by  two   or 

thi'ee  circular  turns.  The 
roller  should  next  be  carried 
oblicxuely  down  to  the  end  of 
the  stumf),  and  a  circular 
turn  should  be  made  around 
it,  and  the  bandage  should 
nest  be  carried  up  the  limb 
by  spiral  or  sjjiral  reversed 
turns,  and  secured  by  two  or  three  circular  turns.  (Fig.  78.)  In  very  short 
stumps  resulting  from  amputations  at  or  near  the  shoulder-  or  hip-joint,  after 
making  the  recurrent  spiral  turns  it  will  be  found  necessary  to  carry  the 
bandage  in  the  case  of  the  shoulder  across  the  chest  to  the  opposite  axilla, 
and  applj^  several  of  these  turns  ;  and  in  the  case  of  hip  amputations  it  will 
be  found  best  to  finish  the  bandage  with  a  few  turns  around  the  pelvis. 

Flannel  Bandages. — These  are  prepared  from  flannel  cut  into  strips 
from  two  to  four  inches  in  width  and  from  five  to  seven  yards  in  length, 
which  are  formed  into  rollers.  By  reason  of  the  elasticity  which  they 
possess  these  bandages  can  be  applied  without  reverses.  They  are  often 
employed  in  applying  dressings  to  the  head,  especially  after  operations 
uijon  the  eyes,  and  as  the  primary  roller  before  the  application  of  the  plas- 
ter-of- Paris  dressing. 

The  Rubber  Bandage. — This  bandage  is  made  from  a  strip  of  rubber 
sheeting  from  one  inch  to  four  inches  in  width  and  three  yards  in  length, 
which  for  convenience  of  application  is 

rolled  into  a  cylinder.     The  rubber  band-  Fig.  79. 

age  for  application  to  the  leg  should  be 
two  and  a  half  inches  in  width  and  three 
yards  in  length.  (Pig.  79.)  It  is  applied 
by  sijiral  turns,  as  reverses  are  not  neces- 
sary in  its  application,  as  its  elasticity 
allows  it  to  conform  to  the  shape  of  the 
limb.     In  applying  the  bandage  it  should 

be  stretched  very  slightly  ;   if  this  pre-  Ruijber  bandage. 

caution  is  not  taken  it  soon  becomes  un- 
comfortable to  the  patient.  In  employing  this  bandage  in  the  treatment 
of  ulcers  no  ointment  should  be  used,  as  oily  dressings  soon  destroy  the 
rubber.  Dry  powders,  such  as  oxide  of  zinc,  iodoform,  or  aristol,  should 
be  dusted  upon  the  ulcer  before  the  bandage  is  applied.  It  is  used  where 
it  is  desirable  to  apply  elastic  pressure  to  a  part,  and  is  often  employed 
in  the  treatment  of  varicose  veins  of  the  leg  and  of  chronic  ulcers,  where 
pressure  is  an  important  element  in  the  treatment. 


PLASTER-OF-PARia  BANDAGE.  147 

Elastic  Webbing  Bandage. — ^This  bandage,  which  is  woven  from 
threads  of  rubber  covered  with  cotton  or  silk,  has  recently  been  introduced, 
and  possesses  all  the  advantages  of  the  rubber  bandage  as  regards  elasticity, 
and  has  the  additional  advantage  that  the  air  can  circulate  through  the 
mesh  of  the  bandage  and  moistui-e  can  evaporate  from  the  surface  covered 
by  the  bandage,  so  that  the  skin  does  not  become  bathed  in  perspiration,  as 
is  the  case  with  the  rubber  bandage.  It  is  applied  in  the  same  manner  and 
for  the  same  purposes  as  the  rubber  bandage. 

FIXED   DRESSINGS   OR   HARDENING  BANDAGES. 

In  applying  these  dressings  substances  are  used  which  are  incorporated 
in  the  meshes  of  some  fabric,  such  as  crinoline  or  cheese-cloth,  or  are  painted 
over  its  surface  to  give  fixity  or  solidity  to  the  dressing.  The  materials 
generally  used  in  the  application  of  fixed  dressings  are  plaster  of  Paris, 
starch,  silicate  of  sodium,  or  silicate  of  potassium.  The  plaster  of  Paris  used 
for  the  j)reparation  of  surgical  dressings  should  be  of  the  same  quality  as 
that  which  dental  surgeons  employ  in  taking  casts  for  teeth, — that  is,  the 
extra- calcined  variety,  which  sets  in  a  few  minutes ;  if  moist,  or  of  inferior 
quality,  it  will  not  set  rapidly  or  firmly  and  will  fail  to  give  sufficient  fixa- 
tion to  the  dressing. 

The  most  convenient  method  of  applying  the  plaster-of- Paris  dressing  is 
by  means  of  bandages  impregnated  with  plaster  of  Paris,  which  are  prepared 
as  follows  :  cheese-cloth,  mosquito-netting,  or  crinoline — the  latter  is  by  far 
the  best  fabric — is  cut  or  torn  into  strips  from  two  and  a  half  to  four  or  five 
inches  in  width  and  five  yards  in  length  ;  these  are  laid  upon  a  table,  and 
plaster  of  Paris  is  dusted  over  them  and  rubbed  into  the  meshes  of  the  fabric ; 
the  material  when  impregnated  with  the  plaster  is  loosely  rolled  into  a  cyl- 
inder, or  the  bandages  may  be  prepared  by  a  machine  made  for  this  purpose, 
which  distributes  the  plaster  through  the  meshes  of  the  fabric.  Plaster-of- 
Paris  bandages  should  be  freshly  prepared,  or  if  they  are  to  be  kept  for  any 
time  they  should  be  placed  in  air-tight  jars  or  cans.  Bandages  which  have 
been  exposed  to  the  air  or  have  been  kept  for  a  long  time  are  not  apt  to  set 
well  when  applied  ;  however,  if  such  bandages  are  placed  in  a  hot  oven  and 
baked  for  half  an  hour,  they  will  be  found  to  set  as  satisfactorily  as  those 
freshly  made. 

Application  of  the  Plaster-of-Paris  Bandage. — Before  apply- 
ing this  dressing  the  part  to  be  encased  should  be  covered  by  a  flannel  roller, 
and  bony  i^rominences  should  be  protected  by  pads  of  cotton.  In  applying 
this  dressing  to  the  leg,  for  instance,  a  flannel  bandage  or  closely  fitting 
stocking  may  be  used  to  cover  the  part.  The  bandage  is  prepared  for 
application  by  soaking  it  in  warm  water  for  a  few  moments,  and  as  soon 
as  bubbles  of  air  cease  to  escape  it  is  an  indication  that  it  is  thoroughly 
soaked,  and  is  ready  for  use.  Upon  removing  the  bandage  from  the  water, 
the  excess  of  water  should  be  squeezed  out  by  the  hands ;  the  bandage 
should  then  be  evenly  applied  to  the  limb  without  re%^erses,  and  with  just 
enough  firmness  to  make  it  fit  the  part  neatly.  Only  so  many  bandages 
should  be  applied  as  will  make  a  firm  dressing, — three  rollers  of  the  above 
dimensions  being  usually  ample  for  a  dressing  for  the  leg, — and  when  the 


148 


PLASTEE-OF-PAEIS  DRESSINGS. 


last  roller  lias  been  applied  some  dry  plaster  should  be  mixed  with  water 
until  it  has  the  consistencj'  of  thick  cream,  and  this  should  be  rubbed  evenly 


Plaster-of-Paris  bandage  of  the  leg. 

over  the  surface  of  the  bandage  to  give  it  a  finish.  (Pig.  80.)  If  a  good 
quality  of  plaster  has  been  used,  the  bandage  should  be  quite  firm  in  from 
ten  to  fifteen  minutes ;  but  the  patient  should  not  be  allowed  to  put  any 
weight  on  it  for  several  hours.     An  equally  firm  dressing  may  be  secured 

by  the  use  of  a  lesser  number  of 
Fig.  81.  bandages   if   the   surface   of   each 

layer  of  bandage  is  rubbed  over 
with  a  little  moist  plaster  of  Paris. 
A  firm  plaster-of-Paris  dressing 
may  also  be  applied  by  the  use  of 
A'ery  few  bandages  if  narrow  strips 
of  tin,  zinc,  or  binder's  board  be 
incor];)orated  in  the  layers  of  the 
bandage.  In  applying  the  plaster- 
of-Paris  bandage  to  the  upper  part 
of  the  thigh  and  pelvis,  the  use  of  a  pelvic  supporter,  shown  in  Figs.  81  and 
82,  will  be  found  most  satisfactory. 

Fig.  82. 


Pelvic  supporter  for  applying  plaster-of-Paris  bandage 
to  the  pelvis  and  thigh.     (Dr.  H.  Reed. ) 


Supporter  in  place  for  application  of  pla5ter-of-Paris  bandage. 

Interrupted  Plaster-of-Paris  Dressing.— This  form  of  plaster-of- 
Paris  dressing  is  applied  by  first  covering  the  limb  with  a  flannel  roller 
up  to  the  lower  limit  of  the  part  wliich  is  to  be  left  exposed,  and  then 
applying  the  flannel  roller  from  the  upper  limit  of  the  part  which  is  to 


Interrupted  plaster-of-Paris  dressing     (Stimson  ) 


PLASTER-OF-PARIS  DRESSINGS.  149 

be  exposed  as  far  as  may  be  desired  to  apply  the  plaster  of  Paris.  A 
few  tarns  of  the  plaster-of-Paris  bandage  are  next  made  around  the  lower 
portion  of  the  limb,  covering  in  the  part  included  in  the  flannel  roller. 
The  plaster-of-Paris  roller  is  next  applied  above  the  exposed  region,  and 
is  carried  up  the  limb  as  far 

as  desired.     A  narrow  strip      ^  ^"^-  ^^■ 

of  metal  is  then  placed  under 
the  extremity,  extending 
some  distance  above  and  be- 
low the  point  at  which  the 
dressing  is  to  be  interrujited, 
and  this  is  iixed  in  place  by 
a  few  turns  of  i^laster  bandage 
above  and  below  the  portion 
of  the  limb  which  is  to  be  left 
exposed.  Three  pieces  of 
stout  wire  or  metal  strips  are  next  bent  into  loops,  the  extremities  of  which 
are  incorporated  in  the  subsequent  turns  of  the  plaster-of-Paris  bandage  ;  a 
number  of  turns  of  the  bandage  are  applied  to  fix  the  loox)S  firmlj',  and  the 
limb  is  held  in  the  desired  position  until  the  plaster  sets.     (Fig.  83.) 

Moulded  Plaster  Splints.— The  application  of  the  ordinary  plaster 
dressings  to  parts  irregular  in  shape  is  often  difficult,  and  it  is  sometimes 
desirable  to  have  a  splint  which  can  be  removed  with  ease.  These  indica- 
tions are  best  met  by  the' application  of  moulded  plaster  splints,  which  may 
be  made  by  cutting  a  paper  pattern  of  the  part  to  be  covered  in  and  then 
cutting  pieces  of  crinoline  to  conform  to  this  pattern  ;  eight  or  ten  pieces 
will  usually  form  a  splint  of  sufficient  thickness.  One  of  these  pieces  of  crino- 
line is  laid  upon  a  table  and  dry  plaster  is  rubbed  into  its  meshes,  another  is 
laid  upon  this  and  plaster  is  applied  to  it  in  the  same  way,  and  so  on  until 
all  the  pieces  have  been  jilaced  in  position,  one  over  the  other,  with  plaster 
rubbed  into  their  meshes.  The  dressing  is  then  folded  up,  dipped  in  water, 
squeezed  out,  and  moulded  to  the  part,  and  held  in  position  by  the  turns  of 
a  bandage.  The  edges  should  slightly  overlap,  and  in  applying  the  dressing 
a  strip  of  waxed  paper  should  be  placed  under  the  overlapping  edge  to  pre- 
vent its  adhesion  to  the  dressing  below,  and  thus  facilitate  its  removal. 

Fenestrated  Plaster  Dressing.— When  a  plaster-of-Paris  dressing 
is  aijplied  to  a  part  where  there  is  a  wound,  it  is  well  to  make  some  pro- 
vision whereby  the  plaster  dressing  over  the  site  of  the  wound  can  be  cut 
away,  making  a  trap  or  window  through  which  the  wound  can  be  inspected 
or  dressed  if  necessary.  To  accomplish  this,  before  applying  the  plaster  a 
compress  of  lint  or  gauze  should  be  placed  over  the  wound,  which  when  the 
dressing  is  completed  forms  a  projection  upon  its  surface,  indicating  the 
position  of  the  wound,  and  which  also  allows  the  surgeon  to  cut  away  the 
dressing  without  injuring  the  skin  below.  These  traps  may  be  cut  out  after 
the  baiulage  is  partially  set,  or  after  it  has  become  hard. 

Removal  of  Plaster  of  Paris  from  the  Hands.— The  difficulty 
of  removing  plaster  of  Paris  from  the  hands  of  the  surgeon  is  one  objection 
to  the  use  of  the  plaster  dressings,  as  is  also  the  harsh  condition  in  which  the 


150 


EEMOVAL  OF  PLASTER  DRESSINGS. 


skin  of  the  bauds  is  left  after  its  removal.  This  objection  may  be  readily 
overcome  if  the  hands  are  washed  in  a  solution  of  carbonate  of  sodium 
(washing-soda),  a  tablespoonful  to  a  basin  of  water,  which  will  readily 
remove  the  plaster  and  leave  the  skin  in  a  comfortable  condition. 

Removal  of  the  Plaster-of-Paris  Bandage.— When  the  plaster 
bandage  is  applied  to  obtain  a  cast  of  the  part,  or  when  its  removal  will 
probably  be  necessary  in  a  few  days,  a  strip  of  sheet-lead  half  an  inch  in 
width  is  placed  over  the  flannel  bandage  so  that  it  will  project  at  each  end 
beyond  the  plaster  dressing  when  applied.  The  plaster  bandage  is  then 
applied,  and  when  it  is  partially  set  it  can  be  readily  cut  through  upon  this 


Fig.  84. 


Cutting  plaster  bandage  on  lead  strip. 


strip  with  a  knife  without  injury  to  the  parts  below.     (Fig.  84.)     It  may 
also  be  removed  by  means  of  a  saw  devised  for  this  purpose  (Fig.  85)  or 


Fig.  85. 


) 


Plaster-of-Paris  saw. 


by  strong  cutting  shears.      (Fig.  86.)     If  the  bandage  has  not  been  cut 
directly  after  its  application,  as  previously  described,  the  most  satisfactory 

Fig.  86. 


Plaster-of-Paris  shears. 


method  of  removing  it  is  by  the  use  of  the  saw  or  shears  ;  care  should  be 
exercised  in  using  them,  as  the  final  layers  of  the  bandage  are  divided,  to 
avoid  injuring  the  skin.     The  bandage  may  also  be  cut  by  Gigii's  wire  saw 


SILICATE   OF  POTASSIUM  BANDAGE.  151 

drawn  nuder  the  bandage  by  a  string  :  it  cuts  rapidly  and  does  not  endanger 
the  skill. 

The  Starched  Bandage.— The  starched  bandage  is  prepared  by  first 
mixing  the  starch  with  cold  water  until  a  thick  creamy  mixture  results ; 
this  may  be  heated  until  a  clear  mucilaginous  fluid  is  obtained.  The  part 
to  which  the  dressing  is  to  be  applied  is  first  covered  with  a  flannel  roller, 
and  over  this  a  few  layers  of  cheese-cloth  or  crinoline  bandage  which  has 
been  shrunken  are  applied  ;  the  starch  is  then  smeared  or  rubbed  with  the 
hand  evenly  into  the  meshes  of  the  material,  and  the  part  is  covered  with 
another  layer  of  turns  of  the  bandage,  and  the  starch  is  again  applied.  This 
manipulation  is  continued  until  a  dressing  of  the  desired  thickness  is  pro- 
duced. It  usually  requires  from  twenty-four  to  thirty-six  hours  for  the 
starched  bandage  to  become  dry  and  thoroughly  set.  The  starched  bandage 
may  be  emijloyed  for  the  same  purposes  as  the  plaster-of- Paris  bandage,  and 
is  often  available  w^hen  the  plaster-of- Paris  bandage  cannot  be  obtained. 

Silicate  of  Potassium  or  Sodium  Bandage. — This  bandage  is 
applied  by  first  covering  the  part  with  a  flannel  roller  and  several  layers  of 
cheese-cloth  or  crinoline  bandage ;  the  surface  of  the  latter  is  then  covered 
with  silicate  of  sodium  or  of  potassium,  applied  by  means  of  a  brush  ;  then 
a  second  layer  of  bandage  is  applied  and  j)ainted  over  in  the  same  manner 
with  the  silicate  of  sodium  or  of  potassium,  and  this  manipulation  is  con- 
tinued until  a  dressing  of  the  desired  thickness  is  produced.  It  usually 
requires  twenty-four  hours  for  this  dressing  to  become  firm,  but  Ave  have 
found  that  by  covering  the  silicate  bandage  with  a  layer  of  tissue-paper  and 
then  applying  a  light  plaster- of- Par  is  bandage,  fixation  of  the  parts  is  made 
secure  after  the  setting  of  the  plaster-of- Paris  bandage,  and  this  may  be 
removed  in  twenty-four  hoars,  when  the  silicate  bandage  will  be  found  per- 
fectly hard.  The  silicate  bandage  may  be  removed  with  saw  or  shears,  or 
may  be  softened  by  soaking  in  warm  water,  when  it  can  be  readily  cut 
through  with  scissors. 

Raw-Hide  or  Leather  Splints. — Splints  prepared  from  i-aw  hide  or 
leather  are  often  used  in  the  tieatment  of  fractures  or  for  fixation  dressings. 
In  preparing  these  si^lints  of  raw  hide  or  leather,  it  is  necessary  to  apply  a 
plaster-of- Paris  bandage  to  the  part  to  which  the  raw-hide  splint  is  to  be 
fitted,  and  as  soon  as  the  plaster  has  set  it  is  removed  ;  a  solid  plaster  cast  is 
next  made  by  greasing  the  inner  surface  of  the  mould  and  pouring  in  liquid 
plaster  of  Paris.  When  this  has  become  dry,  a  piece  of  raw  hide  which  has 
been  soaked  for  several  days  in  water  is  moulded  to  the  cast  and  held  firmly 
in  contact  with  it  by  a  bandage  or  by  means  of  tacks  until  it  has  become 
perfectly  dry,  which  often  lequires  a  number  of  days.  It  should  then  be 
removed,  and  its  surface  covered  with  several  coats  of  shellac  to  prevent  its 
absorbing  moisture  from  the  skin  and  changing  its  shai^e  when  apj)lied. 
Eyelets  or  hooks  are  fastened  to  the  edges  of  the  splint,  through  which 
strings  are  passed  to  secure  it  in  place. 

Binder's  Board  Splints. — Binder's  board,  which  may  be  obtained 
in  sheets  of  different  thicknesses,  is  frequently  employed  for  the  manufacture 
of  splints.  In  moulding  these  splints  a  portion  of  the  board  of  the  requisite 
size  and  thickness  is  dipped  into  boiling  water  for  a  short  time,  and  when  it 


152 


PLASTERS. 


lias  become  softened  it  is  removed  and  allowed  to  cool.     A  thick  layer  of 

cotton  batting  is  next  applied  over  it,  and  it  is  then  moulded  to  the  part  and 

held  firmly  in  position  by  the  turns  of  a  roller  band- 

FiG.  87.  age  ;  in  a  short  time  it  becomes  dry  and  hard.    (Fig. 

87.) 

Porous  Felt  Splints.— This  material  also  is 
employed  for  the  juanufacture  of  splints,  and  is 
applied  by  dipping  it  in  hot  water  and  moulding  it 
to  the  part ;  as  it  dries  it  becomes  hard. 

Plasters. — The  varieties  of  plasters  which  are 
most  commonly  employed  in  surgical  dressings  are 
adhesive  or  resin  plaster,  isinglass  plaster,  rubber  ad- 
hesive or  zinc  oxide  plaster,  and  soa})  plaster.  Before 
using  plasters,  if  the  part  to  which  they  are  to  be 
applied  is  covered  by  hairs,  these  should  be  re- 
moved by  shaving,  otherwise  traction  upon  them, 
if  the  plaster  is  used  for  the  pur^jose  of  extension, 
will  give  the  patient  discomfort  or  j)ain.  If  this 
precaution  has  been  neglected,  the  final  removal  of 
the  p)h\ster  also  will  cause  severe  pain. 

Resin  Plaster. — This  plaster  is  often  employed 
in  surgical  dressings.  It  is  cut  into  strips  of  the 
required  width  and  length,  and  is  heated  before 
being  applied  to  the  surface  by  applying  the  un- 
spread  side  to  a  vessel  containing  hot  water,  or 
by  passing  it  rapidly  through  the  flame  of  an  alcohol  lamp.  This  variety 
of  plaster  is  generally  used  in  making  the  extension  apparatus  for  the  treat- 
ment of  fractui-es,  for  strapping  the  chest  in  fractures  of  the  ribs  and  ster- 
num, and  for  strapping  the  testicle,  ulcers,  or  joints. 

Isinglass  Plaster. — This  plaster  is  made  by  spreading  a  solution  of 
isinglass  upon  silk  or  muslin,  and  was  formerly  employed  in  the  dressing  of 
superficial  wounds.     It  is  made  to  adhere  to  the  surface  by  moistening  it. 

Rubber  Adhesive  Plaster. — This  plaster  is  made  by  spreading  a 
prepai'ation  of  india-rubber  on  muslin,  and  has  the  advantage  over  ordinary 
resin  plaster  that  it  adheres  without  the  application  of  heat.  When  applied 
continuously  to  the  skin  for  some  time  it  is  apt  to  produce  a  certain  amount 
of  irritation.     It  is  employed  for  the  same  purposes  as  resin  jplaster. 

Zinc  Oxide  Plaster. — This  pUister  is  made  by  spreading  a  mixture  of 
zinc  oxide  and  india-rubber  upon  muslin.  It  has  the  same  properties  and  is 
used  for  the  same  purposes  as  rubber  adhesive  plaster,  but  is  more  adhesive 
and  less  irritating  to  the  skin. 

Soap  Plaster. — Soap  plaster  for  surgical  purposes  is  prepared  by 
spreading  emplastrum  saponis  u]3on  kid  or  chamois-skin.  It  has  little  adhe- 
sive power,  but  is  employed  simply  to  give  support  to  parts  or  to  i^rotect 
salient  portions  of  the  skeleton  from  pressure.  It  constitutes  a  useful  dressing 
when  applied  over  the  sacrum  in  cases  of  threatened  bed-sores,  and  may  be 
employed  with  advantage  to  protect  bony  prominences  which  are  subjected 
to  splint  pressure  in  the  treatment  of  fractures. 


Binder's  board  splint  for  leg 
and  foot. 


STRAPPING.  153 

Strapping. — The  application  of  strips  of  plaster  to  produce  pressure 
or  fixiitiou  is  often  resorted  to  in  surgical  practice. 

Strapping  the   Testicle. — In   strapping-  the  testicle  strips  of   resin 
plaster  are  usually  employed,  half  an  inch  in  width  and  twelve  inches  in 
length.     The  scrotum  should  be  washed 
and  shaved,  and  the  surgeon  then  draws  Fig.  88. 

the  skin  over  the  affected  organ  tense  by 
liassing  the  thumb  and  finger  around  the 
scrotum  at  its  upper  portion  ;  a  strip  of 
plaster  which  has  been  heated  is  passed 
in  a  circular  manner  about  the  organ  and 
is  tightly  drawn  and  secured  ;  this  isolates 

the  testicle  and  prevents  the  other  strips  strapping  the  testicle.    (Bryant.; 

from  slipping  ;  strips  are  next  applied  in 

a  longitudinal  direction,  the  first  strip  being  fastened  to  the  cii'cular  strip 
and  carried  over  the  most  prominent  i^art  of  the  testicle,  and  then  back  to 
the  circular  strip  and  fastened.  A  number  of  these  strips  are  applied  in  an 
imbricated  manner  until  the  skin  is  covered  (Fig.  88),  and  the  dressing  is 
completed  bj^  passing  transverse  strips  around  the  testicle  from  its  lowest 
portion  to  the  circular  strip,  care  being  taken  that  no  portion  of  the  skin  is 
left  uncovered. 

Strapping  of  Ulcers. — Strapping  is  frequently  employed  in  the  treat- 
ment of  ulcers.  To  strap  an  ulcer  of  the  leg,  strijas  of  resin  plaster  one  and 
a  half  inches  in  width  and  long  enough  to  extend  two-thirds  around  the  limb 
are  required.  The  ulcer  should  be  thoroughly  cleansed  and  the  skin  sur- 
rounding it  well  dried  ;  the  first  strip  being  heated,  it  is  applied  transversely 
or  obliquely  to  the  long  axis  of  the  leg,  about  two  inches  below  the  ulcer, 
and  is  carried  two-thirds  around  the  limb ;  the  next  strip  covers  in  about 
one-third  of  the  previously  applied  strip,  and  a  sufficient  number  of  strips 
are  applied  to  cover  the  ulcer  and  extend  several  inches  beyond  it.  Care 
should  be  taken  that  the  strips  are  so  placed  as  not  to  cover  the  entire  cir- 
cumference of  the  limb,  as  injurious  circular  compression  may  result.  This 
dressing  is  usually  reinforced  by  the  application  of  a  firmly  ajiplied  spiral 
reversed  or  spica  bandage  of  the  leg.  Strapping  of  ulcers  may  also  be 
accomplished  by  Using  two  strijDS  which  are  fastened  to  the  skin  at  some 
distance  from  the  edges  of  the  ulcer  ;  traction  is  made  upon  them,  and  they 
are  made  to  cross  obliquely  over  the  ulcer  ;  additional  strips  are  applied  in 
this  manner  until  the  surface  of  the  ulcer  is  covered. 

Strapping  of  Joints. — In  strapping  joints,  strijjs  of  resin  or  rubber 
adhesive  plaster,  from  one  to  one  and  a  half  inches  in  width  and  long 
enough  to  extend  two-thirds  around  the  joint,  are  required.  The  first  strip 
is  applied  a  few  inches  below  the  joint,  and  strii3S  are  then  applied  over 
this,  each  strip  covering  in  two-thirds  of  the  preceding  one,  until  the  joint 
is  covered  in  and  the  dressing  extends  a  few  inches  above  and  below  it. 
Strapping  of  joints  will  be  found  a  satisfactory  dressing  in  the  treatment  of 
siarains  of  joints  in  tlieir  acute  or  chronic  stages. 

Irrigation  and  Baths. — Irrigation  may  be  accomplished  by  allow- 
ing the  irrigating  fluid  to  run  over  a  wound  or  an  inflamed  part,  or  by  per- 


154 


lEEIGATION. 


mitting  the  cold  or  warm  fluids  to  i)ass  througli  rubber  tubes  whicb  are  iu 
contact  with  or  surround  the  jtart :  the  former  method  is  known  as  direct  or 
immediate  irrigation,  the  latter  as  mediate  irrigation. 

Direct  Irrigation. — In  employing  direct  irrigation  iu  the  treatment  of 
wounds  or  inflammatory  conditions,  a  funnel-shai^ed  can  or  glass  jar  with  a 

stop-cock  at  the  bottom,  or  a  rubber  bag, 
Fig.  89.  is  suspended  over  the  part  at  a  distance 

of  a-few  inches  (Fig.  89) ;  the  can  or  bag 
is  filled  with  water,  and  this  is  allowed 
to  fall  drop  by  drop  upon  the  part  to  be 
irrigated,  which  should  be  placed  upon 
a  piece  of  rubber  sheeting  so  arranged 
as  to  permit  the  water  to  run  off  into  a 
receptacle  and  prevent  the  wetting  of  the 
patient's  bed.  The  irrigating  fluid  may 
also  be  allowed  to  pass  directly  into 
draiuage-tubes  inserted  in  the  wound 
or  incisions  in  the  part.  The  water 
employed  may  be  either  cold  or  warm, 
according  to  the  indications  in  special 
cases.  If  it  is  desirable  to  make  use  of 
antiseptic  irrigation,  the  water  is  im- 
Direct  irrigation.  prcgnatcd  with  carbolic  acid  or  bichlo- 

ride of  mercury  ;  a  1  to  60  to  80  carbolic 
acid  solution  or  a  1  to  4000  to  8000  bichloride  solution,  or  a  1  to  500  acetate 
of  aluminum  solution  or  normal  salt  solution,  is  frequently  employed  with 
good  results.  In  the  treatment  of  abscess  cavities  direct  irrigation  may  be 
employed  with  advantage  and  also  in  extensive  lacerated  wounds  of  the 
extremities.  In  appljang  this  method  of  treatment  the  wound  and  sur- 
rounding skin  should  first  be  cleansed  and  foreign  bodies  removed  ;  the  limb 
should  next  be  arranged  upon  pillows  covered  by  rubber  sheets  or  suspended 
from  a  wire  cradle  by  strips  of  bandage  so  that  the  fluid  passing  over  the 
wound  can  escape  into  a  vessel  and  not  wet  the  patient's  bed.  The  skin  of 
the  limb  for  some  distance  around  the  wound  should  be  rubbed  with  boric 
ointment,  to  prevent  its  becoming  sodden  from  the  continuous  presence  of 
moisture.  The  fluid  used  for  irrigation  is  a  1  to  4000  to  8000  bichloride 
solution,  warm  or  about  the  temperature  of  the  body,  which  is  allowed  to 
run  drop  by  drop  over  the  part  from  an  irrigatiug-can  with  a  stop-cock  to 
regulate  the  flow  of  fluid,  or  from  an  improvised  irrigator  made  from  ajar 
and  a  few  pieces  of  lamp-wick.  The  irrigating  reservoir  should  be  placed 
only  a  few  inches  above  the  wound.  This  form  of  irrigation  may  be  kept 
up  for  days,  and  under  its  use  lacerated  wounds  often  become  clean  and 
covered  with  healthy  granulations.  When  the  wound  is  in  this  condition, 
dry  sterilized  dressings  may  be  substituted,  or  it  may  be  dressed  with  boric 
ointment.  In  lacerated  wounds  in  which  suppuration  or  sloughing  has 
occurred  after  the  ordinary  antiseiDtic  dry  dressings  have  been  apjplied,  it  is 
often  found  of  advantage  to  ajjply  continuous  antiseptic  irrigation.  In  some 
cases  in  which  there  are  large  superficial  lesions,  permanent  baths  have  been 


COUNTERIRRITATION.  155 

successfullj^  emijloyed,  tlie  limb  being  suspended  by  bandages  in  the  same 
manner  in  a  small  bath-tub  beneath  the  level  of  the  fluid. 

Mediate  Irrigation. — In  this  method  a  flexible  tube  of  india-rubber, 
half  an  inch  in  diameter  and  from  sixteen  to  twenty  feet  in  length,  with 
thin  walls,  is  applied  to  the 

limb  like  a  spiral  bandage,  Pj^,  qq 

or  is  applied  in  a  coil  to  the 
head,  breast,  joints,  or  abdo- 
men, and  held  in  place  by  a 
few  turns  of  a  bandage.  The 
end  of  the  tube  is  attached  to 
a  reservoir  filled  with  cold  or 
warm  water  above  tlie  level 
of  the  j)atieut's  bed,  and  the 
water  is  allowed  to  flow  con- 
stantly through  the  tube, 
whence  it  escapes  into  the 
receptacle  arranged  to  receive  Mediate  irrigation. 

it.     (Fig.  90.) 

Cold  Water  Dressings. — These  dressings  are  applied  by  bringing 
water,  whose  temperature  may  vary  from  that  of  cool  water  to  that  of  ice- 
water,  directly  in  contact  with  the  part,  or  by  applying  it  by  means  of  a 
rubber  bag  or  bladder.  Cold  water  dressings  are  employed  in  local  inflam- 
matory conditions,  and  a  popular  method  of  application  is  by  means  of 
cold  compresses,  which  are  made  of  a  few  layers  of  surgical  lint  dipped  in 
water  of  the  desired  temperature  and  applied  to  the  part ;  they  should  be 
renewed  as  they  become  warm.  If  it  is  desirable  to  have  the  compresses 
very  cold,  they  may  be  laid  upon  a  block  of  ice  or  in  a  basin  with  broken 
ice.  The  ice-hag,  which  consists  of  a  rubber  bag  or  bladder  filled  with 
broken  ice,  is  used  to  obtain  the  direct  action  of  cold  upon  the  part.  It  is 
often  employed  as  an  ax^plication  to  the  head  in  inflammatory  conditions  of 
the  brain  or  its  membranes,  and  it  is  also  used  upon  the  surface  of  the  body 
to  control  internal  hemorrhage. 

Hot  Fomentations. — Hot  fomentations  may  be  employed  to  combat 
inflammatory  action,  or  to  keep  up  the  vitality  of  parts  which  have  been 
subjected  to  severe  injury.  They  are  applied  by  means  of  pads  of  gauze, 
old  muslin,  surgical  liut,  or  flannel  cloths,  which  are  soaked  in  water  having 
a  temperature  of  120°  F.  (40.5°  G.)  ;  these  are  wrung  out  and  placed  upon 
the  part  and  covered  with  waxed  paper  or  rubber  tissue ;  a  second  pad 
should  be  ready  to  apply  as  soon  as  the  first  begins  to  cool,  and  so  by  con- 
tinuously reapplying  them  the  part  is  kept  constantly  covered  with  a  hot, 
moist  dressing. 

Counterirritation. — This  consists  in  producing  external  irritation  to 
influence  internal  morbid  jDrocesses,  the  results  obtained  being  due  to  the 
action  of  the  irritant  upon  the  blood-vessels  and  nerves.  Counterirritauts 
are  substances  employed  to  excite  external  irritation.  The  extent  of  their 
action  varies  with  the  material  used  and  the  duration  of  its  application. 
They  are  used  as  local  revulsants  in  cases  of  congestion  or  inflammation. 


156  COUNTEEIERITATION. 

Hot  Water. — When  it  is  desired  to  make  a  quick  impression  upon  the 
skin,  the  application  of  muslin  or  flannel  cloths  wrung  out  of  hot  water 
and  renewed  frequently  will  produce  a  superficial  redness  of  the  integument. 

Spirit  of  Turpentine. — This  drug  when  applied  to  the  skin  is  a  very 
active  counterirritant.  Its  action  may  be  obtained  by  rubbing  it  directly 
upon  the  surface  of  the  skin,  when  marked  redness  results,  or  when  less 
decided  action  is  desired  it  may  be  combined  with  equal  parts  of  olive  oil 
before  it  is  applied.  The  turpentine  stupe,  which  is  prepared  by  sprinkling 
spirit  of  turj)entine  over  flannel  cloths  which  have  been  wrung  out  of  hot 
water,  or  by  dipping  them  in  warm  si^irit  of  turpentine,  and  apijlying  them 
to  the  siirface  of  the  body,  is  a  method  frequently  employed  to  obtain  the 
rubefacient  action  of  spirit  of  turpentine.  Chloroform,  mustard,  capsicum, 
and  aqua  ammonite  may  also  be  api)lied  for  their  rubefacient  action. 

Tincture  of  Iodine. — This  drug  is  frequently  used  as  a  counteriri-itant 
in  chronic  inflammation.  It  is  painted  upon  the  part  daily  for  one  or  two 
days,  and  when  irritation  of  the  tissue  is  observed  its  use  is  discontinued  for 
a  few  days  before  repeating  the  application. 

Vesicants. — Vesicants  are  substances  which  by  their  action  on  the  skin 
cause  an  effusion  of  serum  or  of  serum  and  lymph  beneath  the  cuticle,  giving 
rise  to  vesicles  or  blisters.  The  substance  most  commonly  emj)loyed  to  jjro- 
duce  vesication  is  cantharis,  or  Spanish  fly,  which  is  used  in  the  form  either 
of  ceratum  cantharidis,  which  is  spread  upon  adhesive  plaster,  leaving  a  mar- 
gin of  half  an  inch  in  width  uncovered,  which  will  adhere  to  the  skin,  or  of 
cantharidal  collodion,  several  layers  of  which  are  iiainted  upon  the  surface 
and  produce  vesication. 

Actual  Cautery. — This  constitutes  one  of  the  most  powerful  means  of 
counterirritation  and  revulsion.  Counterirritatiou  by  this  method  is  accom- 
plished by  bringing  in  contact  with  the  skin  some  metallic  substance  brought 
to  a  high  degree  of  temperature.  The  cautery-irons  generally  employed 
have  their  extremities  fashioned  in  a  variety  of  shapes,  and  are  fixed  in 
handles  of  wood  or  other  non-conducting  material.  The  irons  are  heated 
by  placing  the  extremities  in  an  ordinary  fire,  or  by  holding  them  in  the 
flame  of  an  alcohol  lamj),  and  they  should  be  used  at  a  black  or  dull  red 
heat.  The  actual  cautery  is  often  employed  to  control  hemorrhage  or  to 
destroy  morbid  growths. 

Paquelin's  Thermo-Oautery. — This  is  a  convenient  and  efficient 
means  of  applying  cauterization,  which  utilizes  the  property  of  a  heated 
platinum  sponge  to  become  incandescent  when  exposed  to  the  action  of 
vapor  of  benzene  or  rhigolene.  This  form  of  cautery  may  be  used  at  a  white 
heat  or  at  a  dull  red  heat :  its  great  advantage  consists  in  the  ease  with 
which  it  can  be  prepared  for  use.  This  instrument  may  be  used  to  produce 
counterirritation,  as  well  as  in  operations  upon  vascular  tumors  where  the 
use  of  a  knife  would  be  accompanied  by  profuse  hemorrhage,  or  for  con- 
trolling hemorrhage  in  cases  where  the  ligature  cannot  be  satisfactorily 
employed.  Wounds  made  by  the  actual  cautery  are  aseptic  wounds,  and 
when  dusted  with  iodoform  they  generally  heal  promptly. 

Gal vano-Cautery.— This  form  of  cautery  is  often  emi^loyed  for  the 
same  puri^ose  as  the  actual  cautery,  but  is  more  convenient  for  application 


ASPIRATION. 


157 


Fig.  91. 


in  the  various  cavities  of  the  body,  as  the  electrodes,  which  are  made  of 
various  shapes  and  sizes,  can  be  introduced  iuto  the  cavities  while  cold  and 
quickly  heated  to  a  red  or  white  heat.  It  is  frequently  employed  for  the 
destruction  of  morbid  growths  in  the  nasal  passages,  the  throat,  the  vagina, 
or  the  uterus,  and  its  employment  in  these  cases  may  be  rendered  ijractically 
painless  by  previously  thoroughly  cocainizing  the  parts. 

Aspiration. — This  procedure  is  ado^jted  to  remove  fluids  from  a 
closed  cavity  without  the  admission  of  air,  and  the  instrument  employed  is 
known  as  an  aspirator.  Po- 
tain's  aspirator  (Fig.  91)  is 
the  one  most  convenient  for 
use.  In  using  this  aspirator 
the  bottle  is  exhausted  of  air 
by  using  an  air-pump  ;  the 
canula  enclosing  the  trocar 
is  uext  pushed  through  the 
tissues  into  the  cavity  con- 
taining the  fluid  to  be  re- 
moved ;  the  trocar  is  with- 
drawn, and  upon  opening 
the  stop-cock,  fluid  is  forced 
out  of  the  cavity  by  atmos- 
pheric pressure  and  passes 
into  the  bottle  or  receiver. 
Great  care  should  be  exer- 
cised that  the  trocar  and  canula  are  thoroughly  sterilized  by  boiling  before 
being  used.  The  pain  produced  in  introducing  the  trocar  and  canula  may 
be  diminished  by  holding  in  contact  with  the  part  which  is  to  be  ijunctured, 
for  a  few  minutes,  a  i)iece  of  ice  wj'apped  in  a  towel,  or  by  the  subcuta- 
neous injection  of  a  few  drops  of  cocaine.  After  removing  the  canula, 
the  small  puncture  remaining  should  be  dressed  with  a  compress  of  gauze. 
The  aspirator  is  used  to  ascertain  the  character  of  the  contents  of  deep- 
seated  tumors  containing  fluid,  and  is  also  emi:)loyed  to  empty  the  chest  or 
abdomen  of  fluids,  as  in  hydrothorax,  empyema,  or  ascites,  to  evacuate  the 
contents  of  tuberculous  abscesses  in  diseases  of  the  hip  and  spine,  and  some- 
times to  relieve  a  distended  bladder  until  a  more  radical  operation  can  be 
performed. 

Massage. — This  consists  in  a  variety  of  manipulations,  such  as  pinch- 
ing up  the  integuments  or  muscles  and  rolling  them  between  the  thumb  aiid 
fingers,  and  stroking  or  rubbing  the  surface  with  the  palm  of  the  hand  from 
the  periphery  towards  the  centre,  to  empty  the  distended  veins  and  lym- 
phatics. Massage  may  also  be  practised  by  rubbing  the  parts  circularly,  or 
by  kneading  them,  or  by  tapping  the  surface  of  the  affected  part  with  more 
or  less  force  with  the  tips  of  the  fingers  held  in  a  row,  or  with  the  ulnar 
border  or  the  palm  of  the  hand.  If  the  part  upon  which  these  manipula- 
tions are  to  be  practised  contains  a  heavy  growth  of  hair,  this  should  be  care- 
fully removed  by  shaving,  otherwise  the  manipulations  are  apt  to  give  the 
patient  pain,  and  abscesses  may  result  from  infection  of  the  hair-follicles. 


158  CUPPING. 

The  parts  should  also  be  rubbed  over  with  olive  oil,  vaseline,  or  cacao  butter 
before  and  during  the  manipulations.  Massage  will  be  found  of  great  ser- 
vice in  the  later  treatment  of  fractures  involving  the  joints  or  in  their  vicin- 
ity, in  restoring  the  motion  of  the  parts,  as  well  as  imjjroviug  the  nutrition 
of  muscles  which  have  become  wasted  from  disuse. 

Passive  Motion. — This  maniiDulation  consists  in  alternately  flexing 
and  extending  or  rotating  the  limb  to  imitate  the  normal  joint  movements. 
The  manipulations  should  be  carefully  practised,  and  in  cases  of  fracture 
should  not  be  undertaken  until  there  is  union  at  the  seat  of  fracture. 
Massage  may  often  be  employed  in  conjunction  with  passive  motion  for  the 
treatment  of  the  troublesome  stiffness  in  joints  resulting  from  fractures, 
dislocations,  or  sprains. 

Compression. — This  is  a  means  of  preventing  swelling  in  the  early 
stages  of  inflammation  and  producing  the  absorption  of  the  effusion  in  its 
later  stages.  It  may  be  aj)i)lied  by  means  of  compresses,  bandages,  or  strap- 
ping. Pressure  applied  in  this  manner  is  often  employed  in  the  treatment  of 
injuries  of  the  joints  and  bursse,  and  in  chronic  inflammatory  swellings. 
It  should  be  used  with  caution  where  the  circulation  of  the  tissues  is 
impaired. 

Bloodletting. — Bloodletting  is  often  employed  to  obtain  both  the  local 
and  the  general  effects  following  the  withdrawal  of  blood  from  the  circula- 
tion. Local  depletion  is  accomplished  by  means  of  scarification,  cupping, 
and  leeching,  while  general  depletion  is  effected  by  means  of  venesection. 

Scarification. — Scarification  consists  in  making  numerous  small  parallel 
incisions  with  a  sharp-j)ointed  knife,  which  should  correspond  with  the  long 
axis  of  the  part,  and  care  should  be  taken  in  making  them  to  avoid  wound- 
ing superficial  veins  and  nerves.  Incisions  thus  made  relieve  tension  by 
allowing  blood  and  serum  to  escape  from  the  engorged  capillaries  of  the 
infiltrated  tissue  of  the  part.  Scarification  is  employed  with  advantage  in 
inflammatory  conditions  of  the  skin  and  subcutaneous  cellular  tissue,  and 
in  acute  inflammatory  swelling  or  oedema  of  the  mucous  membrane.  A 
modification  of  scarification,  known  as  deep  incisions,  is  j)ractised  in 
urinary  infiltration,  to  establish  drainage  and  relieve  the  tissues  of  the 
contained  urine,  and  to  prevent  sloughing.  In  cellulitis  and  in  threatened 
gangrene  the  same  procedure  is  often  adopted  to  relieve  tension  or  to  facili- 
tate the  escape  of  blood  and  serum.  Warm  fomentations  applied  over  the 
incisions  will  increase  and  keep  up  the  flow  of  blood  and  serum. 

Cupping. — Cupping  is  a  convenient  method  of  employing  local  deple- 
tion by  inviting  the  blood  from  the  deeper  parts  to  the  surface  of  the  skin, 
and  may  be  accomplished  by  the  use  of  dry  or  wet  cups. 

Dry  Cupping. — Dry  cups,  as  ordinarily  applied,  consist  of  small  cup- 
shaped  glasses  which  have  a  valve  and  stop-cock  at  their  summit.  The  cup 
is  placed  upon  the  skin,  and  an  air-pump  is  attached,  and  as  the  air  is  ex- 
hausted the  congested  integument  is  seen  to  bulge  into  its  cavity.  (Fig.  92.) 
In  cases  of  emergency,  where  the  ordinary  cuppiug-glasses  and  air-pump 
cannot  be  employed,  a  very  satisfactory  substitute  may  be  obtained  by  burn- 
ing a  little  paper  or  alcohol  in  a  wineglass,  and  before  the  flame  is  extin- 
guished, rapidly  inverting  it  upon  the  skin. 


LEECHING. 


159 


Fig. 


Cupping-glasg. 


Wet  Cupping. — Wheu  the  abstraction  of  blood  as  well  as  tlie  deriva- 
tive action  is  desired,  wet  cujas  are  resorted  to.  Before  applying  wet  cups 
the  skin,  as  well  as  the  scarificator,  should  be  carefully  steril- 
ized. A  dry  cup  should  first  be  applied,  to  produce  superficial 
congestion  of  the  skin.  This  is  removed  and  the  scarificator  is 
apijlied  ;  and,  when  the  skin  has  been  cut  by  springing  the 
blades,  the  cup  is  immediately  applied  and  exhansted,  and  is 
kept  in  place  as  long  as  the  blood  continues  to  flow.  A  sharp- 
pointed  bistoury  which  has  been  sterilized  may  be  enii)loyed  to 
make  a  few  incisions  in  the  skin  instead  of  the  scarificator,  and 
the  improvised  cups  may  be  employed  if  the  ordinary  cupping 
apparatus  cannot  be  obtained.  After  the  removal  of  wet  cuj)s 
the  wounds  should  be  thoroughly  washed  with  a  bichloride  or 
saline  solution,  and  a  gauze  dressing  apj)lied. 

Leeching. — Before  aijplying  leeches  to  the  skin  it  should 
be  carefully  washed  with  soap  and  watei',  and  the  leech  should 
be  applied  on  the  part  from  which  the  blood  is  to  be  drawn,  and 
confined  to  this  place  by  inverting  a  tumbler  or  glass  jar  over 
it ;  if  it  does  not  take  hold,  a  little  blood  should  be  smeared 
upon  the  surface,  which  will  generally  secure  the  desired  result. 
When  the  leech  has  ceased  to  draw  blood  it  is  apt  to  let  go  its  hold  and  fall 
off ;  if,  however,  it  is  desirable  to  remove  leeches,  they  maj'  be  made  to  let 
go  their  hold  by  sprinkling  them  with  salt.  After  the  removal  of  leeches 
bleeding  from  the  bites  may  be  encouraged  by  the  application  of  warm 
fomentations.  It  sometimes  happens,  however,  that//-ee  bleeding  continues 
from  leech-bites,  and  if  this  cannot  be  controlled  by  the  application  of  a 
compress,  the  bleeding  ijoi  nt  should  be  touched  with  the  point  of  a  steel 
knitting-needle  heated  to  a  dull  red  heat.  Leech-bites  should  be  washed 
with  bichloride  solution  and  dressed  with  a  compress  of  sterilized  gauze. 
Leeches  should  not  be  employed  directly  over  inflamed  tissues,  but  should 
be  applied  to  the  surrounding  area ;  they  should  not  be  allowed  to  take 
bold  directly  over  a  superficial  artery,  vein,  or  nerve,  and  should  never  be 
applied  to  a  part  where  there  is  delicate  skin  or  a  large  amount  of  loose 
cellular  tissue,  as  the  eyelid  or  the  scrotum,  since  extensive  ecchymoses  are 
apt  to  result. 

Venesection. — Venesection  is  an  operation  by  which  general  depletion 
or  bleeding  is  accomplished.  It  consists  in  the  division  or  opening  of  a 
vein;  the  median  cephalic  vein  is  the  one  usually  selected.  (Fig.  93.) 
The  patient's  arm  having  been  carefully  sterilized,  a  few  turns  of  a  roller 
bandage  should  be  placed  around  the  middle  of  the  arm,  being  applied 
tightly  enough  to  obstruct  the  venous  circulation  and  make  the  veins  below 
prominent.  The  surgeon  should  next  find  the  median  cephalic  vein,  and, 
steadying  it  with  the  thumb  and  finger,  should  pass  the  point  of  the  bistoury 
or  lancet  beneath  it  and  cut  quickly  outward,  making  a  free  skin  opening. 
The  blood  usually  escapes  freely,  and  the  amount  withdrawn  is  regulated  by 
the  condition  of  the  pulse  and  the  appearance  of  the  patient.  The  patient 
should  be  in  the  sitting  or  semi-reclining  position  wheu  venesection  is  per- 
formed, as  the  operator  can  then  better  judge  as  to  the  constitutional  effects 


160  TRANSFUSION  AND   INFUSION. 

of  tlie  loss  of  blood.  When  a  sufficient  quantity  of  blood  has  been  removed, 
a  gauze  compress  should  be  placed  over  the  wound  and  the  bandage  removed 
from  the  arm  above,  and  the  compress  held  in  posi- 
FiG.  93.  ^JQjj  ]jjy  ^  bandage.     The  dressing  need  not  be  dis- 

turbed for  five  or  six  days,  at  the  end  of  which  time 
the  wound  is  usually  found  to  be  healed.  Vene- 
section is  also  sometimes  practised  upon  the  external 
jugular  vein  or  upon  the  internal  saphenous  vein,  in 
cases  where  the  veins  at  the  bend  of  the  elbow  cannot 
be  easily  found,  as  often  happens  in  children. 

Transfusion  and  Intravenous  Injection. 

— These  procedures  are  employed  respectively  to 
introduce  blood  or  normal  salt  or  saline  solution 
into  the  body  of  a  i^atient  who  suifers  from  acute 
anwmia  resulting  from  profuse  hemorrhage. 

Direct  Transfusion   of  Blood. — This  proce- 
dure is  now  rarely  practised,  and  is  accomplished  by 
making  a  direct  communication  between  a  vein  of 
the  person  supplying  the  blood  and  one  of  the  pa- 
~l  LJM    \h  ^11"/       tient  by  means  of  a  piece  of  rubber  tubing,  to  the 
E7?H&  \  it=-  ,       extremities  of  which  are  attached  two  canulse. 
""'"'("fson.r"'"'  Auto-Transfusion  of  Blood.— Auto-transfu- 

sion  is  a  procedure  which  is  recommended  in  cases 
of  excessive  hemorrhage  to  support  a  moribund  j)atieut  until  other  means 
of  resuscitation  can  be  adopted.  It  consists  in  the  axiplication  of  muslin  or 
rubber  bandages  to  the  extremities  for  the  purpose  of  forcing  the  blood 
towards  the  vascular  and  nervous  centres. 

Intravenous  Injection  of  Saline  Solution. — Clinical  experience  has 
proved  that  the  injection  of  saline  solution  into  tlie  veins  is  more  efficacious 
in  supplying  volume  to  and  restoring  a  rapidly  failing  circulation  than  that 
of  human  blood,  and,  as  the  former  can  be  obtained  with  much  more  ease 
than  blood,  its  use  has  largely  suj)erseded  that  of  the  latter.  Iiformal  saline 
solution  (see  p.  117)  should  be  used  at  a  temperature  of  about  100°  to  120°  P. 
In  injecting  normal  salt  solution  a  vein  of  the  patient,  preferably  at  the 
elbow,  should  be  exposed,  and  should  have  placed  under  it,  about  half  an 
inch  apart,  two  catgut  ligatures ;  the  distal  ligature  is  then  tied,  and  an 
opening  is  made  into  the  vein  between  the  ligatures.  The  canula  is  next 
inserted  into  the  opening  in  the  vein,  in  the  direction  in  which  the  blood 
flows,  and  is  secured  in  position  by  tying  the  proximal  ligature.  Before  in- 
troducing the  canula  care  should  be  taken  that  the  canula,  tube,  and  funnel 
are  filled  with  saline  solution,  and  as  the  funnel  is  raised  the  saline  solution 
passes  into  the  vein  ;  the  funnel  should  be  kept  constantly  filled  with  the 
solution ;  the  quantity  introduced  should  be  regulated  by  the  condition  of 
the  patient's  pulse.  When  a  sufficient  quantity  has  been  introduced,  the 
canula  should  be  removed  and  the  catgut  ligatures  tied,  and  the  wound 
should  be  closed  with  sutures. 

Hypodermoclysis. — This  i^rocedure,  known  also  as  saline  infusion, 
consists  iu  the  introduction  of  saline  solution  into  the  cellular  tissue  by 


ARTIFICIAL   KESPIKATION. 


161 


means  of  a  large  hypoderuiic  needle  passed  into  the  connective  tissue 
and  connected  bj'  a  rubber  tube  with  a  reservoir  containing  the  solution. 
The  usual  locations  for  the  introduction  of  the  solution  are  the  external 
portions  of  the  thighs  and  the  anterior  portion  of  the  abdominal  walls. 
As  much  as  two  or  three  pints  of  the  solution  may  be  introduced  in 
this  manner,  with  as  satisfactory  results  as  those  obtained  by  inti'a\'enous 
injection. 

Artificial  Respiration. — Artificial  respiration  is  resorted  to  in  cases 
of  threatened  death  from  apncea  consequent  upon  profound  ansesthetization, 
the  inhalation  of  irrespirable  gases,  or  drowning,  or  in  cases  where  from  any 
cause  there  is  interference  with  the  function  of  breatliing.  Before  resorting 
to  artificial  respiration  care  should  be  taken  that  the  mouth  and  air-passages 
are  free  from  anj^  substance  which  would  obstruct  the  entrance  of  air  into 
the  lungs,  such  as  mucus,  foreign  bodies,  or  liquids,  and  also  that  all  tight 
clothing  interfering  with  the  free  expansion  of  the  chest  walls  is  removed. 
If  there  is  a  foreign  body  in  the  larj^ux  or  trachea,  tracheotomy  should  be 
performed  before  artificial  respiration  is  attempted.  In  practising  artificial 
respiration  the  manipulations  should  be  persevered  in  for  some  time,  even 
if  no  apparent  spontaneous  respiratory  movements  are  excited  ;  for  resusci- 
tation has  been  accomplished  in  apparently  hopeless  cases  by  perseverance 
with  the  manipulations.  As  soon  as  natural  respiratory  movements  are 
detected  the  surgeon  should  not  cease  artificial  respiration,  but  should  con- 
tinue these  manipulations  in  such  a  way  as  to  coincide  with  the  spontaneous 
inspiratory  and  expiratorj^  movements  until  the  breathing  has  resumed  its 
regular  character. 

Direct  Method  of  Artificial  Respiration. — The  manipulations  in 
Howard's  direct  method  of  artificial  respiration  are  as  follows : 

First. — "  To  exjiel  water  from  the  stomach  and  lungs,  strij)  the  j)atient  to 
the  waist,  and  if  the  jaws  are  clinched,  separate  them  and  keep  them  apart 
by  placing  between  them  a  piece 

of  cork  or  a  small  piece  of  wood.  ^^^-  ^4- 

Place  the  patient  face  downward, 
the  pit  of  the  stomach  being 
raised  above  the  level  of  the 
mouth  by  a  large  roll  of  clothing 
placed  beneath  it.  (Pig.  94.) 
Throw  your  weight  forcibly  two 
or  three  times  upon  the  patient's 
back,  over  the  roll  of  clothing,  so 
as  to  press  all  fluids  in  the  stomach 
out  of  the  mouth. ' '  These  manip- 
ulations are  applied  only  to  cases 
of  drowning. 

Second. — "To    perform  artifi- 
cial respiration,  turn  the  patient 

upon  his  back,  placing  the  roll  of  clothing  beneath  it  so  as  to  make  the  breast- 
bone the  highest  point  of  the  body.  Kneel  beside  or  astride  the  patient' s  hijjs. 
Grasp  the  front  part  of  the  chest  on  either  side  of  the  pit  of  the  stomach, 

11 


First  manipulation  in  direct  method  ot  artitieial  re-spira- 
tion.     (Howard.) 


162 


AETIFICIAL  EESPIEATIOX. 


Direct  method  of  artificial  re=;piration      (Ho^  ard.) 


rest  the  fingers  along  tlie  spaces  between  the  short  ribs.  Press  your  elbows 
against  your  sides,  and,  steadily  grasping  and  pressing  forward  and  upward, 
throw  your  whole  weight  upon  the  chest,  gradually  increasing  the  pressure 

while  you  count  one,  two,  three. 
Fig.  9.1.  (Fig.    95.)     Then  suddenly  let 

go  with  a  final  push,  which 
brings  you  back  to  your  first 
position.  Eest  erect  upon  your 
knees  while  you  count  one,  two  ; 
then  make  pressure  again  as  be- 
fore ;  repeat  the  entire  motions, 
at  first  about  four  or  five  times 
a  minute,  gradually  increasing 
them  to  about  ten  or  twelve 
times.  Use  the  same  regularity  as  blowing  bellows  and  as  seen  in  the  natural 
breathing  whicli  you  are  imitating." 

Silvester's  Method  of  Artificial  Respiration. — The  patient  should 
be  placed  uxDon  his  back  upon  a  firm  flat  surface  ;  a  cushion  should  be  placed 
under  the  shoulders,  and 

the     head      should     be  Fig-  96. 

dropped  lower  than  the 
body  by  tilting  the  sur- 
face upon  which  it  is 
laid.  The  mouth  being 
cleared  of  mucus  and 
foreign  substances,  the 
tongue  should  be  drawn 
forward  and  secured,  or 
held  by  an  assistant. 
The  operator,  standing 
at  the  patient's  head, 
grasps  the  arms  at  the 
elbows  and  carries  them 
first  outward  and  then 
upward  until  the  hands 
are  brought  above  the  head  ;  this  manipulation  represents  inspiration.  (Pig. 
96.)  They  should  be  kept  in  this  position  for  two  seconds,  after  which  they 
are  brought  slowly  back  to  the  sides  of  the  thorax  and  pressed  against  it  for 
two  seconds;  this  manipulation  represents  expiration.  (Pig.  97.)  Simul- 
taneous pressure  on  the  abdomen  by  an  assistant  greatly  increases  the  effect 
of  this  movement.  These  movements  are  repeated  from  twelve  to  fifteen 
times  in  a  minute  until  the  breathing  is  restored,  or  until  it  is  evident  that 
the  case  is  a  hopeless  one. 

Forced  Respiration. — In  this  method  of  artificial  respiration  air  is 
forced  into  the  lungs  either  through  the  mouth  and  larj^nx  or  throtigh  a 
tracheotomy  tube  by  means  of  a  bellows.  An  intubation  tube,  to  which 
a  rubber  tube  is  attached,  may  also  be  placed  in  the  larynx,  and  to  this  is 
attached  a  bellows,  or  Fell's  apparatus  may  be  employed. 


Silvester's  method — inspiration.    (Esmarch.) 


SUTURES  AND  LIGATURES. 


163 


Fig.  97. 


Silvester's  method — expiration.     (Esmarch.) 


Forced  respiration  has  proved  of  value  in  cases  of  narcotic  poisoning  and 
other  accidents,  in  which  death  is  produced  by  respiratory  paralysis. 

Laborde's  Method  of 
Artificial  Respiration.— This 
method,  which  consists  in  sys- 
tematic and  rhythmic  traction 
of  the  tongue,  has  proved  to  be 
a  valuable  means  of  restoring  the 
respiratory  reflex,  and  conse- 
quently the  function  of  respira- 
tion. The  procedure  is  accom- 
plished as  follows  :  The  body  of 
the  tongue  is  seized  between  the 
thumb  and  the  iinger,  or  by 
tongue  or  dressing  forceps,  and 
traction  is  made  ui^on  it  with 
alternate  relaxation  fifteen  or 
twenty  times  in  a  minute,  imi- 
tating the  function  of  resi^iration, 
taking  care  to  draw  well  on  the  tongue.  As  soon  as  a  certain  amount  of 
resistance  is  felt  it  is  a  favorable  sign,  for  it  indicates  that  the  respira- 
tory function  is  being  restored,  which  is  manifested  by  noisy  respiration. 
This  method  is  not  applicable  when  the  tongue  is  fixed  by  inflammation  or 
cancer.  This  form  of  artificial  respiration  bids  fair  to  supersede  all  other 
forms,  and  has  been  emijloyed  with  success  in  cases  of  drowning,  toxic 
asphyxia,  chloroform  asphyxia,  and  asphyxia  from  strong  electric  currents. 
In  any  case  where  it  is  employed  the  traction  should  be  persisted  in  for  half 
an  hour  to  an  hour  before  it  is  abandoned  as  hopeless. 

SUTURES   AND   LIGATURES. 

Sutures. — Several  varieties  of  materials  are  employed  for  sutures,  such 
as  silk,  catgut,  silver  wire,  silkworm-gut,  kangaroo  tendon,  celluloid  thread, 
and  horse-hair.  Of  these,  catgut  and  kangaroo  tendon  are  practically  the 
only  substances  employed  which  are  absorbed ;  the  other  sutures  require 
removal,  although  some,  such  as  silk,  silkworm-gut,  and  silver  wire,  when 
buried  in  wounds,  may  become  encysted  and  remain  indefinitely  in  the  tissues. 

Surgical  Needles. — Surgical  needles  are  of  different  sizes  and  shapes. 
Straight  needles  are  the  ones  most  commonly  employed,  but  curved  ones  are 
most  convenient  for  the  introduction  of  sutures  in  certain  localities.  Hage- 
dorn  needles,  which  are  flat  and  have  sharp  cutting  edges,  make  a  narrow 
linear  wound  in  the  tissues.  The  ordinary  sewing-needles  are  usually  em- 
ployed for  intestinal  and  visceral  sutures,  as  the  punctures  resulting  from  them 
do  not  bleed.  Handled  needles  with  the  eye  near  the  point  of  the  needle 
are  also  useful  in  introducing  sutures  in  deep  wounds.  Eeverdin's  needle 
is  of  this  variety.  Needles  should  be  sterilized  by  boiling,  and  may  be  kept 
ready  for  use  in  a  saturated  solution  of  sodium  carbonate  or  albolene. 

Sutures  of  Relaxation. — Sutures  of  relaxation,  also  called  tension 
sutures,  are  those  which  are  entered  and  brought  out  at  some  distance  from 


164  SUTURES. 

the  edges  of  the  wound,  and  are  employed  to  prevent  dangerous  tension 
upon  the  sutures  which  approximate  the  edges  of  the  skin.  These  sutures 
may  be  employed  in  the  form  of  the  quilled,  button,  or  plate  suture. 

Sutures  of  Coaptation. — These  are  superficial  sutures  applied  closely 
together,  and  including  only  the  skin  and  connective  tissue.  They  are 
employed  to  secure  accurate  apposition  of  the  cutaneous  surfaces  of 
wounds. 

Sutures  of  Approximation. — These  sutures  are  passed  deeply  into 
the  tissues  to  secure  api^roximation  of  the  deep  ijortions  of  a  wound.  They 
are  often  employed  in  the  form  of  the  quilled,  biitton,  or  plate  suture. 

Secondary  Sutures. — These  sutures  are  einployed  where  primary 
sutures  have  failed  to  secure  apposition  of  the  edges  of  a  wound,  or  in  cases 
of  secondary  hemorrhage  where  the  wound  has  been  opened  to  turn  out  the 
blood-clot  and  secure  a  bleeding  vessel ;  they  are  also  employed  where  it  is 
necessary  to  jjack  a  wound  with  gauze,  to  control  hemorrhage  after  the 
operation,  or  where  hfemostatic  forceps  have  been  allowed  to  remain  clamped 
upon  bleeding  tissues  in  the  wound  after  an  operation.  The  sutures  may 
in  such  a  case  be  introduced  and  loosely  tied  at  this  time,  and  when  the 
packing  or  forceps  is  removed  at  the  end  of  two  or  three  days  or  after 
granulation  has  begun  the  sutures  are  tightened,  so  as  to  secure  ai^iiosition 
of  the  surfaces  of  the  wound. 

Method  of  securing  Sutures. — Metallic  sutures  are  usually  secured 
by  twisting  the  ends  together,  or  by  passing  the  ends  through  a  perforated 
shot  and  clamping  the  shot  with  a  shot- compressor.  Sutures  and  ligatures 
of  catgut,  silk,  silkworm-gut,  or  kangaroo  tendon  are  secured  by  tying,  and 
several  different  knots  are  employed  in  securing  them. 

Reef  or  Flat  Knot. — This  is  one  of  the  best  forms  of  knot  to  use  in 
securing  sutures  or  ligatures,  and  it  is  made  by  passing  one  end  of  the 
thread  over  and  around  the  other  end,  and  the  knot  thus  formed  is  tight- 
ened. The  ends  of  the  thread  are  next  carried  towards  each  other,  and  the 
same  end  is  again  carried  over  and  around  the  other ;  and  when  the  loop 
is  drawn  tight  we  have  formed  the  reef  or  flat  knot.     (Fig.  98. ) 

Fig.  98.  Fig.  99. 


Reef  or  flat  knot.  Surgeon's  knot. 

Surgeon's  Knot. — This  knot  is  formed  by  carrying  one  end  of  the 
thread  twice  around  the  other  end,  and,  after  tightening  this  loop,  the  same 
end  is  carried  over  and  around  the  other  end,  as  in  the  case  of  the  final  knot 
of  the  reef  or  flat  knot.  (Fig.  99.)  The  surgeon's  knot  and  reef  knot 
combined  is  a  very  excellent  method  of  securing  sutures  or  ligatures  of  cat- 
gut or  silk,  because  in  the  ordinary  method  the  first  knot  is  apt  to  relax 
before  the  second  knot  is  applied. 


SUTUEES. 


165 


Interrupted  Suture. — This  variety  of  suture  is  the  one  usually  em- 
ployed iu  the  apposition  of  wounds,  and  consists  of  a  number  of  single 
sutures,  each  of  which  is  entirely  independent  of  those  on  either  side.  In 
applying  this  suture  the  surgeon  holds  the  edge  of  the  wound 
with  the  fingers  or  forceps,  and  thrusts  the  needle,  previously 
threaded,  through  the  skin  from  one-eighth  to  one-third  of 
an  inch  from  the  edge  of  the  wound.  He  next  passes  the 
needle  from  within  outward  through  the  tissues  of  the  oppo- 
site flap  at  the  same  distance  from  the  edge  of  the  wound 
(Fig.  100)  ;  each  stitch  is  secured  as  soon  as  it  is  apijlied,  by 
tying  if  a  silk,  catgut,  or  silkworm-gut  suture  is  used,  or  by 
twisting  if  a  wire  suture  is  employed.  The  suture  may  be 
used  with  a  needle  threaded  on  each  end,  in  which  case 
both  needles  are  ]3assed  from  within  outward.  In  applying 
sutures  care  should  be  taken  that  they  exert  no  tension  on 
the  edges  of  the  wound,  and  that  they  are  so  introduced  as 
to  make  the  best  possible  apposition  of  the  parts. 

Buried  Sutures. — These  are  sutures  which  are  intro- 
duced into  deep  wounds  and  cut  short  after  being  secured, 
and  are  allowed  to  remain  in  the  wound,  superficial  sutures 
also  being  introduced.  The  former  effect  apposition  of  the  muscles  and  the 
deep  fascia  ;  the  superficial  ones  approximate  the  superficial  fascia  and  the 
skin.  The  best  materials  to  emjjloy  for  deep  or 
buried  sutures  are  catgut,  silk,  or  kangaroo  tendon. 
Continued  Suture. — This  is  applied  in  the 
same  manner  as  the  interrupted  suture,  but  the 
stitches  are  not  cut  apart  and  tied  ;  it  is  secured 
by  drawing  it  double  through  the  last  stitch,  and 
using  the  free  end  to  make  a  knot  with  the  double  portion  attached  to  the 
It  is  often  employed  in  securing  aijposition  of  wounds 


Interrupted  suture. 


Fig.  101. 


\rv 


Continued  suture. 


needle.     (Fig.  101.) 
in  loose  tissues. 


Fig.  102. 


Subcuticular  suture.    (After  Bloodgood.) 


Subcuticular  Suture. — This  variety  of  suture,  which  has  been  recom- 
mended by  Halsted,  is  employed  to  avoid  infection  of  the  wound  by  the  skin 


166 


SUTURES. 


Fig.  103. 


Twisted  or  harelip 
suture. 


COCCUS,  whicli  maj^  be  introduced  by  the  suture  if  passed  tlirougli  the  skin 
from  without  inward.  In  applying  this  suture  the  needle  is  introduced  on 
the  under  surface  of  the  skin  ou  one  side,  and  is  brought 
out  just  beneath  the  cut  edge  ;  it  is  then  entered  in  the 
reverse  direction  below  the  epidermic  surface  opposite, 
and  when  tied  it  will  lie  wholly  out  of  sight,  or  it  may 
be  api)lied  as  a  continuous  suture.  (Fig-  102.)  For  this 
suture  fine  silk  or  catgut  should  be  used,  which  may  be- 
come encysted,  may  be  absorbed,  or  may  be  removed. 

Twisted  or  Harelip  Suture. — This  form  of  suture  is 
employed  where  great  accuracy  and  firmness  of  apposi- 
tion of  the  surfaces  of  a  wound  are  desired.  It  is  applied 
by  thrusting  jiins  or  needles  deeply  thi-ough  both  lips  of 
the  wound,  the  edges  being  brought  in  contact  by  figure- 
of-eight  turns  of  silk.  (Fig.  103.)  In  using  this  suture 
the  points  of  the  pins  should  be  cut  off  with  x:)in-cutters 
after  the  sutures  are  applied,  or  should  be  protected  by 
pieces  of  cork  or  j)laster  to  prevent  them  from  injuring 
the  skin.  Harelip  sutures  are  employed  in  i^lastic  operations  about  the 
face  or  other  parts  of  the  body  where  accurate  apposition  and  support  of  the 
flaps  is  desired.  ^^^^  ^^ 

Mattress  Suture. — This 
form  of  suture  is  made  with  silk 
or  catgut,  and  is  employed  in 
wounds  where  it  is  important  to 
have  very  close  apiiroximation 
of  the  parts  and  to  prevent  bag- 
ging.    (Fig.  101.) 

Quilled  Suture. — In  ap- 
plying this  suture,  a  needle 
armed  with  a  double  thread  of 
wire  or  silk  is  passed  through 

the  tissues  as  in  applying  the  in-  5-   ij.i" 

terrupted  suture,  but  at  a  greater 
distance  from  the  edges  of  the 
woiind  ;  a  quill,  a  glass  rod,  or 
a  piece  of  flexible  catheter  or 
roll  of  gauze,  is  inserted  into  the 
loops  on  one  side  of  the  wound, 
and  on  the  opposite  side  the  free 
ends  of  the  sutures  are  carried 
around  a  similar  object  before 
being  tightened.  (Fig.  105.)  This  variety  of  suture  makes  deep  and  equable 
pressure  along  the  whole  line  of  the  wound.  In  using  this  form  of  suture  it  is 
often  found  advisable  to  introduce  a  few  superficial  interrupted  sutures  along 
the  line  of  the  wound,  to  secui-e  accurate  approximation  of  the  skin.  The  use 
of  deep  or  buried  sutures  to  secure  accurate  ajiposition  of  the  deep  x^ortions 
of  the  wound  has  largely  supplanted  the  use  of  this  variety  of  suture. 


Mattress  suture. 


SUTURES. 


167 


Button  or  Plate  Suture. — la  applying  this  suture,  a  thread  armed 
with  two  needles  is  first  passed  through  the  eyes  of  a  button  or  through 
perforations  in  a  lead  plate.  The  needles  are  next  carried  through  the 
edges  of  the  wound,  and  upon  the  opposite  side  are  passed  through  the  eyes 
of  another  button  or  through  the  perforations  of  a  lead  plate.  After  the 
sutures  have  been  passed  in  this  way  they  are  tightened  and  tied  over  the 
button  or  plate.  (Fig.  106.)  This  variety  of  suture  may  be  employed  in 
deep  wounds  to  accomplish  the  same  purpose 
as  the  quilled  suture,  and,  as  it  does  not  bring  ^^'^-  ■'■'^^• 
about  very  close  apposition  of  the  cutaneous 

Fig.  107. 


Button  suture. 


Shotted  suture. 


margius  of  the  wound,  a  few  interrui^ted  sutures  may  be  emploj^ed  in  con- 
junction with  it. 

Shotted  Suture. — The  shotted  suture  receives  its  name  from  the 
method  by  which  it  is  secured.  After  the  suture  has  been  introduced  the 
needle  is  removed,  and  the  ends  are  passed  through  a  perforated  shot  and 
drawn  upon  to  bring  the  edges  of  the  wound  in  contact ;  the  shot  is  then 
pressed  down  to  the  skin  and  clamped  with  a  shot-compressor,  and  the  suture 
is  cut  off  flush  with  the  surface  of  the  shot.  (Fig.  107.)  This  method  of 
securing  sutures  is  especially  useful  in  closing  wounds  in  mucous  cavities, 
such  as  the  vagina,  rectum,  and  mouth,  where  a  knot  or  twist  of  the  wire  or 
silkworm-gut  might  cause  irritation.  The  presence  of  the  shot  also  facilitates 
the  removal  of  the  suture,  as  the  shot  is  not 
apt  to  be  obscured  by  the  swollen  tissues,  and 
is  easily  seized  with  forceps  before  the  loop  is 
divided. 

Lembert's  Suture. — This  suture  is  gener- 
ally used  in  wounds  of  the  viscera  covered  by 
the  peritoneum,  with  the  object  of  bringing  in 
contact  the  peritoneal  surfaces.  It  is  the  form 
of  suture  usually  employed  in  closing  wounds  of 
the  intestine,  bladder,  or  stomach.     Inap)i)lying 

this  suture  an  ordinary  sewing-needle  should  be  employed,  in  preference  to 
the  bayonet-pointed  needle,  as  less  bleeding  is  apt  to  result  from  its  puncture. 
The  needle  is  first  carried  through  the  peritoneal  and  muscular  coats  of  the 
intestine,  and  is  then  carried  across  the  wound  and  jjassed  through  the  same 


Lembert's  suture. 


168 


LIGATURES. 


Fig.  109. 


portion  of  the  intestine  a  short  distance  from  the  edge  of  the  wonnd  on  the 
opposite  side ;  when  the  suture  is  tightened  the  peritoneal  surfaces  of  the 
intestine  are  inverted  and  brought  into  contact  with  each  other.'  (Fig.  108.) 
The  interrupted  or  continued  sutui-e  may  he  employed  in  making  this  form 
of  suture. 

Removal  of  Sutures. — Catgut  sutures  usually  undergo  absorption  in 
from  five  to  fifteen  days  :  the  loop  buried  in  the  tissues  is  absorbed,  and  the 
knot  may  be  removed  with  forceps  or  may  come  off  with  the  dressings. 
Sutures  of  silk,  silkworm-gut,  or  silver  wire  are  removed  by  cutting  one 
side  of  the  loop  and  making  traction  upon  the  knot  of  the  suture  with, 
forceps ;  in  case  of  the  silver  wire  suture,  after  dividing  the  loop  and 
straightening  out  one  end  of  it,  the  wire  should  be  withdrawn  in  a  curved 
direction.  Sutures  which  do  not  cause  any  irritation  should  be  allowed  to 
remain  in  position  until  the  wound  is  healed  ;  the  time  usually  required  for 
their  retention  in  the  case  of  aseptic  wounds  is  from  eight  to  twelve  days. 

Ligatures  used  for  the  Strangulation  of  Growths.— Various 
forms  of  ligatures  are  used  for  the  strangulation  of  growths.  The  material 
employed  is  usually  strong  silk,  JiemiJ  thread,  catgut,  or  silver  wire. 

Single  Ligature. — Tliis  is  applied  by  inserting  a  harelip  pin  through 
the  skin  near  the  edges  of  the  growth,  passing  it  under  the  growth,  and 

bringing  its  point  out  through 
the  skin  opposite  the  point  of 
entry  ;  a  strong  silk  or  hemp 
ligatui'e  is  then  passed  under 
the  ends  of  the  pin,  surround- 
ing the  base  of  the  tumor,  is 
drawn  tightly  enough  to  stran- 
gulate the  growth,  and  is  se- 
cured by  two  knots.  (Fig. 
109.)  If  the  growth  is  of  considerable  size,  it  is  better  before  applying  the 
ligature  to  introduce  a  second  pin  at  right  angles  with  the  first  one  and  then 
secure  the  ligature  under  the  ends  of  the  pins.  In  apply- 
ing this  ligature,  the  separation  of  the  mass  is  hastened 
by  cutting  a  groove  in  the  skin  with  a  knife  at  the  j)oint 
where  the  ligature  is  to  be  applied ;  the  ligature  when  tied 
is  buried  in  the  groove  thus  made. 

The  Double  Ligature. — This  ligature  is  applied  by 
passing  a  needle,  or  a  needle  with  a  handle,  armed  with  a 
double  ligature,  through  the  skin  near  the  growth,  and 
then  passing  it  under  the  tumor  and  bringing  it  out  through 
the  skin  at  a  point  directly  opj)osite  the  point  of  insertion  ; 
the  ligature  is  then  divided  and  the  needle  is  removed. 
The  growth  is  strangulated  by  tying  firmly  the  correspond- 
ing ends  of  the  ligature  on  each  side  of  the  tumor,  each 
ligature  including  one-half  of  the  growth.  The  double 
ligature  may  also  be  applied  by  iiassing  a  pin  under  the 
growth  and  then  passing  a  needle  armed  with  a  double  thread  under 
the  tumor  at  right  angles  to  the  pin.     After  removing  the  needle  the  ends 


Single  ligature  applied  with  pin. 


Fig.  110. 


Double  ligature. 


LIGATURES.  169 

of  the  ligatme  are  tied  and  the  tumor  is  strangulated  in  two  sections.    (Fig. 
110.) 

Quadruple  Ligature. — In  applying  this  ligature  two  needles,  each 
carrying  a  double  ligature,  are  passed  under  the  growth  at  right  angles  to 
each  other  ;  the  needles  being  removed,  the  surgeon  ties  two  ends  of  the 
ligature  together,  and  repeats  the  procedure  until  the  growth  has  been  stran- 
gulated in  four  sections. 

Subcutaneous  Ligature. — The  subcutaneous  ligature  is  applied  by  in- 
troducing a  needle  armed  with  a  ligature  through  the  skin  near  the  growth, 
and  carrying  it  through  the  subcutaneous  tissues  around 
the  growth  for  a  short  distance,  then  bringing  it  out  through  Fig.  111. 

the  skin.     The  needle  is  again  introduced  through  the  '^ 

same  puncture  and  again  brought  out  through  the  skin 
at  the  same  distance  from  the  first  point  of  exit,  and  is 
next  introduced  through  this  puncture  and  brought  out  at 
a  more  distant  point.  In  this  way  the  growth  is  completely 
encircled  by  a  subcutaneous  ligature,  which  is  finally 
brought  out  at  the  point  of  entrance.  The  tumor  is  stran- 
gulated by  firmly  tying  together  the  ends  of  the  ligature. 
(Fig.  111.)  If  a  needle  armed  with  a  double  ligature  is  subcutaneous ugatol 
first  passed  under  the  growth,  the  ligature  is  divided  ;  by 
passing  each  end  of  the  divided  ligature  subcutaneously  around  the  growth 
it  may  be  strangulated  subcutaneously  in  two  sections. 

Elastic  Ligatures. — Ligatux'es  made  of  india-rubber  of  various  thick- 
nesses are  occasionally  made  use  of  in  surgery.  They  may  be  used  to  stran- 
gulate growths,  such  as  moles  or  nfevi,  or  may  be  employed  in  the  treatment 
of  fistula  in  ano.  In  applying  an  elastic  ligature  to  a  fistula  the  ligature, 
after  being  passed  through  the  fistula  by  means  of  a  probe,  is  carried  out 
through  the  internal  opening,  and  the  ends  of  the  ligature  are  tied  firmly 
together  ;  the  greater  the  tension  made  before  the  ligature  is  tied,  the  more 
rapidly  will  it  cat  its  way  out. 


CHAPTER   XIA^. 

"WOUNDS. 
By  Heney  E.  Wharton,  M.D. 

A  A¥OUND  is  a  solution  of  continuity  or  divisioja  of  the  tissues  produced 
by  cutting,  tearing,  or  compressing  force.  Wounds  are  usually  classified 
according  to  their  causation  or  nature,  as  incised,  when  resulting  from  a 
sharp-edged  instrument ;  lacerated,  when  the  tissues  are  extensively  torn 
or  separated  ;  contused,  when  resulting  from  a  more  diffused  force  tearing 
and  bruising  the  tissues  ;  punctured,  when  produced  by  some  narrow 
insti'ument  which  causes  a  wound  whose  depth  is  greater  than  its  external 
surface,  such  as  a  stab  wound  ;  subcutaneous,  such  as  occur  in  the  tissues 
from  the  fragments  in  simple  fractures ;  poisoned,  when  some  poisonous 
substance  enters  the  wound  and  produces  both  local  infection  and  constitu- 
tional disturbance  ;  gunshot,  when  the  injury  results  from  fire-arms  or  the 
explosion  of  powder.     The  repair  of  wounds  is  considered  upon  page  75. 

Contusions. — A  contusion  is  a  subcutaneous  bruising  or  laceration  of 
the  tissues  involving  the  connective  tissue,  the  muscles,  veins,  arteries,  lym- 
phatics, and  nerves,  and  in  extreme  cases  the  periosteum  and  bone  may  also 
suffer.  When  it  involves  only  the  superficial  tissues  it  is  known  as  a  bruise. 
Contusions  result  from  blows  with  blunt  objects,  and  from  violent  compres- 
sion of  the  parts,  and  the  amount  of  injury  inflicted  depends  upon  the 
extent  of  the  application  of  the  force,  and  may  vary  from  a  mere  bruise  to  a 
comi)lete  disorganization  of  the  subcutaneous  tissues.  In  slight  contusions 
a  few  vessels  are  ruptured  in  the  cellular  tissue,  giving  rise  to  the  discolora- 
tion or  ecchymosis  seen  in  ordinary  bruises,  which  later  develops  the  hlack 
and  blue  appearance.  If  the  contusion  of  the  parts  is  severe,  a  large  quan- 
tity of  blood  may  escape  from  the  vessels,  and  if  it  becomes  clotted  it  forms 
a  clot  or  coagulum  in  the  tissues.  If,  however,  the  blood  remains  fluid  and 
is  circumscribed  by  the  condensation  of  the  surrounding  tissues,  it  is  known 
as  a  hcematoma.  Subcutaneous  collections  of  effused  blood,  whether  licxuid 
or  clotted,  rarely  suppurate,  and  usually  undergo  absorption.  Accidental 
infection  of  the  effusion  may  occur  by  means  of  the  circulation,  through 
sloughing  of  the  skin  covering  it,  or  through  injudicious'  attempts  to  remove 
the  fluid  by  puncture.  The  effusion  is  sometimes  surrounded  by  a  layer  of 
granulation-tissue,  which  is  in  time  converted  into  fibrous  tissue  ;  the  cen- 
tral portions  of  the  effusion  become  decolorized,  and,  being  surrounded  by 
fibrous  tissue,  a  serous  cyst  may  be  formed  ;  in  time  the  liquid  portions  may 
be  absorbed,  and  a  firm  fibrous  mass  is  left  in  the  tissues. 

Symptoms. — Pain  of  a  dull  character  is  usually  present  in  contusions, 

and  depends  largely  upon  direct  injury  to  the  nerves  or  upon  the  amount  of 

tension  in  the  parts  ;  swelling  is  always  present  to  a  greater  or  less  extent, 

and  depends  upon  the  amount  of  blood  effused  and  the  looseness  of  the  tissues. 

170 


CONTUSIONS.  171 

Discoloration  is  another  symj)tom  which  appears  soon  after  the  accident  if 
the  contusion  is  superficial,  but  may  not  appear  for  some  clays  if  the  deep 
tissues  are  involved.  In  severe  contusions  shock  is  often  a  prominent  symp- 
tom. If  important  vessels  have  been  ruptured,  the  blood  may  escape  in  such 
quantities  that  the  vitality  of  the  tissues  is  imi^aired  by  tension,  and  gan- 
grene may  result,  or  the  same  result  may  follow  from  contusion  and  second- 
ary occlusion  of  the  blood-vessels.  We  have  seen  a  severe  contusion  of  the 
elbow  involving  the  brachial  vessels  followed  in  a  few  days  by  gangrene, 
necessitating  amputation  of  the  arm.  In  severe  contusions  fever  is  usually 
present,  its  degree  depending  upon  the  amount  of  the  extravasation  and 
laceration  of  the  tissues. 

Treatment. — The  skin  covering  a  contused  surface  should  be  carefully 
examined,  to  see  if  any  small  wound  or  fissure  exists  through  which  the 
subjacent  tissues  may  become  infected.  If  such  is  found,  it,  as  well  as  the 
skin  should  be  carefully  washed  with  soap  and  water  and  irrigated  with  a 
1  to  2000  bichloride  solution,  and  the  small  wounds  should  be  covered  with 
strips  of  gauze  and  iodoform  collodion.  The  apj)lication  which  we  have 
found  to  give  the  most  comfort  to  the  patient  and  to  hasten  tlie  absorption 
of  the  effused  blood  is  the  following:  Ammonii  chloridi,  oil;  tr.  opii,  foSs; 
alcoholis,  f.^ss;  aqute,  fsvi.  Lint  is  saturated  with  this  lotion  and  laid  on 
the  contused  part,  which  is  covered  with  waxed  paiier  or  oiled  silk ;  a  layer 
of  cotton  and  a  bandage  being  next  applied  over  the  dressing  with  moderate 
firmness.  Best  is  an  important  part  of  the  treatment  not  only  of  contused 
wounds  but  of  all  varieties  of  wounds.  It  may  be  secured  by  putting  the 
patient  to  bed,  by  the  use  of  splints  and  bandages,  or  of  fixed  dressings, 
such  as  the  plaster- of- Paris  or  silicate  of  sodium  dressing,  or  by  the  use  of 
straj)j)ing.  In  the  later  stages  of  contusions  with  effusion  of  blood  the 
absorption  of  the  latter  may  be  hastened  by  massage. 

Strangulation  of  Parts. — When  a  part  has  its  circulation  interfered 
with  bj'  the  application  of  a  constricting  band,  it  raj)idly  becomes  swollen 
and  discolored,  and  soon  passes  into  a  condition  of  gangrene.  Strangulation 
of  parts  often  occurs  from  the  application  of  a  too  tight  bandage,  or  from  the 
presence  of  a  tight  ring  upon  a  part  which  has  been  injured  and  becomes 
swollen,  and  unless  the  constriction  be  promptly  relieved  the  parts  soon 
become  gangrenous. 

Treatment. — In  the  treatment  of  a  part  which  has  been  strangulated 
by  a  tight  band  the  first  indication  is  to  remove  the  constricting  band ;  this 
can  usually  be  done  without  difficulty,  but  in  the  case  of  metal  rings  their 
removal  is  often  more  troublesome.  In  removing  rings  from  the  fingers  the 
part  in  advance  of  the  ring  should  be  firmly  wrapped  with  a  piece  of  tape, 
the  end  of  which  is  carried  under  the  ring,  and  as  it  is  unwound  the  ring- 
may  be  slipped  off ;  if,  however,  the  ring  cannot  be  removed  in  this  way, 
it  may  be  necessary  to  divide  it  with  a  file  or  forceps.  The  swollen  and 
cedematous  condition  of  the  parts  caused  by  strangulation  may  be  in  a 
measure  relieved  by  free  incisions,  which  permit  of  the  escape  of  the 
effused  fluids  and  diminish  the  risk  of  gangrene.  After  the  incisions  have 
been  made  the  parts  should  be  irrigated  with  bichloride  solution,  and  a 
gauze  dressing  applied. 


172  INCISED  WOUNDS. 

Incised  Wounds. — An  incised  wound  is  one  which  is  produced  by 
a  sharp-edged  instrument,  such  as  a  knife,  an  axe,  or  a  piece  of  glass, 
china,  or  metal,  which  divides  the  tissues  cleanly,  producing  no  bruising  or 
tearing.  In  incised  wounds  there  is  usually  some  retraction  of  the  edges  of 
the  wound  and  subjacent  tissues,  the  amount  of  retraction  depending  largely 
upon  the  extent  and  direction  of  the  division  of  the  subjacent  fascia  and 
muscular  tissue  and  the  natural  elasticity  of  the  structures.  •  The  surgeon  in 
making  incised  wounds  in  operations  bears  this  fact  in  mind  and  avoids 
the  transverse  division  of  the  muscles,  recognizing  the  greater  difficulty 
which  will  be  experienced  in  bringing  about  coaptation  of  the  edges  of 
such  a  wound  and  the  strain  which  will  naturally  follow  upon  the  cica- 
trix. The  j;aift  in  incised  wounds  is  usually  of  a  sharp,  burning  character, 
and  varies  with  the  nature  of  the  instrument  by  which  they  are  x^roduced; 
a  sharp  instrument  produces  less  pain  than  a  dull  one,  and  the  pain  varies 
also  with  the  part  upon  which  the  wound  is  inflicted,  wounds  of  parts 
freely  supplied  with  nerve-filaments  being  more  painful  than  those  of 
parts  in  which  they  are  less  abundant.  Hemorrliage  is  usually  free  in  in- 
cised wounds,  but  varies  with  the  number  and  size  of  the  vessels  divided. 
In  incised  wounds  of  the  scalp  free  hemorrhage  occurs  even  if  no  large 
vessels  are  divided,  for  the  reason  that  the  density  of  the  structure  of 
the  scalp  prevents  retraction  and  contraction  of  the  vessels.  In  incised 
wounds  of  the  hands  and  face  the  bleeding  is  also  very  profuse,  even 
when  no  large  vessels  are  injured,  because  of  the  great  vascularity  of  the 
parts. 

Treatment. — Incised  wounds,  for  convenience  of  treatment,  should  be 
divided  into  two  classes :  those  which  are  inflicted  by  the  surgeon,  which 
should  be  aseptic  wounds,  and  those  which  result  from  accident  and  may  or 
may  not  be  infected  before  they  come  under  the  surgeon's  care. 

Incised  Wounds  produced  by  the  Surgeon.— In  these  wounds,  if 
rigid  aseptic  precautions  have  been  observed,  we  have  all  the  conditions 
favorable  for  rapid  repair,  as  the  division  of  important  nerves,  tendons, 
arteries,  and  veins  has  been  as  far  as  possible  avoided,  and  the  incisions 
have  been  so  planned  as  to  avoid  transverse  section  of  the  muscles,  thus 
preventing  gaping  of  the  wound. 

Treatment. — In  the  treatment  of  such  wounds,  after  controlling  the 
bleeding  by  pressure,  or  bj^  ligature  if  necessary,  and  providing  for  drainage 
by  the  introduction  of  a  drainage-tube,  if  the  wound  is  an  extensive  or  a 
deep  one,  the  deep  parts  of  the  wound  may  be  brought  together,  if  it  be 
thought  advisable,  by  the  use  of  buried  sutures  of  catgut  or  silk  ;  the  edges 
of  the  superficial  wound  are  next  approximated  by  continuous  or  interrupted 
sutures  of  silk,  catgut,  or  silkworm-gut,  and  a  di-essing  of  sterilized  or  anti- 
septic gauze  and  cotton  is  then  applied. 

Accidental  Incised  Wounds. — In  the  treatment  of  these  wounds  a 
careful  exploration  of  the  wound  is  necessary  to  ascertaia  its  extent  and 
whether  any  important  structures  have  been  divided.  Too  much  attention 
cannot  be  paid  to  the  examination  of  this  variety  of  incised  wounds,  for 
we  have  seen  patients  in  whom  such  wounds  of  the  hands  and  of  the  fore- 
arm had  been  closed  without  such  examination,  and  after  healing  it  was 


INCISED   AVOrNDS.  173 

found  that  the  hands  were  useless  by  reason  of  the  fact  that  divided  nerves 
or  tendons  had  not  been  approximated  by  sutures  before  tlie  wounds  were 
closed.  The  fact  that  the  wound  may  have  been  infected  should  be  consid- 
ered by  the  surgeon,  and  should  lead  him  to  use  some  form  of  antiseptic 
irrigation  or  other  method  of  sterilization  before  closing  the  wound. 

Treatment. — The  surgeon  should  first  separate  the  edges  of  the  wound 
and  irrigate  it  with  a  1  to  2000  bicliloride  solution  or  sterilized  water,  and 
if  there  is  any  bleeding  the  vessels  should  be  found  and  tied.  If  the  wound 
is  so  deep  that  its  lowest  portion  cannot  be  well  explored,  it  may  be  neces- 
sary to  enlarge  it  by  increasing  the  length  of  the  original  wound  super- 
ficially, or  by  a  transverse  incision.  When  the  surgeon  has  satisfied  himself 
that  no  important  structures  have  been  divided,  the  wound  may  be  closed, 
as  will  be  described  later.  If  upon  exploration  of  the  wound  he  finds  that 
an  important  nerve  or  tendon  has  been  divided,  that  muscles  have  been 
divided  transversely,  or  that  an  important  fascia  has  been  severed,  these 
structiu-es  should  be  brought  together  by  sutures  before  the  wound  is  closed. 
Suturing  of  the  deep  foscia  will  often  prevent  hernia  of  the  muscles  after  the 
wound  has  healed. 

When  the  surgeon  has  satisfied  himself  that  the  wound  is  in  condition  to 
close,  if  the  wound  be  a  deep  one,  he  should  introduce  a  rubber  drainage- 
tube  or  a  few  strands  of  catgut,  to  secure  free  drainage.  Sutures  should  be 
introduced  to  approximate  the  edges  of  the  wound,  and  it  should  next  be 
covered  with  a  number  of  layers  of  sterilized  or  bichloride  gauze  and  a  few 
layers  of  sterilized  or  bichloride  cotton,  and  the  dressings  held  in  position 
by  a  gauze  bandage. 

If  a  drainage-tube  has  been  employed,  the  dressing  should  be  changed 
in  three  or  four  days,  the  drainage-tube  removed,  and  the  wound  should  be 
dressed  as  i^reviously  described.  If  the  wound  runs  an  aseptic  course  it 
usually  requires  no  dressing  for  another  week,  at  which  time  the  dressings 
should  be  taken  off  and  the  sutures  should  be  removed,  the  wound  usually 
being  found  perfectly  healed.  It  is  well,  however,  to  keep  the  cicatrix  cov- 
ered for  a  little  longer  time  with  a  pad  of  gauze  or  cotton  to  protect  it. 

In  approximating  deep  wounds  involving  the  muscles,  the  surgeon  should 
be  careful  to  put  the  parts  in  such  a  position  as  to  take  advantage  of  mus- 
cular relaxation. 

Superficial  incised  wounds  involving  only  the  skin  or  the  skin  and  cel- 
lular tissue,  if  of  limited  extent,  may  be  irrigated,  the  edges  being  brought 
together  by  a  few  sutures,  no  drainage  being  required ;  the  wound  may  then 
be  covered  by  a  few  strips  of  gauze,  which  are  next  painted  over  with  iodo- 
form collodion,  or  tr.  benzoin,  3i,  collodion,  ovii,  several  layers  of  strij)S  and 
collodion  being  applied  so  that  the  whole  wound  is  covered  by  an  antiseptic 
scab. 

Foreign  Bodies  in  Wounds.— The  majority  of  wounds  resulting 
from  accident  contain  foreign  bodies,  such  as  earth,  sand,  pieces  of  wood, 
stone,  glass,  or  iron,  portions  of  the  clothing,  buttons,  and  fragments  of 
bone.  These  bodies  may  produce  infection  of  the  wound  and  also  seriously 
interfere  with  its  repair,  although  in  some  cases  if  the  foreign  bodies  are  not 
infected  they  may  become  encysted  and  cause  little  trouble.     A  foreign  body 


174  LACERATED  WOUNDS. 

remaining  in  a  wound  producing  no  symptoms  may  change  its  position  after 
the  wound  has  healed  and  cause  serious  symptoms  from  coming  in  contact 
with  nerves  or  blood-vessels. 

Treatment. — It  is  therefore  a  safe  rule  to  remove  all  foreign  bodies  from 
a  wound  at  the  first  dressing  ;  this  may  be  accomplished  by  irrigation  with 
saline  or  bichloride  solution,  the  use  of  gauze  sponges  and  forceps,  and  some- 
times by  the  use  of  a  curette. 

Lacerated  Wounds. — Lacerated  wounds  are  such  as  have  resulted 
from  blunt  instruments  ^hich  have  torn  thei  skin  and  subcutaneous  tissues. 
These  wounds  result  from  machinery  accidents  or  from  heavy  bodies  passing 
over  the  parts,  as  the  wheels  of  wagons  or  cars,  and  present  irregular  and 
jagged  edges  with  extensive  laceration  of  the  subcutaneous  tissues,  and  are 
also  apt  to  contain  a  considerable  quantity  of  foreign  matter  which  has  been 
ground  into  the  tissues.  The  most  serious  lacerated  wounds  occur  as  the 
result  of  machinery  accidents,  the  extremities  or  other  portions  of  the  body 
being  caught  by  belting  or  drawn  between  cog-wheels  or  rollers,  or  the  hands 
being  caught  in  the  picking  machines  employed  in  cotton  or  woollen  mills. 
As  the  result  of  such  injuries  the  parts  may  be  completely  disorganized, 
or  avulsion  of  a  greater  or  lesser  portion  of  the  limb  may  occur.  In  such 
wounds  extensive  removal  of  the  skin  may  occur  without  serious  injury 
to  the  deeper  parts.  Extensive  lacerations  of  the  body  are  also  seen  as  the 
results  of  railway  accidents  and  from  the  body  being  caught  in  the  fall  of  tim- 
bers, stones,  or  earth,  or  in  blasting  accidents.  The  pain  in  lacerated  wounds 
is  usually  of  a  dull  character,  and  hemorrhage  is  not  apt  to  be  profuse  unless 
large  vessels  have  been  torn,  it  being,  as  a  rule,  controlled  by  the  twisting 
and  bruising  of  the  vessels.  Secondary  hemorrhage  is,  however,  likely  to 
occur  in  this  variety  of  wounds,  if  infection  and  sloughing  take  place.  We 
have  seen  the  femoral  artery  exposed  in  a  case  of  avulsion  of  the  thigh  from 
railroad  injury,  and  although  it  pulsated  to  within  an  inch  or  two  of  its 
divided  extremity  not  a  drop  of  blood  escaped  from  it.  In  this  variety  of 
wounds  the  vitality  of  the  tissues  is  much  impaired,  so  that  sloughing  to  a 
greater  or  less  extent  is  ajit  to  occur.  Shock  is  often  well  developed  in 
severe  lacerated  wounds.  Lacerated  wounds  usually  heal  by  granulation, 
except  when  they  occur  in  a  very  vascular  part,  such  as  the  face,  in  which 
case  union  by  adhesion  may  result. 

Treatment. — In  the  treatment  of  lacerated  wounds  the  first  indication 
is  to  arrest  hemorrhage,  if  it  is  present  to  any  considerable  extent ;  the 
wounds  should  next  be  irrigated  with  a  1  to  2000  bichloride  solution  or  nor- 
mal salt  solution,  to  remove  blood-clots  and  any  foreign  bodies  which  may 
be  present,  and  the  skin  surrounding  the  wounds  should  be  scrubbed  with 
soap  and  water,  and  finally  irrigated  with  bichloride  solution.  Many  lacer- 
ated wounds,  especially  those  which  result  from  machinery  and  railroad 
accidents,  have  grease,  dirt,  and  cinders  ground  into  the  tissues,  and  it  is 
often  a  difficult  matter  to  remove  these  entirely.  Turpentine  may  be  em- 
ployed to  dissolve  the  grease,  and  soap  and  water  should  be  freely  used,  fol- 
lowed by  a  1  to  2000  bichloride  solution.  Much  of  the  foreign  matter  may 
be  removed  by  forceps  and  a  curette,  and  it  is  sometimes  necessary  to  trim 
away  ^\Tith  scissors  tissue  which  has  dirt  so  thoroughly  incorporated  with  it 


CONTUSED  AVOUNDS.  175 

tliat  it  cannot  be  cleansed.  Divided  tendons,  nerves,  or  muscles  should  be 
brought  tog>ether  by  sutures.  When  the  wound  has  been  cleansed  as  thor- 
oughly as  possible,  the  question  of  approximating  the  edges  has  to  be  con- 
sidered. As  a  I'ule,  the  introduction  of  sutures  in  lacerated  wounds  is  to  be 
avoided,  unless  a  few  be  used  to  hold  the  edges  of  flaps  loosely  in  contact. 
If  attempts  be  made  to  approximate  closely  the  edges  of  lacerated  wounds 
by  sutures,  great  tension  is  apt  to  result  from  swelling  of  the  tissues,  which 
may  cause  gangrene  of  the  parts,  which  are  often  partially  devitalized  by 
the  traumatism.  Partially  detached  portions  of  the  tissue  or  skin  may  be 
placed  in  their  normal  positions  and  secured  by  a  few  loosely  applied  sutures, 
and  if  deep  cavities  exist,  drainage-tubes  should  be  introduced.  The  wound 
should  then  be  covered  with  a  niimber  of  layers  of  sterilized  or  bichloride 
■  gauze  and  a  few  layers  of  sterilized  or  bichloride  cotton,  the  dressings  being 
held  in  position  by  a  gauze  bandage.  Even  if  the  wound  has  been  rendered 
aseptic  and  remains  so,  there  is  usually  free  oozing  of  serum,  which  soaks 
the  dressings  and  necessitates  theu-  removal  in  a  few  days,  at  which  time 
the  wound  should  be  redressed  in  the  same  manner. 

Avulsion  of  a  limb,  or  extensive  lacerations  of  the  extremities  when  the 
vitality  of  the  parts  is  destroyed,  demand  primary  amputation.  Where  the 
part  has  been  completely  stripped  of  skin,  or  a  limb  has  been  completely 
girdled,  immediate  skin-grafting  may  occasionally  be  employed  with  suc- 
cess, but  in  the  latter  case  amputation  as  a  j)rimary  procedure  is  generally 
indicated.  In  the  case  of  avulsion  of  the  soalii,  if  the  detached  scalp  is  not 
extensively  lacerated,  the  wound  should  be  sterilized,  and  the  scalp  should 
be  replaced  and  held  in  place  by  a  few  sutures  and  a  gauze  compress  and 
bandage,  and  in  some  cases  adhesion  may  occur.  If  the  scaljj  does  not  retain 
its  vitality,  skin-grafting  may  subsequently  be  employed. 

Another  method  of  treatment  of  severe  lacerated  wounds  is  by  continuous 
antiseptic  irrigation,  which  is  esj)ecially  applicable  to  lacerated  wounds  of 
the  extremities.     (See  p.  153.) 

In  lacerated  wounds  where  a  large  granulating  surface  exists,  much  time 
in  healing  may  be  saved  and  often  excessive  contraction  of  neighboring  parts 
avoided  by  making  use  of  some  of  the  various  methods  of  skin-grafting. 

Contused  Wounds. — A  contused  wound  is  one  in  which  the  edges  of 
the  wound  and  the  surrounding  tissues  have  been  bruised  or  crushed,  the 
subcutaneous  tissues  often  being  severely  damaged  far  beyond  the  area  of 
the  skin  wound.  Contused  and  lacerated  wounds  have  many  features  in 
common  and  often  result  from  the  same  causes.  The  best  examples  of  con- 
tused wounds  are  those  resulting  from  heavy  bodies  passing  over  parts, 
where  the  skin  wound  is  insignificant,  but  the  subcutaneous  tissues  are 
often  completely  pulpified  and  the  bones  comminuted.  Contused  wounds 
if  extensive  and  severe  are  usually  accomisanied  by  marked  shock.  Exter- 
nal bleeding,  as  a  rule,  is  not  excessive,  although  there  may  be  extensive 
subcutaneous  hemorrhage.     Sloughing  and  gangrene  may  also  occur. 

Treatment. — In  a  contused  wound  where  there  is  great  distention  of 
the  parts  from  effused  blood  and  serum,  and  the  wound  is  small,  it  is  often 
advisable  to  enlarge  it,  and  if  the  collection  is  below  the  deep  fascia,  to 
divide  this  also  to  the  full  extent  of  the  external  wound,  to  give  exit  to  the 


176  PUNCTUEED   AVOUKDS. 

effused  fluids.  Incisions  may  also  be  made  at  other  points  to  accomplisli  the 
same  object.  This  may  so  diminish  the  tension  of  the  parts  that  gangrene 
will  be  averted. 

Before  making  such  incisions  the  j)arts  should  be  thoroughly  sterilized. 
After  the  incision  has  been  made,  copious  moist  antiseptic  dressings  should 
be  applied,  either  bichloride  or  acetate  of  aluminum  gauze  being  employed, 
these  dressings  being  removed  as  they  become  soaked  with  discharges  from 
the  wound.  Continuous  antiseptic  irrigation  may  also  be  employed  in  the 
treatment  of  contused  wounds.  The  conditions  presented  by  contused 
wounds  are  so  similar  to  those  in  lacerated  wounds  that  the  same  methods 
of  treatment  may  be  adopted,  and  the  same  caution  should  be  observed  not 
to  attempt  to  apj)roximate  the  edges  of  the  wounds  by  means  of  sutures. 

Brush-Burn. — This  is  a  form  of  suijerficial  contused  wound  which  is 
produced  by  friction  api^lied  to  the  surface  of  the  body.  The  appearance  of 
a  well-marked  brush-burn  is  very  similar  to  that  of  a  burn  or  scald  after 
the  cuticle  has  separated.  This  form  of  injury  often  occurs  from  a  roj)e 
being  rapidly  drawn  through  the  closed  hands,  or  from  parts  of  the  body 
coming  in  contact  with  rapidly  moving  belting  or  machinery,  or  from  the 
body  being  dragged  violently  over  a  rough  surface.  This  injury  may  be 
suiDcrficial  and  involve  only  the  external  layer  of  the  skin,  or  may  involve 
the  whole  thickness  of  the  skin.  Treatment. — If  the  brush-burn  is  super- 
ficial, the  surface  should  be  irrigated  with  a  1  to  2000  bichloride  solution 
and  dusted  with  jjowdered  boric  acid,  and  a  sterilized  gauze  dressing  should 
be  applied.  If,  however,  the  injury  involves  the  true  skin,  sloughs  are 
apt  to  form,  and  here  the  dressings  should  consist  of  gauze  which  has 
been  moistened  in  acetate  of  aluminum  solution,  which  should  be  applied 
until  the  sloughs  have  separated,  when  an  ointment  of  boric  acid  may  be 
substituted. 

Punctured  Wounds. — These  wounds  are  produced  by  thrusts  from 
pointed  instruments,  such  as  knives,  swords,  bayonets,  nails,  siilinters  of 
wood  or  metal,  wire,  sticks,  or  needles,  and  their  depth  is  much  greater 
than  their  superficial  area.  The  character  of  a  punctured  wound  depends 
upon  the  object  by  which  it  is  j)roduced.  The  wound  resulting  from  the 
puncture  of  a  knife  or  of  a  narrow  strip  of  jnetal  or  glass  will  resemble  an 
incised  wound,  while  that  resulting  from  a  rough  stick  or  splinter  or  from 
the  ferrule  of  a  cane  will  be  a  contused  or  a  lacerated  wound.  Punctured 
wouuds  produced  by  clean  and  smooth  instruments,  unless  important 
vessels  or  nerves  have  been  injured  or  imi^ortaut  cavities  penetrated,  ai-e 
accompanied  by  no  more  risk  than  incised  wounds,  and  heal  as  promptly. 
If,  however,  the  wound  is  produced  by  a  rough  or  an  infected  instrument, 
or  if  vessels  have  been  punctured  or  divided,  suppuration  is  more  likely  to 
occur  than  in  open  wounds,  and  is  liable  to  spread  widely  through  the  tissues. 
If  important  vessels  are  punctured  or  divided,  hemorrhage  occurs,  and  the 
punctured  wound  of  an  artery  may  give  rise  to  a  traumatic  aneurism,  or  the 
simultaneous  puncture  of  a  vein  and  an  artery  in  close  proximity  may  cause 
an  arteriovenous  aneurism  or  an  aneurismal  varix.  The  instrument  inflicting 
the  punctured  wound  may  break,  and  a  portion  of  it  remain  in  the  wound 
and  cause  subsequent  irritation.     A  common  form  of  punctured  wound  is 


PUNCTUKED  WOUNDS. 


177 


caused  by  a  needle  penetrating  the  body  and  a  portion  breaking  off  and 
remaining  in  the  tissues.     (Fig.  112.) 

A  very  serious  form  of  punctured  wound  arises  from  the  impaling  of  a 
portion  of  the  body  by  pieces  of  wood  or  metal,  the  part  being  transfixed  or 
simply  penetrated.  The  penetrating  object  may  break  off,  leaving  a  portion 
of  it  in  the  wound,  or  may  retain  its  position  in  the  body,  so  that  it  is  diffi- 
cult to  remove  it.  This  accident  usually  results  from  falling  upon  sharp 
sticks,  wooden  or  iron  palings. 

Fig.  113. 


Skiagraph  of  a  needle  in  tlie  iiand. 


Sliiagrapli  of  a  piece  of  a  needle  in  tlie  foot. 


Treatment. — In  punctured  wounds  produced  by  clean,  smooth  instru- 
ments, the  treatment  consists  in  irrigating  the  wounds  with  bichloride  solu- 
tion and  applying  a  sterilized  gauze  dressing. 

In  a  punctured  wound  in  whi(;h  free  bleeding  occurs,  or  in  which  the 
region  of  the  wound  is  stuffed  with  blood,  it  is  necessary  to  enlarge  the 
wound  and  turn  out  the  clotted  or  fluid  blood  and  find  the  injured  vessel, 
complete  its  division  if  only  j)artly  divided,  and  secure  its  ends  by  means 
of  ligatures.  In  punctured  wounds  made  by  rough  or  infected  instruments, 
the  wounds  should  be  enlarged  by  free  incisions  and  irrigated  with  a  1  to 
2000  bichloride  solution,  a  drainage-tube  being  inserted  if  necessary,  and 
the  wounds  should  be  dressed  with  sterilized  or  bichloride  gauze.  In  cases 
of  impaling,  the  removal  of  the  foreign  body  is  often  difficult,  but  this  should 
be  done  even  if  it  is  found  necessary  to  enlarge  the  wound  or  make  a  counter- 
opening  ;  the  wound  should  then  be  irrigated  and  drained  and  dressed  as 
described  above. 

In  a  punctured  wound  in  which  the  penetrating  body  has  broken  and  a 
portion  of  it  remains  in  the  tissues,  the  wound  should  be  enlarged  and  the 
foreign  body  sought  for  and  removed.  In  searching  for  foreign  bodies  in 
punctured  wounds,  such  as  needles,  or  splinters  of  wood  or  of  metal,  the 
Esmarch  bandage  is  most  useful,  a.s  the  sui'geon  in  enlarging  the  wound  is 

12 


178  PUNCTURED  WOUNDS. 

not  embarrassed  by  hemorrhage,  and  is  able  often  to  see  and  follow  the 
track  of  the  body  and  recognize  the  different  tissues.  The  Eontgeu  or 
X-rays  are  employed  with  success  in  locating  foreign  bodies,  such  as 
pieces  of  metal  or  glass,  in  punctured  wounds.  By  their  use  a  skiagraiih 
may  be  obtained  by  which  the  foreign  bodies  may  be  located.  (Fig.  113. ) 
As  a  matter  of  course,  .rigid  asepsis  should  be  observed  in  enlarging  these 
wounds  and  in  their  subsequent  dressings. 

When  the  vulneratiug  body  is  barbed,  as  in  the  case  of  an  ordinary  fish- 
hook, and  remains  in  the  tissues,  its  withdrawal  is  often  difficult,  and  it  lias 
to  be  cut  down  upon  and  removed,  or,  if  embedded  in  the  fingers,  as  is  often 
the  case,  it  can  be  pressed  through  until  its  barbed  end  projects  upon  the  other 
side,'when,  this  being  cut  off  with  cutting  pliers,  the  shaft  can  be  withdrawn. 

Arrow  Wounds. — This  variety  of  wounds  is  not  seen  in  civil  prac- 
tice, but  is  common  in  conflicts  with  savage  tribes.  They  give  rise  to  serious 
injuries,  and  are  often  fatal  if  they  involve  the  thoracic  or  the  abdominal 
cavity.  The  head  of  the  arrow  attached  to  the  shaft  may  become  fixed  in  a 
bone,  or  it  may  become  detached  and  remain  in  the  tissues.  Treatment. — 
Attemi>ts  should  be  made  to  remove  the  head  of  the  arrow  by  traction,  or  by 
enlarging  the  wound  if  necessary  and  grasping  it  with  force^js,  or,  when  it 
has  penetrated  a  part  and  is  near  the  surface  upon  the  oj)posite  side,  it  may 
be  pressed  through,  when,  the  head  being  removed,  the  shaft  is  withdrawn. 
After  the  removal  of  the  arrow  the  wound  should  be  enlarged  and  irrigated, 
and  a  bichloride  or  sterilized  gauze  dressing  applied. 

Sword  Wounds. — Sword  woiiuds  may  be  of  the  nature  of  incised 
wounds,  punctured  wounds,  or  contused  and  lacerated  wounds.  They 
should  be  irrigated  with  an  antiseptic  solution,  and  if  external  and  clean-cut 
they  should  be  closed  with  sutures.  If  they  penetrate  imijortant  cavities 
they  should  be  treated  as  other  xiunctured  wounds  of  cavities. 

Bayonet  Wounds. — These  wounds  vary  with  the  shape  of  the  bayonet 
with  which  they  are  inflicted, — either  the  triangular-shaped  or  the  sword- 
shaped  bayonet.  Bayonet  wounds  are  said  to  be  especially  liable  to  be 
infected  and  cause  deep-seated  suppuration.  The  wound  produced  by 
the  sword-bayonet  is  of  the  nature  of  an  incised  wound,  and  heals  more 
promptly  than  that  produced  by  the  triangular-shaped  bayonet.  The 
wounds  should  be  irrigated  with  a  1  to  2000  bichloride  solution,  and  a 
bichloride  gauze  dressing  applied. 

Poisoned  Wounds. — Dissection  Wounds. — Wounds  received  in  the 
dissection  of  dead  bodies  or  in  making  post-mortem  examinations  often  pre- 
sent a  special  virulence.  Poisoned  wounds  of  this  variety  are  usually  received 
in  the  post-mortem  examination  of  bodies  recently  dead  from  infectious  dis- 
eases, the  poison  entering  through  a  wound  or  an  abrasion,  but  infection  may 
also  occur  through  the  ducts  of  the  sweat-glands  or  sebaceous  glands.  Bodies 
in  which  death  has  occurred  from  septic  peritonitis,  erysipelas,  pysemia,  and 
septicteniia  are  most  likely  to  give  rise  to  serious  infection  of  post-mortem 
wounds.  The  infective  micro-organisms,  however,  retain  their  virulence 
for  only  a  short  time  after  death,  and  are  replaced  by  the  bacteria  of  putre- 
faction. Persons  who  handle  dead  animals  may  be  infected  through  wounds 
or  abrasions,  and  may  develop  wounds  of  the  same  character.     Infection 


POISONED  WOUNDS.  179 

may  develop  iu  wouuds  received  by  tlie  surgeou  in  operating  upon  infected 
cases,  giving  rise  to  a  similar  specific  infection,  or  a  mixed  infection  may 
result.  Individiials  vary  in  their  susceptibility  to  the  infection  of  wounds 
received  in  jjost-mortem  examinations  and  iu  operating  upon  infected  sub- 
jects. If  the  individual  be  in  ill  health  the  constitutional  resistance  is 
diminished,  and  a  wound  accompanied  by  serious  symxjtoms  is  more  apt  to 
develop. 

Symptoms. — The  symptoms  following  a  dissection  wound  vary  with 
the  character  and  the  amount  of  the  poison  introduced.  Occasionally  the 
symx)toms  following  such  a  wound  are  those  of  acute  septic  intoxication ;  the 
wound  becomes  painful,  red,  and  swollen,  and  sloughing  of  the  tissues  in 
the  neighborhood  of  the  wound  may  occur  ;  the  patient  exhibits  the  symp- 
toms of  collapse,  the  pulse  becoming  rapid  and  feeble,  and  he  may  become 
delirious  and  die  in  a  few  days.  A  cellulitis  may  develop  which  rapidly 
extends  up  the  ai'm,  the  temperature  being  103°  or  104°  F.  (38.5°  or 
40°  C),  the  pulse  rapid  and  feeble,  with  profuse  sweating ;  suppuration  or 
gangrene  may  occur,  and  the  patient  may  die  of  septicaemia,  pj'temia,  or 
exhaustion,  or  may  recover  after  a  ijrotracted  illness.  On  the  other  hand, 
the  wound  may  become  red  and  painful,  a  papule  or  jsustule  may  develop, 
and  the  lymphatic  vessels,  becoming  inflamed,  may  be  seen  as  red  lines  run- 
ning up  the  arm.  The  axillary  glands  become  enlarged  and  iiainful,  and  the 
patient  complains  of  a  chilly  feeling,  followed  by  marked  fever ;  an  abscess 
develops,  and  after  this  is  opened  the  local  and  constitutional  symptoms 
rapidly  disappear. 

Owing  to  the  fact  that  infection  may  occur  from  an  unsuspected  abrasion 
of  the  skin,  or  from  absorption  of  the  poison  by  the  sweat-glands  or  seba- 
ceous glands,  it  is  a  wise  precaution  before  making  post-mortem  examina- 
tions to  smear  the  hands  thoroughly  with  cosmoline  or  wear  rubber  gloves. 

Treatment. — The  prompt  treatment  of  a  wound  received  in  dissecting 
or  in  operating  may  prevent  serious  consequences.  If  one  receives  a  wound 
in  making  a  post-mortem  examination  upon  a  subject  who  has  died  of  an 
infectious  disease,  or  in  operating  upon  an  infected  subject,  the  wound 
should  be  shut  off  from  the  general  circulation  bj^  a  ligature,  firmly  tied 
above  the  part,  thoi-oughly  washed,  as  well  as  the  surrounding  skin,  with 
a  1  to  1000  bichloride  solution,  then  squeezed,  and  its  surface  wiped  over 
with  a  thirty-grain  solution  of  chloride  of  zinc.  The  ligature  should  then 
be  removed,  and  the  wound  dressed  with  a  moist  dressing  of  bichloride 
or  acetate  of  aluminum  gauze  and  cotton. 

When  infection  of  the  wound  has  occurred,  as  evidenced  by  severe  pain, 
the  development  of  a  iiustule,  and  inflammation  of  the  lymi^hatic  vessels  and 
glands,  the  treatment  should  consist  in  first  thoroughly  washing  the  parts 
with  soap  and  water  and  bichloride  solution  ;  the  pustule  being  opened,  and 
the  skin  freely  trimmed  away,  so  as  to  obtain  a  full  exposure  of  the  wound, 
this  should  be  washed  with  a  1  to  2000  bichloride  solution,  and  swabbed 
with  a  thirty-grain  solution  of  chloride  of  zinc.  The  wound  should  then 
be  dressed  with  moist  acetate  of  aluminum  or  sublimated  gauze,  and  the 
patient  should  be  given  quinine  in  full  doses,  and  stimulants  if  the  appetite 
fails.     Under  this  treatment,  even  when  the  lymphatic  vessels  and  glands 


180 


ANATOMICAL    TUBERCLE. 


Fig.  114. 


were  involved,  we  have  usually  seen  the  local  trouble  as  well  as  the  con- 
stitutional disturbance  rapidly  disappear.  In  cases  which  exhibit  symptoms 
of  acute  septic  intoxication  from  the  start,  unfortunately,  treatment  seems 
to  have  very  little  effect :  the  wound  and  swollen  tissues  should  be  incised 
to  relieve  tension,  irrigated  with  a  1  to  2000  bichloride  solution,  and  dressed 
with  a  moist  antiseptic  dressing.  The  patient  should  be  given  quinine  and 
tincture  of  chloride  of  iron  in  full  doses,  as  well  as  strychnine  and  stimu- 
lants, and  should  also  be  given  a  concentrated  and  nutritious  diet.  If  imme- 
diate death  is  averted,  sloiighing  and  profuse  suppuration,  with  septicaemia 
or  pyaemia,  may  cause  a  fatal  termination  at  a  later  period  ;  if  the  patient 
does  not  succumb,  it  may  be  a  long  time  before  he  regains  his  health. 
Change  of  air  and  scene  is  very  important  in  establishing  convalescence, 
and  should  be  recommended  as  soon  as  the  j)atient  can  be  moved. 

Anatomical  Tubercle. — This  name  is  applied  to  warty  or  papular 
growths  which  occur  upon  the  thin  skin  of  the  back  of  the  hand,  over  the 
knvickles  and  the  metacarpal  bones,  of  those  who 
constantly  handle  the  dead  bodies  of  human  beings 
or  animals.  (Fig.  114.)  The  growths  consist  of 
enlargements  of  the  cutaneous  papillae,  which  are 
covered  with  a  dense  layer  of  epidermis,  presenting 
somewhat  the  appearance  of  ordinary  warts.  They 
are  tender  upon  pressure,  and,  if  irritated,  serum 
exudes,  which  may  dry  and  form  scabs  upon  their 
surface.  Eecent  investigations  have  shown  that 
many  of  these  growths  are  due  to  the  local  inocula- 
tion of  tubercle  bacilli.  Anatomical  tubercle  is  not 
a  common  affection  in  this  country,  but  is  quite 
common  in  Europe.  Treatment. — If  the  hands  are 
protected  from  the  causes  which  favored  their  devel- 
opment, the  growths  will  often  disappear ;  if,  how- 
ever, the  growths  fail  to  disappear  after  the  cause  of 
irritation  has  been  removed,  nitric  or  acetic  acid 
should  be  aj)i)lied  to  them,  and  will  accomj)lish  their 
removal.  If  the  surface  involved  is  extensive,  they  may  be  removed  by  the 
use  of  a  curette. 

Stings  of  Insects. — These  wounds,  produced  by  bees,  wasps,  spiders, 
or  bugs,  although  often  exceedingly  i^ainful  for  a  short  time,  are  usually  fol- 
lowed by  no  serioiis  consequences.  In  tropical  climates,  however,  it  is  said, 
the  stings  of  spiders,  centipedes,  tarantulas,  and  scori^ions  may  result  in 
death ;  and  death  has  been  i-ecorded  from  the  stings  of  bees  when  a  large 
number  of  stings  were  inflicted  upon  the  face  and  scalp.  The  fatal  cases  of 
insect-stings  have  generally  been  preceded  by  inflammation  and  gangrene  of 
the  parts  injured,  and  it  is  possible  in  these  cases  that  the  stings  were  simply 
the  wounds  of  entrance  for  microbic  infection.  "We  have  seen  a  few  cases  of 
serious  phlegmonous  cellulitis,  especially  upon  the  face  and  hands,  following 
the  bites  or  stings  of  insects,  and  have  also  seen  very  serious  oedema  of  the 
tongue  resulting  from  the  sting  l>f  a  bee.  Treatment. — As  the  poison  in 
insect  stings  or  bites  is  principally  an  acid,  it  is  often  found  that  the  pain 


rr 


Anatomiciil  tubercle. 
(After  Bryant.) 


SNAKE-BITES.  181 

is  relieved  by  the  application  of  an  alkali,  such  as  dilute  aqua  ammonise  or 
solution  of  carbonate  of  sodium.  A  preparation  made  from  carbolic  acid  and 
camphor,  known  as  campho-jihmique,  is  a  very  satisfactory  application  to  the 
stings  or  bites  of  insects. 

Snake-Bites. — The  venomous  serpents  in  the  United  States  are  the  rat- 
tlesnake, moccasin,  and  copperhead.  The  poisonous  fluid  in  these  serpents 
is  secreted  by  a  pair  of  glands  situated  on  each  side  of  the  upper  jaw,  and 
is  conducted  by  ducts  to  the  grooved  or  hollow  fangs  in  the  upper  jaw. 
According  to  "VVeir  Mitchell,  the  poison  renders  the  blood  incoagulable,  dis- 
integrates the  red  corpuscles,  causes  wide-spread  blood-extravasation  by 
acting  upon  the  walls  of  the  capillaries,  and  produces  hemorrhage  into  the 
medulla,  profound  depression  of  the  respiratory  nerve-centres,  and  cardiac 
paralysis. 

Symptoms. — The  symptoms  following  the  bite  of  a  poisonous  snake 
depend  uison  the  amount  of  poison  introduced  and  the  rapidity  of  its 
absor^jtion.  There  are  often  pain  and  swelling  in  the  region  of  the  bite, 
ecchymosis  develops  rapidly,  and  cardiac  depression  is  soou  manifested 
by  a  feeble  and  fluttering  f)ulse,  with  marked  respiratory  depression,  pain, 
vomiting,  and  labored  breathing.  Death  usually  occurs  in  from  twenty- 
four  to  forty-eight  hours.  In  some  cases  death  results  rapidly  from  direct 
action  of  the  poison  upon  the  cardiac  centres. 

Treatment. — The  first  indication  in  the  treatment  of  a  bite  from  a 
poisonous  serpent  is  to  prevent,  as  far  as  possible,  the  entrance  of  the 
poison  into  the  circulation.  If  the  bite  be  upon  the  fingers,  hand,  foot,  or 
limbs,  a  tight  band  should  be  twisted  around  the  part  above  the  seat  of 
injury,  and  suction  should  be  made  upon  the  wound  with  the  mouth  to 
encourage  bleeding  and  removal  of  the  poison.  When  it  is  not  possible  to 
shut  off  the  circulation,  the  wound  should  be  promptly  excised.  The  con- 
stricting band  may  be  removed  at  intervals  (the  intermittent  ligature)  if  the 
vitality  of  the  parts  be  threatened,  so  that  only  a  small  amount  of  the  poi- 
son enters  the  system  at  one  time.  The  use  of  permanganate  of  potassium 
injected  into  the  wound  hypodermically  is  highly  recommended,  as  well  as 
the  intravenous  injection  of  ammonia.  The  constitutional  treatment  of 
snake-bites  consists  in  the  use  of  alcohol  or  whiskey  in  full  doses  ;  and  car- 
diac stimulants,  the  best  of  which  is  strychnine,  should  also  be  administered. 

Bites  of  Animals. — Animals  suffering  from  rabies  introduce  a  spe- 
cific poison  into  the  system  (see  page  73).  Bites  of  animals,  unless  they  at 
the  time  are  suffering  from  rabies,  usually  inflict  only  lacerated  wounds. 
These,  however,  may  become  infected  by  micro-organisms  upon  the  teeth 
or  in  the  saliva  and  give  rise  to  serious  symijtoms.  We  have  seen  very 
serious  wounds  inflicted  by  rat-bites,  the  wounds  becoming  inflamed,  oedem- 
atous,  and  gangrenous,^  and  being  accompanied  by  more  or  less  constitu- 
tional disturbance.  Bites  of  horses  may  cause  serious  wounds,  on  account 
of  the  crushing  of  the  tissues,  followed  by  extensive  sloughing  of  the  soft 
parts  and  necrosis  of  the  bones.  Bites  of  human  beings  often  result  in 
wounds  which  run  the  same  course.  We  have  seen  necrosis  of  the  meta- 
carpal bones  result  from  injuries  received  upon  the  knuckles  from  human 
teeth.     Treatment. — As  the  complications  following  bites  of  animals  are 


183  GUNSHOT  WOUNDS. 

probably  due  to  microbic  infection,  it  is  most  important  in  tlie  treatment 
of  the  wounds  that  they  should  be  first  completely  cleansed  by  "washing 
with  an  antiseptic  solution,  and  then  dressed  with  an  antiseptic  dressing. 

GUNSHOT   WOUNDS. 

Gunshot  wounds  may  be  described  as  those  which  result  from  missiles 
whose  force  is  derived  from  the  explosion  of  gunjDowder.  In  military  prac- 
tice such  wounds  are  produced  by  rifle-balls  of  various  kinds,  solid  shot, 
canister,  shot  and  shells,  and  by  splinters  of  wood  or  metal  or  rock  set  in 
motion  by  some  of  these  projectiles.  The  gunshot  wounds  which  the  sur- 
geon meets  with  in  civil  practice  usually  result  from  small  shot  or  pistol- 
balls,  although  he  occasionally  sees  wounds  produced  by  fragments  of  metal 
and  splinters  of  wood  from  the  bursting  of  small-arms,  or  from  fragments  of 
rock  in  blasting  accidents,  which  correspond  very  closely  to  shell  wounds  seen 
in  military  practice.  Very  serious  or  fatal  gunshot  injury  may  be  inflicted 
by  the  discharge  of  powder  or  the  wadding  of  a  gun  fired  at  close  range, 
producing  lacerated  and  contused  wounds  in  conj  unction  with  burns. 

General  Characteristics  of  Gunshot  Wounds. — Gunshot  wounds 
are  contused  and  lacerated  wounds,  and  present  much  variation  in  character, 
according  to  the  nature  of  the  projectile  with  which  they  are  inflicted  and 
its  momentum.  The  injury  of  the  tissues  with  which  the  projectile  comes 
in  contact  often  diminishes  their  vitality  to  such  an  extent  that  more  or  less 
sloughing  occurs  ;  their  repair  is  also  further  interfered  with  in  many  cases 
by  foreign  bodies  which  are  carried  into  the  wound,  such  as  portions  of  the 
clothing,  gun- wadding,  splinters  of  wood,  etc. 

The  majority  of  gunshot  wounds  have  two  apertures, — one  made  by  the 
entrance  of  the  ball,  the  other  by  its  exit ;  the  wound  of  entrance  is,  with 
some  exceptions,  smaller  than  the  wound  of  exit ;  the  size  of  the  latter  is 
increased  by  the  tissues  driven  out  with  the  ball,  by  the  distention  of  the 
tissues,  and  probably  also  by  the  diminished  velocity  of  the  ball.  "When 
one  wound  only  exists  it  may  usually  be  inferred  that  the  ball  remains  in 
the  body.  The  wound  of  exit  does  not  always  occui^y  a  iiosition  in  the 
same  line  as  the  wound  of  entrance,  for  the  ball  may  be  deflected  from 
its  course  by  coming  in  contact  with  strong  fascise,  tendons,  cartilage,  or 
bone  ;  in  a  gunshot  wound  of  the  anterior  portion  of  the  chest,  the  ball  may 
strike  a  rib,  and  following  this  backward  may  have  its  wound  of  exit  near 
the  spine,  or  may  be  found  embedded  in  the  muscle  upon  the  side  of  the 
spine.  One  ball  may  also  produce  several  wounds  of  entrance  and  exit :  a 
ball  striking  the  flexed  leg  may  penetrate  this  as  well  as  the  thigh,  pro- 
ducing four  wounds,  or  may  penetrate  one  of  the  extremities  as  well  as  the 
body.  The  wound  may  be  infected  by  the  ball  or  shot,  or  by  portions  of  the 
clothing  or  skin  carried  into  the  wound  by  the  projectile.  Where  large 
vessels  or  important  organs  are  not  injured,  the  favorable  or  unfavorable 
course  of  the  wound  depends  largely  uj)on  the  absence  or  presence  of  the 
primary  infection  of  the  wound. 

A  gunshot  wound  is  practically  a  subcutaneous  injury,  and  if  the  track 
of  the  wound  is  kept  free  from  infection  from  without,  although  the  tissues 
are  contused  and  lacerated,  healing  often  takes  place  without  the  occurrence 


GUNSHOT  WOUNDS. 


183 


of  suppuration.  Experience  lias  sliowu  that  infection  of  gunshot  wounds 
from  the  projectile  itself  is  not  common,  and  this  has  led  surgeons  to  be 
less  zealous  iu  exploring  and  enlarging  these  wounds  in  attempts  to  remove 
the  missiles.  The  rule,  therefore,  is  not  to  probe  for  the  bullet,  as  the  modern 
small  ball  seldom  gives  rise  to  symptoms  by  its  retention  in  the  tissues. 
There  is  a  jjopular  belief  that  the  dangers  of  a  gunshot  wound  are  much 
diminished  by  the  removal  of  the  ball,  which  will  often  cause  the  i^atient 
and  his  friends  to  insist  upon  the  surgeon's  making  the  attempt  to  do  so  ; 
but  this  should  not  lead  the  surgeon  to  alter  his  judgment  if  he  considers 
the  case  one  in  which  attempts  to  remove  the  ball  should  not  be  made. 
When  a  ball  can  be  located  without  diffi- 
culty it  is  well  to  remove  it,  but  when  the  Fig.  115. 
search  for  and  removal  of  the  ball  neces- 
sitate an  extensive  dissection  of  the  tissues 
it  is  much  better  to  let  it  remain.  The 
position  of  a  ball  may  be  located  by  pal- 
pation of  the  tissues,  by  the  iutroduction 
of  the  finger  into  the  wound,  or  more  fre- 
quently by  the  use  of  a  probe.  The  white 
jjorcelain-tipped  probe  of  K"elaton,  which 
shows  a  lead  mark  if  it  comes  in  contact 
with  the  ball,  will  often  be  found  useful. 
The  Bbntgen  or  X-rays  and  th.Q  fluoroscoxie 
are  usually  employed  to  locate  the  position 
of  bullets  embedded  in  the  tissues.  By 
exposing  the  part  in  which  the  ball  is  \ 
suj^posed  to  be  lodged  to  these  rays  for  a 
few  minutes  a  skiagraph  may  be  obtained  skiagiaph 
by  which  its  position  may  be  located. 
(Pig.  115.)    If  it  is  considered  desirable  to 

use  a  j)robe,  the  patient  should  be  placed  as  nearly  as  possible  in  the  same 
position  as  when  shot,  and  all  probing  should  be  done  with  extreme  gentle- 
ness ;  this  is  especially  the  case  when  the  probe  is  passed  into  soft  tissues, 
"where  the  application  of  force  might  cause  the  probe  to  make  a  track  for 

itself.     Various  forms  of  elec- 
"'^'°-  ^^^-  trical  instruments  have  been 

devised  to  determine  the  pres- 
ence and  locate  the  iDOsition 
of  balls  in  gunshot  wounds, 
and  of  these  the  most  satis- 
factory is  the  telephonic  probe 
of  Girdner.  When  the  bullet 
lias  been  located  it  may  be  removed  through  the  wound  of  entrance,  or  by 
making  a  counter-opening  where  it  occupies  a  position  near  the  skin  and 
can  be  reached  without  much  division  of  the  tissues.  The  form  of  bullet 
forceps  most  convenient  for  use  is  that  shown  in  Fig.  116. 

Symptoms. — The  symptoms  following  a  gunshot  wound  will  vary  with 
the  location  of  the  wound,  the  nature  of  the  missile,  and  the  extent  of  injury 


itjiskl  bUl  in  till 
^^^lll^^d  ) 


184  POWDER  BURNS. 

to  the  various  tissues.  SJioch  is  a  prominent  symptom  in  gunshot  wounds 
involving  the  great  cavities  of  the  body  or  those  accompanied  by  extensive 
laceration  of  the  soft  parts  vrith  comminution  of  the  bones.  Pain  is  not 
usually  a  prominent  symptom  in  gunshot  wounds,  and  may  be  so  slight  that 
the  patient  often  does  not  appreciate  that  he  has  been  injured.  Primary 
hemorrhage  from  gunshot  wounds  is  not  often  excessive  unless  a  large  vessel 
has  been  wounded,  so  that  if  free  bleeding  occixrs  from  such  a  wound  it  is 
well  to  enlarge  the  wound  and  search  for  the  source  of  the  bleeding,  and 
when  found  the  injured  vessel  should  be  secured  by  two  ligatures  applied 
upon  its  distal  and  proximal  ends.  Secondary  hemorrhage  is  apt  to  occur  if 
large  vessels  have  been  contused  and  their  vitality  impaired,  and  infection 
or  sloughing  of  the  tissues  takes  place.  If  the  wound  remains  aseptic  the 
risks  of  secondary  hemorrhage  are  much  diminished. 

Powder  Burns. — These  may  be  received  from  the  explosion  of  gun- 
powder or  fireworks,  from  blasting  accidents,  or  from  the  discharge  of  pow- 
der from  guns  at  close  range.  The  wounds  resulting  from  these  injuries 
usually  present  a  certain  amount  of  laceration  of  the  tissues  in  conjunction 
with  burns.  The  surface  is  blackened,  and  contains  numerous  black  points 
caused  by  particles  of  unburnt  powder  which  have  been  driven  into  the 
skin  and  cellular  tissue.  These  wounds,  as  a  rule,  are  not  serious,  unless 
they  involve  large  surfaces  of  the  body  or  involve  the  eyes  :  in  the  former 
case  the  symptoms  following  extensive  superficial  burns  may  be  presented. 
Treatment. — The  injured  surface  should  be  washed  over  with  soap  and 
water  and  then  with  a  solution  of  bichloride  or  carbolic  acid,  and  the  little 
black  particles  of  powder  should  be  picked  out  of  the  tissues  with  the  point 
of  a  needle  or  a  bistoury  ;  a  gauze  dressing,  with  boric  or  ichthyol  ointment, 
should  then  be  applied  to  the  part.  Powder  grains  may  also  be  removed 
from  scars  by  electrolysis.  In  spite  of  the  greatest  care  in  the  removal  of 
tlie  particles  of  powder,  a  certain  amount  of  tattooing  of  the  tissues  is  apt 
to  remain. 

Wounds  from  Blasting  Accidents. — Serious  injuries  often  result 
from  the  premature  explosion  of  blasts  in  which  gunpowder,  giant  powder, 
or  dynamite  is  used  as  the  exi^losive.  Persons  employed  in  mines  or  quar- 
ries are  aj^t  to  sustain  these  injuries,  which  result  from  masses  or  fragments 
of  rock,  earth,  and  sand  being  thrown  against  the  body  with  great  violence. 
Manj'  of  these  accidents  result  fatally  at  the  time  of  the  explosion  ;  in  other 
cases  the  patients  may  suffer  from  avulsion  of  the  limbs  or  other  portions 
of  the  body,  from  compound  comminuted  fractures,  and  from  extensive 
lacerated  wounds,  the  wounds  being  generally  filled  with  fragments  of  stone, 
sand,  or  earth  ;  at  the  same  time  the  tissues  often  present  extensive  powder- 
burns.  If  death  does  not  result  immediately  from  the  accident,  shock  or 
hemorrhage  may  in  a  few  hours  bring  about  a  fatal  termination. 

Treatment. — The  first  indication  in  the  treatment  of  these  wounds,  if 
severe,  is  to  control  hemorrhage  and  bring  about  reaction  from  the  shock, 
which  is  usually  well  marked.  If  the  extremities  be  so  injured  that  ampu- 
tation is  necessary,  as  soon  as  reaction  has  occurred  this  should  be  j)er formed. 
Extensive  lacerated  and  contused  wounds  in  these  injuries  are  generally 
filled  with  fragments  of  stones,  sand,  and  earth,  so  that  it  is  a  difficult 


WOUNDS  FROM  SMALL  SHOT.      ^  185 

matter  to  cleanse  them :  this  can  best  be  accomplished  by  using  a  stream 
of  water  and  washing  out  the  foreign  matter  as  far  as  possible,  removing  it 
also  by  the  iise  of  forceps  and  curette.  When  satisfactorily  cleansed,  they 
should  be  dressed  as  lacerated  and  contused  wounds,  and  the  same  caution 
observed  as  to  the  non-iutroduction  of  sutures. 

Gunshot  Wounds  from  Small  Shot. — ^These  wounds  vaiy  in  se- 
verity with  the  size  and  number  (if  the  shot  inflicting  the  injury  and  with 
the  distance  at  which  the  charge  is  received.  Small  shot  at  long  range 
produce  slight  injuries,  unless  a  tender  organ,  such  as  the  eye,  be  penetrated, 
which  may  result  in  its  destruction,  or  an  important  vein  or  artery  be  in- 
jured, and  usually  present  a  number  of  distinct  wounds  from  the  scattering 
of  the  charge  ;  the  shot  may  simply  iienetrate  the  skin,  or  may  involve  the 
deeper  tissues,  or  a  few  shot  may  penetrate  the  walls  of  the  chest  or  the 
abdomen.  On  the  other  hand,  if  the  charge  of  sm^U  shot  is  received  at 
close  range,  its  action  upon  the  tissues  resembles  that  of  a  bullet,  and 
extensive  laceration  of  skin,  muscles,  fascite,  vessels,  and  nerves,  as  well  as 
comminution  of  the  bone,  may  result.  We  have  seen  wounds  produced  by 
charges  of  ]^o.  10  shot  at  close  range,  in  which  an  opening  several  inches  in 
diameter  was  made  through  the  tissues,  the  soft  pai-ts  and  the  bones  being 
carried  away  in  the  line  of  the  wound.  Portions  of  the  scalp  and  skull,  or 
of  the  face,  chest,  abdomen,  or  extremities,  maj'  also  be  torn  away.  A  num- 
ber of  such  cases  of  wounds  of  the  extremities  have  come  under  our  obser- 
vation in  which  primary  amputation  was  required.  Wounds  produced  by 
larger-sized  shot,  such  as  No.  1,  BB,  or  buckshot,  are  often  very  serious 
injuries,  even  if  received  at  a  much  longer  range  :  here  the  bones  may  be 
fractured  or  contused,  important  vessels  may  be  injured,  or  the  cavities  of 
the  body  may  be  penetrated  and  their  contained  viscera  injured. 

Treatment. — If  the  skin  has  been  penetrated  by  small  shot,  the  surface 
of  the  skin  should  be  sterilized,  and  if  any  of  the  shot  can  be  felt  they 
should  be  picked  out  with  the  point  of  a  bistoury  and  the  wou^nds  covered 
with  a  gauze  dressing.  If  the  shot  wounds  be  upon  the  face,  where  a  gauze 
dressing  cannot  well  be  applied,  each  little  puncture  may  be  covered  with 
a  scab  of  ganze  and  iodoform  collodion.  Shot  which  have  entered  more 
deeply  into  the  tissues  usually  become  encysted  and  produce  no  subsequent 
trouble.  If  a  few  shot  have  punctured  the  walls  of  the  abdomen  or  the 
chest,  the  external  wounds  should  be  sterilized  and  dressed  with  a  gauze 
dressing,  and  no  attempt  should  be  made  to  remove  them  ;  the  only  indica- 
tion for  enlarging  the  wounds  would  be  the  development  of  symptoms  of 
concealed  hemorrhage  or  inflammation.  The  patient  should  be  put  at  rest 
for  a  few  days  and  watched  for  the  development  of  inflammatory  symptoms. 
We  were  impressed  with  the  fact  that  the  viscera  will  tolerate  the  presence 
of  shot  by  a  post-mortem  examination  of  a  man  whose  body  was  covered 
with  cicatrices  of  small  shot  wounds,  in  whose  liver  were  found  embedded 
many  encysted  bird-shot,  apparently  having  produced  no  trouble. 

Extensive  wounds  from  small  shot  at  close  range,  if  they  involve  the 
extremities  and  have  lacerated  the  soft  parts  extensively  and  comminuted 
the  bones,  usually  require  amputation,  especially  if  the  main  arteries  have 
been  injured,  but  if  the  bones  and  arteries  are  not  injured,  even  though  the 


186  BULLET  WOUNDS. 

skin,  fasciae,  and  muscles  have  been  extensively  lacerated,  it  may  be  possible 
to  save  the  part,  and  the  wound  should  be  sterilized  and  dressed  with  a 
bichloride  gauze  dressing,  or  may  be  treated  by  antiseptic  irrigation  until  a 
healthy  granulating  surface  is  present.  In  extensive  lacerations  following 
gunshot  wounds  of  the  scalp  and  sktdl  or  the  cavity  of  the  chest  or  the  abdo- 
men, or  if  a  solid  viscus,  such  as  the  liver,  be  injured,  the  wound  should  be 
sterilized  and  loosely  packed  with  iodoform  gauze ;  the  same  treatment 
should  be  applied  to  wounds  involving  the  lung.  If  the  stomach  or  intes- 
tines be  exposed  or  lacerated,  attempts  should  be  made  to  bring  the  edges 
of  the  visceral  wound  together  with  sutures,  and  the  external  wound  should 
then  be  loosely  packed  with  iodoform  gauze.  If  the  internal  wound  cannot 
be  treated  in  this  way  it  may  be  allowed  to  remain  oi^en,  in  the  hoj)e  of  a 
fistula  forming  at  this  point,  which  may  later  be  subjected  to  operative  treat- 
ment. Although  these  wounds  are  very  serious  ones  and  usually  terminate 
fatally  in  a  short  time,  yet  occasionally  recovery  follows. 

Wounds  produced  by  buckshot  or  large  shot  are  so  similar  to  those  pro- 
duced by  pistol-balls  that  their  treatment  is  practically  the  same. 

The  treatment  of  joint  wounds  from  small  shot  varies  with  the  extent  of 
damage  to  the  soft  parts  and  the  injury  to  the  joint  itself  When  a  few 
shot  have  simply  entered  the  joint  through  separate  wounds,  these,  with 
the  surrounding  skin,  should  be  sterilized,  the  wound  sealed  with  gauze  and 
iodoform  collodion,  and  the  joint  fixed  upon  a  splint  or  immobilized  in  a 
plaster-of-Paris  dressing,  and  if  no  inflammatory  symj)toms  develop  the 
patient  may  recover  with  a  useful  joint.  If  infection  of  the  joint  occurs,  it 
should  be  opened  and  drained,  and  subsequent  excision  of  the  joint  may  be 
required. 

Wounds  from  small  shot  injuring  important  arteries  or  veins  may  give 
rise  to  hemorrhage,  which  may  require  the  exposure  and  ligation  or  suture 
of  the  injured  vessel,  or  may  subsequently  cause  a  traumatic  aneurism  or 
arteriovenous  aneurism,  necessitating  the  ligation  of  the  artery,  the  open- 
ing of  the  sac,  or  the  amputation  of  the  limb  if  a  vessel  of  the  extremities 
is  involved. 

Bullet  Wounds. — These  wounds  are  inflicted  by  pistol-balls  or  by 
rifle-balls ;  the  former  are  most  commonly  seen  in  civil  practice.  Eifle-ball 
wounds  are  rarely  seen  in  civil  practice,  and  formerly  were  inflicted  by 
round  or  conoidal  balls  varying  from  .50  to  .71  of  an  inch  in  diameter.  The 
modern  rifle  employed  in  warfare  carries  a  slender  cylindro-ogival  bullet 
about  .30  of  an  inch  in  diameter,  made  of  lead  and  antimony,  with  a  cover- 
ing of  steel,  copper,  or  nickel.  The  modern  bullet  has  much  greater  velocity 
than  the  leaden  bullet  formei'ly  used  (often  a  muzzle  velocity  of  two  thou- 
sand feet  per  second),  and  does  not  change  its  shape  so  readily.  It  also  has 
greater  penetrating  power :  the  same  ball  may  penetrate  the  bodies  of  a 
number  of  men,  and  is  apt  to  pass  through  resisting  tissues,  like  bones, 
rather  than  to  comminute  them,  as  was  the  case  with  the  conoidal  leaden 
ball ;  and  it  is  more  likely  to  divide  blood-vessels,  nerves,  and  tendons. 
Primary  hemorrhage  is  therefore  likely  to  be  more  common  and  more  fatal 
in  wounds  produced  by  the  modern  small-arms  ball.  Aneurism  is  not  an 
infi'equeut  sequel  of  injury  of  arteries  by  the  modern  small-arms  baU. 


BULLET  WOUNDS.  187 

The  explosive  effect  of  the  small-caliber  ball  depends  uxjon  its.  velocity, 
striking  energy,  area  of  impact,  and  the  resistance  to  be  overcome,  so  that 
the  damage  to  the  tissues  in  gunshot  injuries  is  always  greater  at  short  range 
and  decreases  gradually  with  the  increase  of  distance.  The  most  marked 
explosive  action  of  the  modern  rifle-ball  is  seen  in  tissues  rich  in  fluid  con- 
tained in  comparatively  unyielding  walls,  where  hydrodynamic  pressure 
may  be  strongly  exerted,  as  seen  in  wounds  of  the  brain,  liver,  and  the 
hollow  viscera  filled  with  fluid  or  semi-fliiid  contents.  Stevenson  holds  that 
to  get  the  explosive  effect  there  must  be  great  velocity  of  the  ball  and  con- 
siderable resistance  of  the  tissues  ;  particles  of  bone  and  other  tissues  receive 
from  the  bullet  so  much  force  that  they  are  put  in  motion  and  act  as  second- 
ary missiles.  The  same  authority  now  holds  that,  "The  conclusions  drawn 
from  experiments  upon  dead  animals  and  men  are  not  borne  out  by  what  is 
observed  when  living  men  are  wounded  by  small-caliber  projectiles.  It 
is  becoming  more  evident  that  the  appalling  destruction  produced  in  dead 
animals  and  cadavers  by  small  projectiles  is  not  exiierienced  when  men  are 
hit  by  them  under  ordinary  conditions."  Woodruff  considers  the  violence 
done  to  the  tissues  due  to  the  vibratory  action  i^roduced,  and  that  the  result 
depends  upon  the  velocity  of  the  ball,  the  character  of  the  tissues,  and  their 
capability  of  taking  up  Aabrations. 

In  wounds  from  rifle-balls,  as  in  those  from  small  shot,  the  range  at  which 
the  injury  is  inflicted  is  an  important  factor  in  determining  the  gravity  of 
the  wound,  as  is  also  the  location  of  the  injury.  A  ball  wound  of  muscles 
of  the  thigh  or  the  arm,  if  no  important  vessels  or  nerves  are  injured  and  the 
wound  is  not  infected,  is  usually  not  a  serious  injury,  while  one  of  the  brain, 
or  of  the  pleural  cavity  or  the  abdomen,  or  of  a  large  joint,  may  be  most  seri- 
ous in  its  conseq'hences.  A  ball  which  enters  the  tissues  may  itself  be  infected, 
or  may  carry  infection  into  the  tissues  from  the  skin  or  clothing.  It  may 
also,  from  its  being  in  close  relation  to  important  structures,  cause  constant 
irritation  until  its  removal  is  accomplished.  On  the  other  hand,  as  is  also 
the  case  with  small  shot,  the  ball  may  become  encysted  and  cause  no  trouble. 

Treatment. — In  a  flesh  wound  produced  by  a  bullet,  where  the  ball 
has  passed  through  the  tissues  and  escaped,  the  skin  surrounding  the 
wound  should  be  sterilized  by  washing  with  soap  and  water  and  with 
bichloride  solution,  and  if  there  is  no  evidence  that  important  vessels 
have  been  injured,  as  shown  by  the  small  amount  of  bleeding,  the  wound 
should  be  dressed  with  a  gauze  dressing.  Probing  to  locate  the  position  of 
the  ball  and  its  removal  should  not  be  undertaken  unless  there  is  distinct 
evidence  that  its  presence  is  a  source  of  danger  (see  page  183).  If,  however, 
t\&  ball  remains  in  the  tissues,  and  can  be  located  without  difficulty  by  pal- 
pation, or  with  the  finger  or  a  probe  introduced  into  the  wound,  or  by  the 
Eontgen  or  X-rays,  it  should  be  removed,  and  the  wound  dressed  as  pre- 
viously described.  If  there  be  free  bleeding  from  the  wound,  it  should  be 
enlarged  and  the  injured  vessel  sought  for  and  ligated.  Gunshot  wounds  of 
the  chest  and  abdomen  are  considered  under  iujiu-ies  of  these  parts  (Chapters 
XXXV.  and  XXXYIII). 

Large  Shot  or  Shell  Wounds.— These  very  serious  injuries  are  met 
with  only  in  military  practice,    and  produce  extensive  lacerated  and  con- 


188  SHELL  AVOUNDS. 

tused  wounds,  and  often  the  destruction  of  considerable  portions  of  the 
body.  The  injuries  resulting  from  blasting  accidents  seen  in  civil  practice 
often  closely  resemble  those  produced  by  the  explosion  of  shells.  Many 
of  these  injuries  are  fatal  at  the  time  of  their  infliction,  particularly  if 
the  trunk  or  head  is  involved.  If  the  extremities,  however,  are  involved, 
the  i^atient  may  survive  the  injury,  although  amjjutation  may  be  required. 
Extensive  laceration  by  large  shot  or  fragments  of  shells  may  be  followed 
by  gangrene  and  secondary  hemorrhage,  and  either  of  these  causes  may 
bring  about  a  fatal  termination.  Treatment. — Shock  is  usualljr  marked, 
and  its  treatment  demands  the  first  attention  ;  the  di-essing  of  the  wound  is 
that  of  a  lacerated  or  contused  wound,  and  if  amj)utation  is  required  it 
should  be  done  as  soon  as  the  reaction  from  shock  has  taken  place.  Foreign 
bodies  present  in  the  wound  should  be  removed,  the  wound  irrigated  with 
a  1  to  2000  bichloride  solution,  a  drainage-tube  introduced,  and  a  gauze 
dressing  applied.  Comjjlications  following  such  wouuds,  as  gangrene  and 
secondary  hemorrhage,  should  be  treated  as  described  under  the  treatment 
of  these  affections  arising  from  other  causes. 

Gunshot  Wounds  of  Special  Tissues.^Skin.— The  skin  in  gun- 
shot injuries  may  be  contused,  lacerated,  or  penetrated,  according  to  the 
velocity  of  the  ball  and  the  angle  at  which  it  strikes.  In  the  case  of  balls 
moving  with  little  velocity  the  elasticity  of  the  skin  may  prevent  its  lacera- 
tion, although  the  subcutaneous  tissues  maj^  be  severely  contused  or  crushed. 
The  wound  in  the  skin  is  apt  to  be  small,  so  that  drainage  from  the  deeper 
parts  of  the  wound  is  not  free,  and  if  suppuration  occurs  it  may  be  neces- 
sary to  enlarge  the  wound  to  provide  free  drainage. 

Fasciae. — Wounds  of  the  fascise  produced  by  modern  balls  of  high 
velocity  result  in  perforation  or  separation  of  the  fibres  of  the  fascia,  the 
wounds  contracting  after  the  passage  of  the  ball  and  leaving  little  opening 
for  drainage. 

Muscles  and  Tendons. — Gunshot  wounds  of  muscles  are  not  usually 
attended  with  extensive  destruction  of  the  tissue,  being  clean  cut  when 
inflicted  by  the  modern  small-arm  bullet.  Gunshot  wounds  of  tendons 
may  cause  their  division  or  j)erf oration.  If  the  ball  is  moving  at  high 
velocity  it  is  not  likely  that  it  will  be  deflected  by  the  tendon. 

Blood-Vessels. — Arteries  and  veins  may  be  divided  or  perforated  in 
gunshot  injuries,  the  wound  being  followed  by  profuse  or  fatal  hemorrhage. 
If,  however,  the  walls  of  the  vessels  are  contused,  repair  may  take  place, 
although  aneurism  may  develop  later,  but  if  the  wound  becomes  infected, 
subsequent  sloughing  of  the  vessel  is  likely  to  occur,  giving  rise  to  sec- 
ondary hemorrhage.  Simultaneous  perforation  of  an  artery  and  a  vein  mq,y 
give  rise  to  an  arteriovenous  aneurism. 

Nerves. — In  gunshot  wounds  nerves  may  be  completely  or  incompletely 
divided  or  contused,  giving  rise  to  pain  or  loss  of  motion  or  sensation  in  the 
parts  supplied  by  the  injured  nerve,  which  may  be  followed  by  trophic 
changes.  Neuralgia  may  also  follow  gunshot  wounds  of  nerves  from  the 
involvement  of  the  nerve-fibres  in  the  cicatrix  at  the  seat  of  injury  or  fi'om 
the  development  of  a  neuroma.  Nerve-trunks  are  more  likely  to  escape 
injury  than  blood-vessels  of  corresponding  size. 


GUNSHOT  FRACTUBES.  189 

GUNSHOT  FRACTUKES. 

These  constitute  a  very  serious  class  of  compound  fractures,  which  may 
be  produced  by  a  small  shot  at  close  range,  pistol-  or  riiie-balls,  round-shot, 
or  fragments  of  shells.      They  are  not  only  ^ 

serious  injuries  as  regards  the  damage  to  the 
bone  itself,  which  may  be  extensively  commi- 
nuted or  fissured  (Fig.  117),  but  they  are  often 
complicated  by  injuries  of  important  blood- 
vessels or  nerves.  The  modern  rifle-ball  at 
certain  ranges  may  produce  marked  explosive 
effects,  and  also  has  great  penetrating  i^ower, 
so  that  both  extensive  comminution  and  pene- 
tration of  bone  may  result.  The  nature  of  the 
injury  to  the  bone  depends  upon  the  density 
of  the  latter,  and  upon  the  size,  shape,  comjio- 
sition,  and  A^elocity  of  the  ball.  In  gunshot 
injury  of  the  spongy  bones,  the  cancellated 
structure  yields  to  pressure  and  the  striking        Gunshot  fracture  of  the  upper  ex- 

.  ,     -,    .      T    .         IT         .-  tremity  of  the  femur.    (Army  Medical 

energy  is  not  transmitted  m  lateral  directions    museum.) 
producing  explosive  effects,  while  in  the  dense 

bones  such  as  the  submaxillary  bone  or  the  shafts  of  the  long  bones,  exten- 
sive comminution  and  Assuring  is  apt  to  result.  In  the  articular  ends  of  the 
long  bones  clean  perforations  are  often  observed,  except  at  close  range,  when 
more  or  less  comminution  of  the  cancellated  structure  may  occur. 

The  tissues  from  the  wound  of  entrance  to  the  bone  are  usually  only 
injured  in  the  line  of  perforation,  but  those  beyond  the  seat  of  injury  are 
often  extensively  lacerated  and  contused  not  only  by  the  ball,  but  also  by  the 
splinters  of  bone  driven  into  the  tissues  and  acting  as  secondary  missiles. 
The  gunshot  fractures  seen  in  civil  practice  usually  result  from  small  shot, 
pistol-balls,  and  rifle-balls,  and,  as  a  rule,  the  damage  to  the  bone  by  these 
missiles  is  not  so  extensive  as  that  produced  by  the  modern  military  ball. 
Gunshot  fractures  produced  by  small  shot  at  short  range,  and  by  fragments 
of  stone  or  wood  in  blasting  accidents,  are  usually  very  serious  injuries,  by 
reason  of  the  extensive  damage  inflicted  upon  the  soft  parts.  It  is  now  pos- 
sible to  save  many  cases  of  gunshot  fractures  which  would  formerly  have 
been  subjected  to  resection  and  amputation. 

Treatment. — The  treatment  of  gunshot  fractures  does  not  differ  mate- 
rially from  that  of  comx)Ound  fractures  received  in  other  ways,  and,  as  in 
the  latter  class  of  injuries,  depends  upon  the  amount  of  injury  done  to  the 
bone  and  surrounding  soft  parts.  It  is  now  recognized  that  the  removal  of 
the  ball  in  cases  of  gunshot  fractures  is  not  the  most  important  part  of  the 
treatment,  and  that  extensive  exploration  of  the  wound  for  this  purpose  is 
unnecessary,  but  that  antiseptic  irrigation  of  the  wound  and  sterilization  of 
the  surrounding  parts  are  much  more  imi>ortant  procedures.  In  a  gunshot 
fracture  in  which  the  bone  has  been  perforated  or  divided  without  com- 
minution, the  wound  or  wounds  should  be  irrigated  with  bichloride  solution 
or  sterilized  water,  the  skin  surrounding  the  wound  sterilized,  a  drainage- 


190  BURNS  AND  SCALDS. 

tube  or  strip  of  gauze  introduced,  and  an  antiseptic  or  sterilized  gauze 
dressing  afterwards  applied.  If  the  ball  can  be  located  and  removed  with- 
out extensive  incisions  or  manipulations,  this  should  be  done.  If  loose 
fragments  of  bone  are  present  in  the  wound  they  should  be  removed,  but 
partially  detached  fragments  should  be  allowed  to  remain.  Primary  fixa- 
tion of  the  fragments  may  be  accomj)lished  by  the  use  of  heavj  wire  sutures 
when  the  bone  is  superficial,  and  their  introduction  does  not  entail  an  exten- 
sive dissection  of  the  soft  parts.  Drainage  should  always  be  emx^loyed  in 
cases  where  there  has  been  much  comminution  of  the  bone  or  laceration  of 
the  soft  xaarts.  Immobilization  of  the  fragments  by  the  use  of  splints  after 
the  wound  has  been  dressed  is  a  very  essential  part  of  the  successful  treat- 
ment of  these  cases,  the  ordinary  splints  and  dressings  emjjloyed  in  similar 
fractures  from  other  causes  being  used. 

Amputation  in  gunshot  fracture  may  be  required  in  the  ijrimary  stage 
when  there  is  great  comminution  of  the  bone  with  laceration  of  important 
vessels,  or  it  may  be  necessary  to  resort  to  this  procedure  later  if  the  wound 
becomes  infected,  and  osteomyelitis,  gangrene,  or  necrosis  occurs.  In  gun- 
shot fractures  of  the  long  bones,  primary  or  secondary  resection  of  the  bones, 
with  wiring  of  the  fragments,  may  sometimes  be  substituted  for  amputation. 

BUENS   AND   SCALDS. 

A  burn  represents  the  destructive  effect  upon  the  tissues  produced  by 
contact  with  a  flame,  radiated  heat,  or  heated  substances.  A  scald  repre- 
sents a  corresponding  effect  produced  by  hot  liquids  or  steam.  In  a  burn 
the  superficial  hairs  are  scorched  or  burned  off,  while  in  a  scald  they  are 
not  changed  in  appearance  but  may  fall  out  later.  Concentrated  acids  and 
alkalies,  either  solid  or  liquid,  apj)lied  to  the  tissues,  produce  a  condition 
very  similar  to  that  resulting  from  burns  and  scalds.  Burns  are  apt  to  be 
more  circumscribed  and  deeper  than  scalds  ;  in  scalds,  from  the  fact  that 
hot  fluids  are  rapidly  diffused  over  the  surface  by  saturation  of  the  clothing, 
the  injury  is  likely  to  be  more  superficial.  Burns  and  scalds  may  involve 
not  only  the  skin  and  subcutaneous  tissues,  but  also  the  mucous  membrane, 
especially  that  of  the  mouth,  j)harynx,  nose,  and  conjunctiva.  Scalds  or 
burns  of  the  mouth  and  epiglottis  may  occur  from  the  inhalation  of  steam 
or  hot  gases. 

The  effects  of  burns  and  scalds  upon  the  tissues  depend  upon  the  actual 
temperature  of  the  heated  body  or  fluid  and  the  duration  of  its  application. 
The  instantaneous  contact  of  a  splash  of  molten  metal  will  i^roduce  a  super- 
ficial burn,  while  a  few  seconds'  contact  with  the  same  substance  will  pro- 
duce deep  destruction  of  the  tissues.  The  conditions  resulting  from  burns 
aud  scalds  are  clinically  so  neai-ly  alike  that  they  may  be  considered  together. 

Classification. — Dui^uytren's  classification  of  burns  in  six  degrees, 
according  to  the  extent  of  injury  inflicted,  is  very  generally  employed  ;  but 
we  are  inclined  to  think  a  more  practical  classification  is  that  of  Morton, 
who  divides  burns  and  scalds  into  three  degrees  or  classes  :  first,  those  which 
present  hyj)er£emia  or  erythematous  inflammation  of  the  skin  without 
vesication ;  second,  those  in  which  there  is  inflammation  of  the  skin  with 
the  formation  of  vesicles  or  bullEe ;  third,  those  in  which  there  is  more  or 


EFFECTS  OF  BURNS  AND  SCALDS.  191 

less  complete  charring  or  destruction  of  the  parts,  skin,  cellular  tissue, 
muscles,  and  bone.  These  injuries  may  involve  a  small  extent  of  tissue,  or 
a  considerable  portion  of  the  body. 

The  Constitutional  Effects  of  Burns  and  Scalds.^Tliese  vary 
with  the  extent  of  surface  in\'t)h-ed  and  the  degree  of  the  burn  or  scald. 

Shock. — This  is  a  marked  symptom  in  all  severe  burns  or  scalds,  and  its 
development  depends  upon  the  position  of  the  burn  or  scald  and  the  extent 
of  surface  implicated.  Superficial  burns  of  great  extent  and  those  involving 
the  trunk  are  accompanied  by  more  marked  shock  than  circumscribed  burns 
with  deep  destruction  of  the  tissues.  Patients  suffering  from  extensive  burns 
have,  as  a  rule,  little  pain,  but  often  complain  of  feeling  cold,  and  may  have 
a  severe  chill.  They  soon  become  comatose,  and  death  results  from  cerebral 
and  visceral  congestion.  If  reaction  occurs,  the  temperature  rises  to  a  high 
point  and  inflammation  of  the  injured  tissue« develops,  which  may  terminate 
in  suppuration  or  gangrene.  Albumin  is  usually  present  in  the  urine  in 
this  stage  of  burns  and  scalds. 

Mortality. — The  mortality  following  extensive  burns  or  scalds  is  very 
high  ;  according  to  Durham,  if  one-half  of  the  surface  of  the  body  is  burned 
or  scalded,  even  superficially,  death  usually  results.  Nussbaum  states  that 
recovery  is  rare  if  a  third  of  the  surface  of  the  body  is  superficially  burned 
or  scalded.  The  majority  of  cases  of  severe  or  extensive  burns  die  of  shock 
within  twenty-four  hours ;  that  is,  before  reaction  is  established.  If  reac- 
tion is  established,  many  cases  die  at  a  later  period,  of  exhaustion  follow- 
ing j)rofuse  suppuration,  septicEemia,  pyaemia,  or  secondary  hemorrhage. 
Gastro-intestinal  inflammation  with  vomiting  and  bloody  stools  may  cause  a 
fatal  termination,  as  well  as  perforating  duodenal  ulcer,  though  the  latter  is 
certainly  a  very  rare  complication  following  burns  or  scalds,  for  in  the  i^ost- 
mortem  examinations  of  one  hundred  and  thirty-eight  patients  dying  of 
burns  and  scalds  in  St.  Bartholomew's  Hospital,  only  three  cases  showed 
intestinal  lesions.  Burns  and  scalds  are  very  fatal  during  the  period  of 
infancy  and  childhood,  and  in  this  class  of  patients  death  usually  results 
from  shook.  CEdema  of  the  glottis  is  a  dangerous  complication  of  burns  or 
scalds  of  the  mouth. 

Treatment. — The  treatment  of  burns  and  scalds  of  the  first  degree  con- 
sists in  the  application  of  bicarbonate  of  sodium  ;  lint  saturated  with  this 
solution  is  wrapped  around  the  part  for  a  few  hours,  and  very  quickly 
relieves  the  pain.  This  dressing  may  be  followed  by  the  application  of 
ungueutum  petrolatum  or  unguentum  zinci  oxidi.  If  the  burn  or  scald  is 
extensive,  shock  may  be  present,  and  should  be  treated  upon  general  prin- 
ciples. This  variety  of  burn  leaves  no  scar.  In  the  treatment  of  exten- 
sive burns  or  scalds  of  the  second  or  third  degree,  pain  and  shock  should 
receive  the  first  attention.  If  pain  is  marked,  it  should  be  relieved  by  the 
administration  of  morphine  hypodermically,  and  the  treatment  of  shock, 
which  is  usually  present,  requires  the  most  careful  attention.  (See  page 
91.)  In  dressing  such  burns,  the  clothing  should  be  carefully  removed  or 
cut  away,  so  as  not  to  tear  or  injure  the  vesicles  or  blebs.  If  a  large  extent 
of  surface  is  injured,  it  should  be  dressed  a  little  at  a  time,  so  as  not  to 
expose  the  whole  of  it  to  the  air  for  any  considerable  time.    Eecent  burns  or 


192  TREATMENT  OF  BURNS   AND   SCALDS. 

scalds  are  aseptic  wounds,  and  if  they  can  be  dressed  so  as  to  preserve  tliis 
condition  healing  should  be  rapid  and  unattended  with  complications. 
Blebs  or  vesicles  should  be  punctured  with  the  point  of  a  knife,  to  allow 
their  contents  to  escape,  and  the  epidermis  should  not  be  removed,  as  it 
serves  to  protect  the  denuded  xDajDillse  until  their  surface  is  again  covered 
with  epithelium.  If,  however,  the  injury  has  been  received  some  time 
before  it  comes  under  the  care  of  the  surgeon,  the  surface  may  be  irrigated 
with  a  1  to  4000  bichloride  solution,  freelj^  dusted  with  powdered  boric  acid, 
and  covered  with  a  few  layers  of  sterilized  gauze  and  cotton.  A  twenty- 
five  per  cent,  ointment  of  ichthyol  with  petrolatum  or  lanolin  may  also  be 
employed.  If  a  moist  dressing  is  preferred,  the  injured  surface  may  be 
covered  with  gauze  moistened  with  boro-salicylic  solution  and  covered  with 
oiled  silk  or  muslin,  or  the  burned  surface  may  be  covered  with  strips  of 
sterilized  rubber  tissue  and  gaiize  moistened  with  salt  solution.  The  fol- 
lowing dressing  for  burns  is  extensively  used :  it  consists  of  white  lead, 
Sviii;  powdered  acacia,  5ii;  bicarbonate  of  sodium,  3i;  and  linseed  oil 
of  sufficient  quantity  to  make  a  mixture  of  the  consistency  of  thick  cream. 
This  is  spread  upon  lint  and  applied  to  the  surfaces. 

When  dry  dressings  are  used  they  should  be  changed  as  infrequently  as 
possible.  The  ajjijlication  of  bichloride  or  of  carbolized  or  iodoform  gauze 
to  the  raw  surface  is  not  to  be  advised,  as  it  may  be  followed  by  toxic  effects. 
If  sloughing  of  the  tissues  occurs,  the  dry  dressings  should  be  replaced  by 
moist  dressings  of  boro-salicylic  or  saline  solution,  and  when  the  sloughs 
have  sei^arated  the  granulating  surface  should  be  dressed  with  boric  oint- 
ment. The  application  of  a  solution  of  nitrate  of  silver,  gr.  v  to  water  f  5  i, 
will  have  a  stimulating  action  upon  the  granulations.  The  constant  warm 
bath  has  been  emjployed  in  the  treatment  of  burns,  especially  in  Germany  : 
it  is  valuable  in  preventing  sepsis,  and  is  said  to  have  very  materially  dimin- 
ished the  mortality.  The  bath  should  be  of  a  temijerature  of  100°  P.  (38.8° 
0.),  and  the  burned  or  scalded  jjart  should  be  kept  in  this  bath  for  some  days, 
until  the  sloughs  have  separated  and  a  granulating  surface  is  present.  This 
method  seems  especially  applicable  to  cases  of  burns  or  scalds  of  the  ex- 
tremities, but  has  also  been  used  in  cases  of  similar  injui'ies  of  the  trunk, 
when  the  whole  body  has  been  kef)t  in  the  bath  for  a  number  of  consecutive 
days.  When  large  healthy  granulating  surfaces  are  left  after  the  seiDaration 
of  sloughs,  much  time  may  be  saved  in  the  healing,  and  the  resulting  de- 
formity from  cicatricial  contraction  may  be  greatly  diminished,  by  employ- 
ing some  form  of  skin-grafting,  such  as  Thiersch's  method  or  the  transplan- 
tation of  skin-flaps.  The  use  of  splints,  extension  apparatus,  and  position 
may  do  much  to  obviate  deformity  after  burns,  and  it  is  well  to  remember 
that  these  appliances  should  be  continued  for  a  considerable  time  after  the 
ulcerated  surfaces  are  completely  healed,  for  the  contraction  is  apt  to  be 
active  for  some  months.  Passive  motion  should  also  be  practised  when  the 
joints  are  involved  ;  this  is  especially  demanded  early  in  the  case  of  burns 
involving  the  fingers. 

The  treatment  of  burns  or  scalds  involving  the  mucous  membrane  of  the 
mouth  consists  in  the  use  of  antiseptic  washes,  and  here  subsequent  ulcer- 
ation and  contraction  may  interfere  with  the  motion  of  the  jaw. 


EFFECTS   OF  COLD.  193 

Sunburn. — Exposure  to  the  sun  produces  u^jou  exposed  parts  a  condi- 
tion of  the  superficial  layer  of  the  skin  corresponding  to  a  burn  of  the  first 
degree  ;  if  the  skin  be  delicate  and  the  exjiosnre  prolonged,  dermatitis  with 
vesication  may  occur.  The  symptoms  are  swelling,  redness,  and  burning 
pairi.  If  a  large  surface  of  the  body  Is  involved,  sunburn  may  be  followed 
by  a  fatal  result,  as  in  the  case  of  burns  of  the  first  degree.  Treatment. — 
If  the  surface  be  covered  with  lint  saturated  with  soda  solution,  followed  by 
the  api^lication  of  vaseline,  or  of  a  lotion  composed  of  oil  of  almonds  and 
bismuth,  the  pain  will  be  relieved,  and  the  inflammation  quickly  subside. 
Exfoliation  of  the  superficial  layers  of  the  epidermis  is  apt  to  occur. 

EFFECTS   OP   COLD. 

The  constitutional  effects  of  prolonged  exposure  to  cold  are  manifested 
by  numbness,  drowsiness,  indisijosition  to  move,  a  tendency  to  sleep,  slow 
respiration  and  feeble  pulse,  coma,  and  death.  The  causes  of  death  from 
exposure  to  cold  vary  with  the  intensity  of  the  cold,  the  length  of  the  expo- 
sure, and  the  constitutional  condition  of  the  subject.  A  person  suffering 
from  hunger  or  fatigue,  or  one  in  a  debilitated  condition,  will  be  much  less 
able  to  resist  exposure  to  cold  than  one  in  whom  diffeient  conditions  obtain. 
In  this  climate  death  from  exposure  to  cold  is  most  frequently  seen  in 
intoxicated  jaersons.  Sudden  exposure  to  intense  cold  may  produce  death 
by  cerebral  anaemia,  while  prolonged  exposure  may  produce  the  same  result 
by  cerebral  congestion.  After  exposure  to  severe  cold,  if  the  patient  is  sud- 
denly subjected  to  warmth,  death  may  result  from  embolism. 

Treatment. — In  the  treatjuent  of  a  person  who  exhibits  the  constitu- 
tional effects  of  cold,  care  should  be  taken  that  reaction  does  not  occur  too 
rapidly.  The  patient  should  be  placed  in  a  cold  room  and  rubbed  with  ice 
and  snow,  and  this  rubbing  should  be  followed  by  friction  of  the  surface 
of  the  body  with  rough  towels ;  if  the  respiration  is  feeble,  artificial  respira- 
tion should  be  resorted  to,  and  stimulants,  such  as  aromatic  spirit  of  am- 
monia and  whiskey,  should  be  cautiously  given  by  the  mouth  or  by  enema, 
the  object  being  to  bring  about  gradual  reaction,  and  when  this  has  occurred 
the  patient  should  be  covered  with  woollen  blankets,  and  stimulants  cau- 
tiously administered  until  )-eaction  is  comxilete. 

Chilblain,  or  Pernio. — This  is  a  condition  produced  by  exposure  to 
cold,  and  results  from  a  vasomotor  i^aralysis,  producing  intense  congestion 
of  the  parts.  The  portions  of  the  body  usually  affected  are  the  toes,  feet, 
heels,  fingers,  face,  ears,  and  nose.  The  parts  become  deeply  congested  and 
swollen,  and  are  the  seat  of  intense  itching  and  burning ;  in  severe  cases 
blebs  may  form  upon  the  surface.  The  sudden  application  of  heat  after 
exposure  to  cold  is  apt  to  cause  rapid  development  of  the  affection.  A 
person  who  has  once  sutfered  from  chilblain  is  liable  to  suffer  from  a  recur- 
rence of  the  affection  upon  exposure  to  even  a  moderate  degree  of  cold. 

Treatment. — The  prophylactic  treatment  of  chilblain  consists  .in  bring- 
ing about  very  gradual  reaction :  to  accomplish  this,  the  part  which  has 
been  exposed  to  cold  should  be  rubbed  with  snow,  or  placed  in  cold  water, 
or  have  a  cold  water  dressing  applied.  The  part,  after  reaction  has  been 
established,  should  be  frequently  ijainted  over  with  a  solution  of  niti-ate  of 

13 


194  FEOST-BITE. 

silver  (gr.  v  to  fgi)  and  covered  with  raw  cotton.  A  very  satisfactory  ap- 
plication iu  these  cases  is  an  ointment  of  ichthyol  (ichthyol,  gii;  lanolin, 
gvi) ;  this  should  be  spread  upon  lint  aud  laid  over  the  parts.  If  blebs 
form,  they  should  be  punctured  to  allow  the  iiuid  to  escape.  The  itching 
which  often  remains  after  chilblain  may  be  relieved  by  rubbing  the  parts 
with  camphorated  soap  liniment  or  with  compound  resin  cerate. 

Frost-Bite. — This  condition  represents  the  more  serious  effects  result- 
ing from  sudden  or  prolonged  exposure  to  cold,  and  is  caused  by  the  ab- 
straction of  heat.  The  parts  of  the  body  most  frequently  found  to  suffer 
from  this  affection  are  the  feet,  hands,  nose,  and  ears,  although  the  limbs 
may  also  be  involved.  The  parts  may  be  so  completely  frozen  that  upon 
thawing  they  are  found  to  be  absolutely  dead,  or  their  vitality  may  be  so 
much  impaired  by  the  cold  that  when  reaction  takes  place  inflammation  and 
strangulation  of  the  tissvies  occur,  producing  gangrene. 

Symptoms. — The  part  becomes  numb  and  sensation  is  gradually  lost, 
and  it  presents  a  white,  blanched  appearance ;  if  completely  frozen,  in  a 
short  time  discoloration  and  swelling  follow  the  primary  blanching.  If 
the  part  is  not  completely  frozen,  and  reaction  is  rapid,  it  becomes  pur- 
ple, swollen,  and  painful,  and  blebs  may  form ;  sensation  is  lost,  the  skin 
becomes  mottled,  and  the  tissues  rapidly  pass  into  a  condition  of  moist 
gangrene. 

Treatment. — In  all  cases  of  severe  frost-bite,  even  when  the  part  ap- 
pears to  be  hopelessly  frozen,  treatment  should  be  instituted  to  bring  about 
moderate  reaction.  The  part  should  be  placed  in  cold  water  or  covered 
with  cloths  wrung  out  of  cold  water,  or  cold  water  irrigation  should  be 
employed.  If  it  has  been  completely  frozen,  gangrene  soon  manifests  itself, 
but  if  the  tissues  are  only  partially  devitalized  by  the  exposure  to  cold,  and 
if  the  subsequent  inflammatory  reaction  can  be  gradually  brought  about, 
gangrene  may  be  averted  or  may  develop  to  but  a  limited  extent.  The  cold 
water  dressings  should  be  continued  for  some  time  after  reaction  has  taken 
place,  and  if  gangrene  has  occurred,  they  should  not  be  discontinued  until 
it  is  evident  that  the  gangrene  is  limited  by  lines  of  demarcation  and  sepa- 
ration. When  the  gangrenous  tissue  has  separated,  the  ulcer  remaining 
should  be  treated  on  general  principles ;  and  iu  the  case  of  gangrene  of  the 
extremities  following  frost-bite,  comijlete  or  partial  amputation  of  the  part 
should  be  practised  as  soon  as  the  lines  of  demarcation  and  separation  are 
well  established. 

Injxiries  frora  Electricity. — Since  the  very  extensive  introduction 
of  electricity  in  the  arts,  injuries  from  contact  with  heavily  charged  wires 
are  of  frequent  occurrence.  If  the  current  bie  a  strong  one,  death  may  be 
instantaneous,  or  the  patient  may  be  knocked  down,  become  unconscious,  and' 
present  severe  burns  at  the  point  of  contact,  then  regain  consciousness,  and 
subsequently  suffer  from  numbness  in  the  extremities,  traumatic  neuroses, 
and  in  rare  cases  true  paralysis.  If  the  skin  be  dry  at  the  time  the  current 
is  received  there  will  be  more  burning,  less  penetration  and  less  shock,  and 
less  danger  of  death.  Electric  burns  present  a  dry  blackened  surface  sur- 
rounded by  an  area  of  pale  skin  for  a  few  hours,  which  finally  becomes  red- 
dened when  sloughing  occurs ;  they  are  not  painful,  but  are  apt  to  be  followed 


LIGHTNING-STROKE.  195 

by  extensive  sloughing  and  are  very  slow  in  healing.  Alternating  currents 
are  more  dangerous  than  continuous  currents  ;  a  continuous  current  of  one 
thousand  volts  is  not  apt  to  be  followed  by  serious  consequences,  whereas 
an  alternating  current  of  the  same  strength  is  likely  to  produce  death. 

Some  difference  of  opinion  exists  as  to  the  cause  of  death  after  exposure 
to  strong  currents.  Van  Gieson  insists  that  microscopic  examination  shows 
nothing  characteristic  except  burns.  The  heart  and  respiration  generally 
stop  simultaneously.  Hedley  attributes  death  to  asphyxia.  The  blood  is 
usually  dark-colored  and  fluid,  rigor  mortis  is  well  marked,  and  the  internal 
organs  may  show  punctate  hemorrhages.  Hedley  thinks  that  in  strong 
alternating  currents  death  is  caused  by  destruction  of  the  tissues,  or  by 
arrest  of  respiration  producing  asphyxia. 

Treatment. — Unfortunately,  in  many  cases  where  strong  currents  have 
been  received,  death  is  instantaneous  from  arrest  of  cardiac  and  respiratory 
action,  but  in  all  cases  it  is  well  to  institute  prompt  treatment.  Donnellan 
reports  a  case  of  recovery  after  the  passage  of  one  thousand  volts,  and  Hed- 
ley mentions  a  case  of  apparent  death  in  a  man  who  received  an  alternating 
current  of  four  thousand  five  hundred  volts  short-circuited  through  his  body 
for  many  miniites,  who  showed  no  signs  of  life  for  thirty  minutes.  In  this 
case,  after  the  employment  of  Laborde's  method  of  artificial  respiration  for 
some  time,  normal  respiratory  action  was  restored  and  the  patient  recovered. 
Artificial  respiration  should  be  practised  in  all  cases,  and  should  be  con- 
tinued until  it  is  certain  that  the  patient  is  dead.  At  the  same  time  strych- 
nine should  be  used  hypodermically  ;  atropine  is  also  strongly  recommended  ; 
and  friction  applied  to  the  surface  of  the  body.  Electric  burns  should  be 
treated  by  dry  antiseptic  dressings,  but  these  often  fail  to  arrest  the  slough- 
ing. J.  C.  Da  Costa  recommends  in  the  early  stage  of  these  burns  the  use 
of  fomentations  of  hot  saline  solution,  which  facilitates  the  separation  of  the 
sloughs,  and  in  the  subsequent  dressing  of  the  wounds  peroxide  of  hydrogen 
followed  by  irrigation  with  saline  solution,  and  finally,  after  the  sloughs  have 
separated,  the  emx^loyment  of  dry  sterilized  dressings. 

Lightning-Stroke. — This  may  be  direct  when  the  body  receives  the 
direct  electrical  discharge,  and  indirect  when  the  electrical  discharge  is  trans- 
mitted from  some  contiguous  object.  A  person  struck  by  lightning  may  die 
instantaneously  or  be  more  or  less  deprived  of  consciousness  for  a  time,  and 
may  suffer  from  burns  superficial  or  deep.  Upon  regaining  consciousness 
the  ijatient  may  complain  of  disturbance  of  vision,  and  may  suffer  from 
paralysis  of  the  nerves  of  motion  or  sensation  ;  paralysis  of  the  lower  limbs 
is  said  to  be  more  common  than  that  of  the  upper  limbs.  The  results  of 
lightning-stroke  upon  the  body  differ  according  as  the  electrical  or  the  burn- 
ing action  predominates ;  there  may  be  present  sevei'e  burns,  or  extensive 
lacerations,  involving  the  muscles,  blood-vessels,  and  bones,  or  sudden  death 
may  result  from  j)aralysis  of  the  respiration  and  circulation.  The  mortality 
from  lightning-stroke  is  estimated  at  seventy-two  per  cent. 

Treatment. — The  treatment  of  the  stage  of  shock  following  lightning- 
stroke  consists  in  the  application  of  external  heat,  the  employment  of  artifi- 
cial respiration,  and  the  administration  of  stimulants.  If  burns  exist  ui^on 
the  surface  of  the  body,  they  should  be  treated  like  burns  arising  from  other 


196  DISEASES   OF  CICATRICES. 

causes.  If  paralysis  of  special  or  general  nerves  persists  some  time  after 
recovery  from  tlie  immediate  effects  of  the  shock,  the  use  of  galvanism  and 
the  administration  of  strychnine  may  be  followed  by  good  results. 

X-Ray  Burn. — A  j)eculiar  lesion  of  the  skin  and  subjacent  tissues, 
following  exposui-e  to  the  X-rays,  and  resulting  in  dermatitis,  ulceration  of 
the  skin  and  subcutaneous  tissues,  and  loss  of  the  nails  and  hair  in  the  dam- 
aged area,  is  known  as  an  X-ray  burn.  This  lesion  differs  from  an  ordinary 
burn  in  that  it  may  not  appear  for  several  days  or  weeks  after  the  exposure, 
and  that  the  inflammatory  or  gangrenous  processes  arise  in  the  tissues  and 
finally  involve  the  skin.  These  lesions  are  very  painful  and  slow  in  healing, 
and  if  an  extensive  surface  be  involved  they  may  result  in  serious  conse- 
'  queuces ;  ami)utation  of  a  limb  has  been  demanded  by  reason  of  a  burn  of 
this  nature.     The  lesion  is  probably  due  to  troj)hic  changes. 

Treatment. — The  dressings  employed  in  ordinary  burns  have  not  proved 
satisfactory  in  these  injuries  ;  dry  sterilized  dressings  may  be  emi:)loyed,  and 
skin-grafting,  when  the  ulceration  is  extensive,  may  be  of  service.  When 
a  small  area  only  is  involved  and  healing  fails  to  occur,  Powell  recommends 
excision  of  the  ulcerated  tissues. 

DISEASES  OE  CICATRICES. 
When  the  edges  of  wounds  have  been  neatly  approximated,  and  healing 
by  first  intention  has  taken  place,  it  is  unusual  for  any  trouble  to  develop 
in  the  cicatrix,  except  keloid,  which  may  occur  even  in  such  cases.  The 
principal  afifections  of  cicatrices  are  loeah  cicatrix,  •painful  cicatrix,  keloid, 
malignant  disease  of  the  cicatrix,  depressed  cicatrix,  and  contracting  cicatrix. 

Weak  Cicatrix. — This  form  of  cicatrix  has  a  tendency  to  break  down 
or  ulcerate  near  its  centre,  and  is  usually  seen  in  cicatrices  following  exten- 
sive wounds,  burns,  or  scalds  when  a.  large  amount  of  skin  has  been  de- 
stroyed, and  the  same  tendency  may  be  observed  in  cicatrices  which  are 
adherent  to  bone.  Cicatrices  in  tuberculous  subjects  are  also  apt  to  break 
down  because  of  tubercular  infection,  even  when  primary  healing  has  been 
satisfactory.  The  surgeon  in  treating  wounds  and  burns  should  direct  his 
attention  to  the  diminution  of  the  extent  of  the  scar,  knowing  that  in  any 
large  cicatrix  the  vitality  of  the  tissues  at  its  centre  is  small,  and  that  it 
is  therefore  liable  to  break  down  or  ulcerate.  The  amount  of  scar-tissue 
resulting  from  the  repair  of  extensive  wounds  may  be  diminished  by  the  use 
of  skin-grafting,  or  by  the  sliding  of  flaps  of  skin  and  connective  tissue. 

Treatment. — When  a  cicatrix  has  a  tendency  to  break  down,  the  dis- 
eased portion  should  be  dissected  out  and  skin-grafts  apiilied  to  the  raw 
surface,  or  healthy  skin  should  be  transplanted  to  coA^er  its  surface.  When 
a  weak  cicatrix  is  adherent  to  bone,  the  separation  of  the  cicatrix  with  a 
tenotome,  or  the  removal  of  a  portion  of  the  bone,  will  often  be  followed  by 
improvement  in  its  condition. 

Painful  Cicatrix. — This  condition  results  from  the  implication  of  a 
nerve  in  the  cicatrix,  producing  a  certain  amount  of  neuritis  from  the  con- 
tracting fibrous  tissue  of  the  scar.  When  a  painful  cicatrix  is  small  or  of 
moderate  size,  the  best  treatment  consists  in  dissecting  it  out  and  filling  the 
resulting  gap  by  sliding  flaps  of  skin.     If,  however,  the  cicatrix  be  too 


EPITHELIOMA   OF  CICATRICES.  197 

extensive  for  this  operation,  relief  from  pain  may  be  afforded  by  performing 
neurotomy,  neurectomy,  or  nerve-stretching  upon  the  nerves  entering  the 
cicatrix. 

Keloid. — This  is  a  form  of  disease  in  cicatrices  which  is  characterized 
by  hyjjertrophy  of  the  scar-tissue,  and  is  seen  especially  in  the  scars  follow- 
ing burns,  but  may  also  develop  in  those  following  other  varieties  of  wounds. 
It  is  very  common  in  the  negro  race.  The  scar  becomes  thickened  and 
irregular,  hard  xjrojections  form  upon  its  surface,  the  surface  of  the  hyper- 
trophied  tissue  often  presents  dilated  veins,  and  claw-like  processes  may  ex- 
tend to  the  adjacent  skin.  Keloid  may  be  the  seat  of  neuralgic  pain,  but  is 
usually  not  painful,  and  is  more  apt  to  be  accompanied  by  intense  itching  ; . 
it  may  ulcerate  and  give  rise  to  bleeding. 

Treatment. — Excision  of  keloid,  although  it  would  seem  the  most  nat- 
iiral  method  of  dealing  with  the  growth,  has  proved  unsatisfactory,  as  the 
disease  usually  returns  in  the  new  cicatrix,  and  the  resulting  growth  is  often 
larger  than  the  original  one.  When  it  is  possible  to  dissect  out  a  mass  of 
keloid  and  approximate  the  edges  of  healthy  skin,  the  resulting  deformity 
may  be  less  marked,  even  if  the  disease  returns  in  the  new  cicatrix.  As  a 
rule,  however,  it  is  better  to  apply  some  treatment  which  diminishes  the 
blood-suijply  of  the  growth,  and  this  may  be  accomplished  by  the  use  of 
pressure  applied  by  comi^resses  and  straps,  or  by  elastic  pressure.  Warren 
recommends  the  following  application  to  be  painted  upon  the  surface  of 
the  growth:  plumbi  acetatis,  gi;  collodion,  3  v.  This  treatment  we  have 
employed  in  keloids  of  recent  development  with  apparently  good  results. 
Scarification  in  mauy  cases  is  followed  by  improvement.  Although  the 
growth  is  unsightly,  and  when  recent  may  cause  pain  and  itching,  the  fact 
should  not  be  lost  sight  of  that  in  time  there  is  a  tendency  to  atrophy,  and 
that  it  may  become  much  less  prominent.  In  tuberculous  subjects  who 
present  keloid  growths  the  use  of  iodide  of  iron  and  cod-liver  oil  may  be 
folloAved  by  benefit. 

Epithelioma  of  Cicatrices.— This  is  a  form  of  ulceration,  very  per- 
sistent in  its  character,  which  is  occasionally  seen  in  old  cicatrices  of  burns 
or  gunshot  wounds.  The  appearance  of  epitheliomatous  degeneration  of 
the  cicatrix  of  a  burn  of  the  knee  in  a  negro  woman,  associated  with  con- 
traction of  the  knee  of  thirty  years'  duration,  is  well  shown  in  Fig.  118. 
The  ulcer  is  covered  with  small  granulations  having  a  j)apillary  appearance 
like  condylomata,  which  often  project  above  the  surface  of  the  surrounding 
tissue.  The  ulcer  may  cause  little  discomfort  for  a  long  time,  or  it  may 
gi-adually  increase  in  size,  become  the  seat  of  intense  pain,  and  be  accom- 
panied by  free  and  offensive  discharge.  A  number  of  oases  of  this  affection 
have  come  under  our  observation  in  cicatrices  of  gunshot  wounds  of  many 
years'  duration.  (Fig  119.)  Treatment. — The  treatment  of  this  affection 
consists  in  dissecting  out  the  ulcer  completely  when  it  is  possible,  aud  in 
filling  the  gap  by  sliding  flaps  of  skin ;  in  other  positions,  such  as  the 
extremities,  when  the  bones  may  be  involved  aud  the  growth  cannot  be 
completely  removed,  amputation  should  be  resorted  to. 

Depressed  Cicatrix. — This  form  of  cicatrix  is  very  common  after  the 
healing  of  wounds  involving  bone  or  the  soft  tissues  when  there  has  been  a 


198 


DEPRESSED   CICATRIX. 


loss  of  substance.  The  best  examples  of  depressed  cicatrices  are  seen  after 
the  healing  of  wounds  from  operations  for  necrosis  and  caries,  and  in  those 
cicatrices  observed  after  suppuration  of  the  cervical  lymphatic  glands.  As 
a  rule,  these  cicatrices  require  no  treatment  except  when  upon  exposed 
sm-faces  of  the  body,  as  the  face  or  the  neck,  where  their  presence  causes 
disfigurement. 

FiCx.  lis. 

Fig.  119. 


Epithelioma  following  burn  of  the  knee. 


Epithelioma  in  cicatrix  of  gunshot 
wound. 


Treatment. — When  the  depressed  cicatrix  is  small  we  have  employed 
with  good  results  the  operation  devised  by  Adams,  which  consists  in  intro- 
duciug  a  tenotome  under  the  cicatrix  from  one  edge  and  dissecting  it  loose 
from  its  subcutaneous  attachments ;  two  harelip  pins  are  then  passed  at 
right  angles  to  each  other  through  the  skin,  and  are  passed  under  the 
loosened  cicatrix  to  hold  it  upon  a  level  with  the  surrounding  skin.  An 
antiseptic  dressing  should  next  be  applied,  and  at  the  end  of  three  or  four 
days  the  pins  are  removed,  at  which  time  a  blood-clot  has  filled  up  the 
cavity  under  the  cicatrix,  which,  becoming  organized,  prevents  subsequent 
depression  of  the  scar.  In  extensive  and  deeply  dejaressed  cicatrices  con- 
nected with  bone  the  deformity  may  be  much  relieved  by  making  a  longitu- 
dinal incision  through  the  tissues  at  the  deepest  portion  of  the  cicatrix, 
dissecting  each  flap  loose  fi-om  the  bone,  and  then  filling  the  cavity  with  bone 
chips  and  bringing  the  edges  of  the  flaps  together  over  them  with  sutures. 
In  an  extensive  and  deep  cicatrix  following  the  removal  of  a  cyst  of  the 
lower  jaw  we  succeeded  by  this  operation  in  relieving  the  disfigurement  very 
satisfactorily. 

Contracting  Cicatrix. — The  most  troublesome  deformities  which 
ai-e  brought  to  the  surgeon  for  correction  are  those  resulting  from  the  con- 
traction of  cicatrices  of  burns  and  scalds.    The  deformities  in  these  cases  are 


CONTRACTING  CICATRIX. 


199 


due  not  only  to  a  loss  of  tissue  from  destruction  by  the  burn  or  scald,  but 
also  to  the  contraction  and  cicatrization  of  the  reparative  material  itself. 
These  cicatrices  may  also  assume  a  keloid  character ;  this  change  is  more 
common  in  children  than  in  adults.  The  contraction  following  burns  or 
scalds  of  the  face  may  cause  ankylosis  of  the  jaw ;  those  of  the  anterior 
part  of  the  neck  and  chest  may  cause  the  chin  to  be  drawn  down  to  the 
sternum,  or  lateral  distortion  of  the  neck  may  take  place ;  the  joints  may 
be  immovably  flexed,  or  the  arm  may  be  bound  down  to  the  chest  so  that  it 
is  practically  useless,  or  the  mouth,  eyelids,  or  ears  may  be  distorted.  The 
contraction  of  the  tissues  following  a  burn  of  the  abdomen  and  upper  part 
of  the  thighs  in  a  girl  of  ten  years,  in  whom  a  hood  was  formed  in  front  of 
the  external  genitals,  is  shown  in  Fig.  120 ;  the  condition  of  this  patient 


Fig.  120. 


Fig.  122. 


Cicatrix  {ollowing  burn  of  abdomen     The  same  case  after  a  plastic 
and  thighs.  operation. 


Contraction  of  hand  from  burn. 
(Agnew.) 


after  operation  is  shown  in  Fig.  121.  The  deformity  following  burns  of  the 
extremities  often  seriously  interferes  with  the  function  of  the  joints.  Cica- 
tricial contraction  following  burns  of  the  flexor  surface  of  the  hand  and 
fingers  may  totally  disable  the  part.  The  deformity  of  the  hand  following 
a  burn  of  the  hand  and  wrist  is  well  shown  in  Fig.  122. 

Treatment.— The  use  of  splints  and  extension  in  the  treatment  of  burns 
where  contraction  is  liable  to  occur  before  the  wounds  have  healed  has  been 
j)reviously  mentioned,  and  the  same  appliances  should  be  made  use  of  in  the 
case  of  recently  healed  burns  with  contracted  cicatrices,  for  while  the  scar- 
tissue  is  soft  and  pliable  it  is  often  f)Ossible  to  diminish  the  amount  of  con- 
traction. If,  however,  the  skin  and  connective  tissue  have  been  destroyed, 
it  is  generally  impossible  to  correct  the  deformity  except  by  a  plastic  opera- 
tion. Simijle  division  of  cicatricial  bands,  or  even  their  excision,  leaving 
the  resulting  raw  surface  to  heal  by  granulation,  is  unsatisfactory,  as  subse- 
quent recontraction  takes  place,  and  the  deformity  is  reproduced.  In  opera- 
tions upon  contracted  cicatrices  it  is  sometimes  necessary  to  use  a  part  of  the 
scar-tissue,  and  therefore  it  is  well  not  to  operate  until  contraction  has  ceased, 
which  will  be  often  as  long  as  six  months  or  a  year  after  the  healing  of  the 


200 


CONTEACTING   CICATRIX. 


Fig.  123. 


wound ;  the  vitality  of  the  scai-- tissue  will  be  usually  at  this  time  so  well 
established  that  it  will  not  be  likely  to  slough. 

In  correcting  the  deformities  resulting  from  contracted  cicatrices,  skin- 
grafting,  preferably  by  Thiersch's  method,  or  a  plastic  ojjeration,  may  be 
resorted  to.  The  first  step  in  these  operations  is  the  division  or  freeing  of 
the  contracted  cicatrix,  so  that  the  parts  which  are  held  in  a  faulty  position 
can  be  brought  as  nearly  as  possible  into  the  normal  position.  In  dividing 
these  tissues  it  is  well  to  remember  that,  especially  in  contracting  cicatrices 
about  the  joints,  important  nerves  and  vessels  may  be  included  in  the  cica- 
trix, and  care  should  be  taken  not  to  injure  them.  Contraction  at  the  elbow 
following  a  burn  or  scald  of  the  anterior  surface  and  forearm  may  be  relieved 
by  making  an  incision  on  each  side  of  the  contracted  tissue  and  dissecting 
up  the  triangular  mass  of  cicatrized  tissue,  after- 
wards bringing  together  the  edges  of  the  incision 
with  sutures.  (Fig.  123.)  A  similar  procedure 
may  be  adopted  in  cases  of  contraction  of  the  knee 
from  a  cicatrix. 

An  operation  devised  by  Croft  has  been  suc- 
cessfully emjjloyed  in  preventing  recoutraction 
after  division  of  the  cicatrices  following  burns.  It 
is  divided  into  two  stages.  The  first  stej)  of  the 
operation  consists  in  raising  a  strijj  of  skin  of  the 
desired  length  and  breadth  from  the  integument  in 
the  neighborhood  of  the  scar.  The  strip  is  freed 
from  the  subjacent  tissues,  but  remains  attached  at 
each  end,  and  a  strip  of  rubber,  tissue  is  placed 
imder  it  to  prevent  its  reuniting,  and  a  gauze  dress- 
ing is  applied.  It  is  dressed  at  intervals  and  care  is 
taken  that  the  rubber  tissue  is  kept  in  place  to  pre- 
At  the  end  of  two  or  three  weeks  the  under  surface 
of  the  strip  will  be  covered  with  healthy  granulations  and  the  second  step  of 
the  operation  is  undertaken,  which  consists  in  dividing  the  cicatricial  band 
until  healthy  tissues  are  exposed  and  then  dividing  the  distal  end  of  the 
strip  and  sliding  it  over  the  raw  surface  left  by  dividing  the  cicatrix  and 
suturing  it  in  place. 


Operation  for  cicatrix  at  elbow. 
(After  Agnew.) 


vent  it  from  reuniting. 


CHAPTEE    XV. 

ANESTHETICS. 
By  Heney  E.  Wharton,  M.D. 

Anaesthesia  may  be  local,  regioual,  or  general. 

Local  anaesthesia  results  from  the  direct  ai^plication  of  anfesthetic  agents 
to  nerve  terminations,  and  produces  analgesia  of  the  tissues  to  a  limited  ex- 
tent only  ;  it  may  be  j)roduced  by  the  use  of  cold,  a  spray  of  ether,  rhigolene, 
or  ethyl  chloride,  cocaine  or  eucaine  hydrochlorate,  holocaine,  or  guaiacol,  or 
bj^  Schleich's  method  of  infiltration. 

Regional  Anaesthesia. — This  is  also  sometimes  described  as  neural 
antesthesia,  and  results  from  the  application  of  anaesthetic  agents  to  the  nerve- 
roots,  nerve-trunks,  or  the  spinal  cord.  The  analgesia  in  this  form  of  anaes- 
thesia extends  to  the  tissues  supplied  by  the  nerve  or  nerves,  and  therefore 
is  limited  to  their  distribution. 

General  Anaesthesia. — This  is  characterized  by  unconsciousness  as  well 
as  abolition  of  sensation,  and  may  be  induced  by  the  administration  of  nitrous 
oxide  gas,  ether,  chloroform,  ethyl  chloride,  A.  C.  E.  mixture,  or  Schleich's 
antesthetic  mixture.  It  may  be  jaroduced  by  combination  of  the  above 
drugs  with  oxygen.  Hypnotism  may  also  be  employed  to  produce  general 
anaesthesia. 

LOCAL   ANESTHESIA. 

Local  anaesthesia  may  be  made  use  of  in  minor  surgical  procedures,  such 
as  aspiration,  the  opening  of  abscesses,  removal  of  foreign  bodies  from  the 
tissues,  and  the  removal  of  supei'ficial  tumors.  It  is  also  occasionally  em- 
ployed in  major  operations  such  as  herniotomy,  amputation,  and  laparotomy, 
when  from  the  patient's  condition  the  administration  of  drugs  to  produce 
general  anaesthesia  is  considered  dangerous.  It  has  the  disadvantage  that  it 
does  not  relieve  the  patient  of  the  dread  or  terror  of  the  operation,  and  does 
not  control  muscular  action,  so  that  it  may  be  impossible  to  restrain  his  move- 
ments dui'ing  its  performance.  For  this  reason  the  emxDloyment  of  local 
anaesthesia  is  not  satisfactory  in  children  and  nervous  or  irrational  subjects. 

Cold. — rLocal  anaesthesia  may  be  produced  by  the  application  of  cold, 
by  holding  either  a  piece  of  ice  or  a  mixture  of  salt  and  ice  in  contact 
with  the  surface  for  one  or  two  minutes ;  the  part  becomes  blanched  and 
insensitive. 

Rhigolene  or  Ether  Spray. — The  applicaition  of  a  spray  of  rhigolene 
or  ether  to  the  surface  of  the  body  for  a  few  minutes  will  jDroduce  a  similar 
result  as  regards  the  production  of  anaesthesia. 

Ethyl  Chloride. — This  may  also  be  used  to  produce  local  ani^sthesia, 
and  is  con\'eniently  furnished  in  glass  tubes,  one  end  of  which  is  drawn  out 
into  a  fine  point  and  hermetically  sealed,  or  provided  with  a  fine  metal  tube 
with  a  screw  cap  ;  when  required  for  use  the  end  of  the  glass  point  is  broken 

201 


202  LOCAL  ANESTHESIA. 

off  or  the  metal  cap  is  removed  and  a  fine  jet  of  ethyl  is  projected  uj)on  the 
surface,  the  warmth  of  the  hand  being  sufficient  to  force  the  fluid  from  the 
tube. 

As  all  these  substances  produce  aufesthesia  by  cold,  if  the  operation  is 
one  requiring  considerable  dissection,  the  application  has  to  be  repeated  a 
nixmber  of  times,  and  the  vitality  of  the  tissues  may  be  so  much  impaired  by 
the  cold  that  primary  union  may  not  be  obtained  or  sloughing  may  take  place. 
For  this  reason  it  is  wise  to  restrict  their  use  to  the  production  of  anaesthesia 
for  the  opening  of  abscesses,  exploratory  puncture,  or  aspiration. 

Cocaine  Hydrochlorate. — Local  anaesthesia,  as  first  demonstrated  by 
Koller,  may  also  be  obtained  by  the  employment  of  an  aqueous  solution  of 
hydrochlorate  of  cocaine  applied  to  mucous  surfaces  or  injected  into  the 
tissues  ;  it  has  no  anaesthetic  action  when  applied  to  the  surface  of  the  skin. 
When  a  solution  of  cocaine  comes  in  contact  with  sensory  nerverendings  an 
area  of  analgesia  results  from  their  temporary  paralysis  ;  it  also  produces  a 
localized  anaemia  of  the  tissues  from  vasomotor  constriction.  The  drug  is 
used  in  solutions  varying  from  one  to  twelve  per  cent.  The  solution  should 
be  freshly  made  with  boiled  water.  We  rarely  use  solutions  of  cocaine  of 
greater  strength  than  from  one  to  four  per  cent.,  and  find  that  analgesia  can 
be  as  satisfactorily  obtained  with  these  as  with  the  stronger  solutions,  while 
by  the  employment  of  the  weaker  solutions  the  risk  of  toxic  effects  is  much 
diminished.  Death  has  followed  the  use  of  a  twelve  per  cent,  solution 
injected  into  the  urethra,  and  we  consider  it  a  safe  rule  never  to  inject  more 
than  one  or  two  grains  of  the  drug  into  a  mucous  cavity  at  one  time,  and 
to  provide  means  for  its  escape.  Certain  individuals  have  an  idiosyncrasy 
for  cocaine  ;  children  seem  more  susceptible  to  its  constitutional  effects  than 
adults.  In  the  former  class  of  patients  we  have  seen  marked  symj^toms  of 
cocaine  i^oisoning  result  from  the  application  of  a  four  jjer  cent,  solution  to 
the  nasal  mucous  membrane.  The  toxic  effects  of  cocaine  are  manifested  by 
headache,  pallor,  cold  moist  skin,  feeble  slow  pulse,  incoherent  speech,  nausea, 
vomiting,  epileptiform  attacks,  dilated  pupils,  dyspnoea,  and  asphyxia.  The 
treatment  of  cocaine  poisoning  consists  in  rest  in  the  recumbent  posture,  the 
use  of  ammonia,  whiskey,  or  ether  bj'  hypodermic  injection,  and  the  em- 
ployment of  artificial  resijiration  if  the  respiratory  function  is  markedly 
disturbed. 

In  the  production  of  anaesthesia  of  mucous  surfaces  the  part  may  be 
brushed  over  with  a  one  or  two  per  cent,  solution  of  cocaine,  or  j)ledgets  of 
absorbent  cotton  may  be  saturated  with  the  solution  and  held  in  contact 
with  the  part  for  a  few  minutes.  It  may  be  applied  to  the  nasal  mucous 
membrane  by  the  use  of  a  spray  or  by  pledgets  of  cotton.  In  operations 
ui)on  the  eye  a  few  drops  of  a  two  per  cent,  solution  are  dropped  into  the 
eye,  and  the  application  is  repeated  until  the  analgesia  is  complete.  To 
produce  analgesia  of  the  urethra  a  drachm  of  a  one  per  cent,  solution  is 
injected  and  allowed  to  remain  from  two  to  five  minutes.  The  injection  of 
cocaine  into  the  rectum  is  not  to  be  recommended,  as  its  use  here  is  often 
attended  with  danger,  but  if  it  is  employed  in  this  organ,  or  applied  to  the 
anus,  a  one  or  two  jjer  cent,  solution  should  be  applied  upon  a  pledget  of 
absorbent  cotton. 


EUCAINE   HYDEOCHLORATE.  203 

When  it  is  desirable  to  produce  analgesia  of  the  skin  or  deeper  tissue,  it 
is  necessary  to  inject  the  sterilized  solution  into  the  skin,  cellular  tissue,  and 
subjacent  tissues,  and  to  avoid  multijDle  punctui-es  the  needle  is  introduced 
at  one  point,  and  after  injecting  a  certain  amorrnt  of  the  solution  it  is  jiartly 
withdrawn  and  thrust  in  another  direction,  this  procedure  being  repeated 
until  a  circumscribed  area  of  tissue  has  been  injected  at  diiferent  points, 
when  the  needle  is  finally  withdrawn.  It  is  a  safe  rule  not  to  employ  more 
than  one  grain  of  cocaine  hypodermically  at  one  time.  The  electrolytic 
method  with  cocaine  upon  the  positive  pole  has  been  highly  recommended. 
It  is  well,  where  it  is  possible,  to  cut  off  the  return  circulation  from  the 
part  to  be  operated  upon  by  placing  around  it  a  rubber  strap  or  tube,  which 
prevents  the  rapid  entrance  of  the  drug  into  the  circulation,  and  thus  enables 
much  lai-ger  quantities  to  be  used  with  safety. 

Cocaine  anaesthesia  is  useful  in  minor  surgical  operations,  such  as 
the  amputation  of  fingers  or  toes,  circumcision,  opening  of  abscesses,  or 
removal  of  superficial  tumors,  and  its  utility  is  most  marked  in  operations 
upon  the  eye  and  those  upon  the  mucous  membranes  of  the  nose,  throat, 
vagina,  and  urethra.  Although  major  operations,  such  as  removal  of  the 
breast,  and  amputations  of  the  leg,  arm,  or  thigh,  have  been  performed  imder 
cocaine  anesthesia,  we  do  not  think  its  use  is  to  be  recommended  in  such 
cases.  Its  employment  in  minor  operations  upon  children  will  not  be  found 
so  satisfactory  as  general  anaesthesia,  for,  in  spite  of  the  fact  that  the  part 
may  be  rendered  anfesthetic,  they  experience  so  much  fright  that  it  is  impos- 
sible to  restrain  their  movements. 

Eucaine  Hydrochlorate. — This  drug,  in  the  form  of  eucaine  b,  pro- 
duces local  anaesthesia  in  the  same  manner  as  cocaine  hydrochlorate,  and  has 
recently  been  widely  employed.  It  is  used  as  a  local  application  to  mucous 
surfaces  and  hypodermically  in  the  deeper  tissues  to  produce  local  antesthesia. 
It  possesses  the  advantage  over  cocaine  that  it  can  be  used  in  much  larger 
quantities,  as  it  is  apparently  free  from  toxic  action  ;  heat  does  not  imjjair  its 
qualities,  so  that  the  solution  can  be  sterilized  by  boiling.  Kiessel  states  that 
two  grammes  (thirty  grains)  can  be  injected  without  the  production  of  toxic 
symptoms.     It  is  conveniently  used  in  solutions  of  fi-om  one  to  four  jjer  cent. 

Holocaine. — This  drug  in  a  one  per  cent,  solution  iiossesses  as  decided 
analgesic  action  as  cocaine  or  eucaine.  It  is  also  strongly  bactericidal  in  its 
action.  It  may  be  used  locally  without  producing  constitutional  symptoms, 
but  cannot  be  used  internally  or  injected  into  the  tissues  on  account  of  its 
marked  toxic  action. 

Guaiacol. — This  may  be  used  externally  as  an  analgesic,  the  part  being 
painted  with  a  solution  of  guaiacol,  gr.  xv,  alcohol,  f3v.  In  epididymitis 
or  gonorrhceal  arthritis,  five  parts  of  guaiacol  to  thirty  parts  of  vaseline  or 
olive  oil  may  be  used  to  relieve  pain.  It  may  also  be  used  hypodermically 
to  produce  local  anaesthesia  in  minor  operations,  a  one- tenth  to  one-twentieth 
solution  in  olive  oil  being  employed.  Its  hypodermic  use  causes  pain  at 
first  and  is  not  unattended  with  danger. 

Infiltration  Anaesthesia.— This  method  of  producing  local  anaes- 
thesia was  first  employed  by  Halstead  and  Schleich.  Liebreich  has  shown 
that  the  injection  of  water  into  the  tissues  in  such  a  manner  as  to  produce 


204  REGIONAL  ANAESTHESIA. 

an  artificial  oedema  will  produce  a  temporary  local  ansestliesia.  Schleich 
found  that  by  combining  a  small  amount  of  cocaine  and  morphine  with  a 
weak  salt  solution  the  period  of  auiesthesia  was  prolonged.  The  anjes- 
thesia  is  produced  in  this  method  by  the  artificial  ischsemia  established  by 
the  tension  and  pressure  to  which  the  tissues  are  subjected,  and  by  the 
direct  action  of  the  injected  drugs  upon  the  nerves.  In  employing  this 
form  of  anjesthesia  a  weak  solution  of  cocaine,  morphine,  and  common  salt 
is  introduced  into  the  tissues  by  means  of  a  hypodermic  syringe.  The  solu- 
tion usually  em]3loyed  is  made  as  follows :  cocainiB  hydrochloras,  gr.  iss ; 
morphinte  sulphas,  gr.  i  ;  sodii  chloridi,  gr.  iii ;  aquae,  fsiii,  3iii.     M. 

The  skin  and  the  syringe  should  be  sterilized,  and  the  surface  which  is 
to  be  punctured  by  the  needle  may  be  rendered  insensitive  by  the  use  of  a 
spray  of  ether  or  ethyl  chloride.  The  needle  should  be  introduced  into  the 
skin  and  the  fluid  injected  at  different  parts  until  wheals  are  raised.  The 
injections  should  then  be  made  into  the  deeper  parts,  until  the  whole  area 
of  tissue  which  is  to  be  operated  upon  is  thoroughly  infiltrated  with  the  solu- 
tion. Matas  recommends  in  place  of  the  ordinary  syringe  a  special  apparatus 
in  which  the  fluid  is  forced  from  the  injecting  bottle  through  the  needle  by 
an  air-pump.     The  resulting  anesthesia  lasts  for  fifteen  or  twenty  minutes. 

Infiltration  anaesthesia  is  employed  in  minor  surgical  i^rocedures,  such  as 
the  opening  of  abscesses,  amputation  of  fingers,  and  removal  of  tumors,  and 
it  has  also  been  employed  satisfactorily  in  major  surgical  operations,  such 
as  herniotomy  and  amputations  of  the  limbs. 

The  disadvantages  of  this  method  of  aniiesthesia  are  the  painful  tension 
of  the  tissues  in  the  early  stage,  the  difficulty  in  recognizing  the  different 
structures  on  account  of  the  oedema,  and  sometimes  the  difficulty  of  accurate 
apposition  on  account  of  the  swelling  of  the  parts. 

EEGIONAL   AN:/ESTHESIA. 

Neural  Anaesthesia. — This  method  consists  in  bringing  anaesthetic 
drugs  in  contact  with  nerve-trunks  at  some  distance  from  the  field  of  opera- 
tion, with  a  view  of  causing  analgesia  in  the  tissues  supplied  by  them.  For 
instance,  in  a  jjroposed  operation  upon  the  leg,  the  injection  would  be  made 
near  or  into  the  anterior  crural  and  sciatic  nerves.  Cocaine,  eucaine,  or 
Schleich' s  solution  may  be  employed  for  the  purpose.  The  nerves  may  be 
anaesthetized  by  the  jjarcwieurfrf  method,  which  consists  in  injecting  the  solu- 
tion in  the  vicinity  of  the  nerve-trunk,  as  near  as  possible  to  the  nerve  ;  or 
by  the  direct  intraneural  method,  which  consists  in  producing  anaesthesia  of 
the  skin  and  cellular  tissue,  and  then  exposing  the  nerve-trunks  by  dissec- 
tion, and  injecting  the  solution  directly  into  them  by  passing  a  hypodermic 
needle  into  their  substance.  This  method  of  anaesthesia  has  been  employed 
with  success  in  both  minor  and  major  surgical  operations,  such  as  the  radical 
cure  of  hernia,  amputation,  the  removal  of  tumors,  and  is  especially  appli- 
cable in  operations  upon  the  extremities. 

Spinal  Subarachnoid  Injection.— As  the  result  of  the  work  of 
Corning,  Bier,  and  Tuffier,  anaesthesia  by  means  of  spinal  subarachnoid 
injection  of  cocaine  or  eucaine  has  been  recently  employed  with  satisfactory 
results.     This  method  of  anaesthesia  is  usually  resorted  to  only  in  operations 


GENERAL  ANAESTHESIA.  205 

111)011  that  portion  of  the  body  below  the  diaphi-agiu.  The  injections  are 
made  into  the  spinal  canal  in  the  lumbar  region  ;  fifteen  to  twenty  minims 
of  a  two  Y>ev  cent,  cocaine  or  eucaine  solution  are  usually  sufficient  to  i^ro- 
duce  satisfactory  anesthesia.  The  technique  of  the  operation  is  as  follows  : 
The  entire  lumbar  and  sacral  regions  should  be  carefully  sterilized,  and  the 
position  of  the  third  lumbar  interspace,  that  is,  the  space  between  the  third 
and  fourth  lumbar  vertebriB,  is  located.  The  patient  next  sits  astride  of  the 
oiierating-table  and  bends  forward  iu  the  position  of  ventral  flexion,  with 
his  ribs  resting  upon  his  knees,  which  widens  the  space  between  the  third 
and  fourth  lumbar  vertebrte.  A  few  drops  of  cocaine  or  eucaiue  are  next 
injected  into  the  skin  over  the  centre  of  this  space  ;  a  needle,  between  one 
and  two  millimetres  in  circumference  and  eight  centimetres  in  length,  at- 
tached to  the  syringe,  is  next  introduced  into  the  skin  midway  between  the 
spinous  processes,  a  little  to  the  right  of  the  median  line,  or  a  puncture  with 
a  tenotome  may  be  made  through  the  skin  and  the  needle  inserted  through 
this.  The  needle  and  syringe  should  be  thoroughly  sterilized  by  boiling 
before  being  used.  The  needle  should  be  pushed  forward  and  a  little  to  the 
left,  to  cause  it  to  enter  the  spinal  canal  in  the  median  line,  and  as  soon  as 
resistance  disappears  and  fluid  appears  in  the  syringe,  it  is  evident  that  the 
canal  has  been  entered.  After  a  few  drops  of  fluid  have  escaped,  the  syringe 
is  removed  from  the  needle  and  replaced  by  one  containing  the  cocaine 
or  eucaine  solution,  and  from  fifteen  to  twenty  minims  of  the  solution  are 
injected  into  the  spinal  canal.  The  needle  is  then  removed  and  the  punc- 
ture is  sealed  with  a  piece  of  gauze  and  collodion,  and  the  patient  is  placed 
in  the  recumbent  posture  ;  in  a  few  minutes  antesthesia  is  usually  far  enough 
advanced  for  the  operation  to  be  begun.  The  injection  is  sometimes  made 
between  the  fourth  and  fifth  lumbar  vertebrae. 

Subarachnoid  spinal  injection  cannot  be  employed  in  nervous  or  excita- 
ble patients,  but  may  be  emx^loyed  in  cases  where  for  any  cause  a  general 
anesthetic  is  contraindicated.  This  method  of  anaesthesia  has  been  employed 
successfully  in  a  great  variety  of  operations,  and  iq)  to  the  i^resent  time  few 
fatalities  have  been  reported  ;  but  it  should  be  remembered,  however,  that 
the  procedure  is  still  on  trial,  and  sufficient  time  has  not  elapsed  to  show  the 
ultimate  results  of  spinal  injections.  A  more  extended  use  of  the  method 
alone  can  prove  that  it  is  safer  than  the  general  anesthesia  as  now  employed. 
The  restriction  of  its  use  to  oj)erations  onljr  in  certain  portions  of  the  body 
also  renders  it  difiicult  to  estimate  its  comi^arative  safety. 

GENERAL   ANAESTHESIA. 

General  anaesthesia  may  be  produced  by  the  use  of  nitrous  oxide  gas, 
ether,  chloroform,  A.  C.  E.  mixture,  ethyl  bromide,  by  combinations  of 
these  drugs  or  by  their  combination  with  oxygen,  or  by  hypnotism.  The 
condition  of  general  anaesthesia  is  one  in  which  there  is  always  some  danger. 
Accidents  may  occur  during  the  development  or  after  the  production  of  this 
condition,  and  the  surgeon,  and  the  assistant  who  administers  the  anaesthetic, 
should  be  mindful  of  this  fact  and  watch  the  patient  most  carefully. 

Choice  of  Ansesthetic. — In  selecting  an  anaesthetic  the  most  impor- 
tant considerations  are  its  safety  and  its  suitability  for  the  individual  case. 


206  PEEPAEATIOX   OF  PATIENT. 

Of  the  anaesthetics  used  to  produce  general  anaesthesia;  in  point  of  safety 
nitrous  oxide  gas  holds  the  first  place,  but  unfortunately  its  use  is  restricted 
to  cases  in  which  only  a  short  period  of  antesthesia  is  required.  Next  in 
safety  is  ether,  and  next  chloroform.  Statistics  show  that  the  mortality  fol- 
lowing the  administration  of  nitrous  oxide  gas  is  1  to  5,250,000 ;  of  ether, 
1  to  16,675 ;  of  chloroform,  1  to  3749.  From  these  figures  it  will  be  seen 
that  nitrous  oxide  gas  is  by  far  the  safest  ansesthetic ;  but  it  should  be 
remembered  that  nitrous  oxide  is  used  only  in  trivial  operations,  while  ether 
and  chloroform  are  employed  in  the  most  serious  surgical  procedures,  and 
that  many  of  the  deaths  attributed  to  the  anaesthetics  maj^  have  been  d)ie 
to  conditions  resulting  from  the  operations  themselves. 

Preparation  of  Patient  for  General  Anaesthesia.— The  patient 

should  take  no  solid  food  for  at  least  five  or  six  hours  before  the  administra- 
tion of  ether  or  chloroform,  biit  nitrous  oxide  gas  may  be  given  one  or  two 
hours  after  taking  food.  The  stomach  may  be  washed  out  immediately 
before  or  after  the  administration  of  ether  or  chloroform  ;  this  is  especially 
imijortant  if  fecal  vomiting  is  present.  When  it  is  possible,  the  bowels 
should  be  previously  opened,  and  the  urine  should  be  voided  just  before 
the  administration  of  the  autesthetic,  as  it  is  apt  to  be  passed  during  the 
anaesthesia,  and  may  infect  the  wound  or  soil  the  clothing. 

In  feeble  patients  the  administration  of  an  ounce  of  whiskey  half  an  hour 
before  the  anaesthetic  is  given  is  a  useful  precaution.  False  teeth  or  foreign 
bodies,  such  as  tobacco,  chewing-gum,  etc.,  should  be  removed  from  the 
mouth.  The  patient  should  be  placed  in  the  recumbent  posture,  syncope 
being  less  apt  to  occur  in  this  position,  as  it  facilitates  the  circulation 
between  the  heart  and  the  brain,  and  the  head  should  be  turned  to  one  side. 
Care  should  always  be  taken  that  there  is  no  tight  clothing  around  the  neck, 
chest,  or  abdomen  which  might  embarrass  the  respiratory  action.  The  lips, 
nose,  and  anterior  nares  should  be  anointed  with  cosmoline,  to  save  them 
from  irritation  by  the  anaesthetic  ;  this  is  especially  important  if  chloroform 
is  employed  ;  the  eyes  should  also  be  covered  with  a  towel,  to  prevent  irri- 
tation of  the  conjunctiva.  The  urine  should  be  i^reviously  examined,  if 
possible,  especially  if  ether  is  to  be  administered. 

The  anaesthetizer  should  always  listen  to  the  heart's  action  as  a  part  of 
the  routine  preparation  before  giving  an  anaesthetic :  this  enables  him  to 
detect  any  irregularity  in  its  action,  and.  at  the  same  time  has  a  good  moral 
effect  uijon  the  jjatient,  especially  if  he  can  assure  him  that  he  can  take  the 
anaesthetic  with  safety.  The  anaesthetizer  should  attend  to  the  administra- 
tion of  the  anaesthetic  only,  and  should  watch  carefully  the  condition  of  the 
pulse,  respiration,  and  pupils. 

In  administering  an  anaesthetic  to  females,  a  second  person  should  always 
be  present,  as  these  drugs  often  cause  erotic  sensations,  and  the  patient  after 
recovering  from  their  effect  may  have  the  impression  that  she  has  been  sub- 
jected to  undue  liberties,  which  imxiression  can  best  be  refuted  by  the  state- 
ment of  a  witness  who  was  present  at  the  time.  It  is  always  well  to  have 
another  physician  present  during  the  administration  of  a  general  anaesthetic, 
as  unforeseen  difficulties  occasionally  arise. 

There  should  always  be  at  hand  tongue  forceps,  and  instruments  with 


KITEOUS  OXIDE  GAS.  207 

■which  tracheotomy  may  be  pei'formecl  if  Decessary,  also  whiskey,  nitrite  of 
amyl,  digitalis,  and  strychnine,  and  a  hypodermic  syringe,  and  in  serious 
cases  a  cylinder  of  oxygen  gas. 

Nitrotis  Oxide  Gas. — Nitrous  oxide  causes  anesthesia  by  arresting 
the  oxygenation  of  the  blood  while  it  is  in  contact  with  it,  and  in  addition 
the  gas  produces  anaesthesia  by  a  direct  action  upon  the  cerebral  cortex. 
This  gas  is  administered  for  the  purjjose  of  producing  anresthesia  of  limited 
duration.  The  apparatus  best  suited  for  its  administration  consists  of  a  cyl- 
inder of  metal  in  which  the  gas  is  compressed  ;  this  is  attached  by  a  tube  to 
a  rubber  bag,  and  to  this  bag  is  attached  a  mouth-piece  provided  with  a 
double  valve,  which  prevents  the  expired  air  from  passing  back  into  the 
bag.  The  flow  of  gas  is  regulated  by  a  stopcock  attached  to  the  cylinder. 
In  administering  this  anfesthetic  the  patient  is  usually  placed  in  the  sitting 
or  recumbent  posture,  and  after  removing  false  teeth  or  foreign  bodies  from 
the  mouth,  and  if  the  operation  be  upon  the  mouth  or  jaws,  the  jaws  are 
held  apart  by  a  gag  or  a  cork  or  jpiece  of  wood,  with  a  safety  string  attached, 
which  is  j)laced  between  the  molar  teeth.  The  mouth-piece  is  next  placed 
over  the  mouth,  the  nostrils  are  closed  with  the  thumb  and  fingers,  the  gas 
is  turned  on,  and  the  patient  is  instructed  to  take  deep  breaths.  Soon  after 
the  gas  is  inhaled  slight  cyanosis  of  the  face  appears,  and  usually  in  one 
minute  it  loses  its  expression  and  is  deeply  cyanosed,  the  puj)ils  dilate,  the 
breathing  becomes  stertorous,  the  conjunctiva  insensitive,  and  the  respira- 
tion slow  and  shallow.  Complete  anaesthesia  is  indicated  by  cyanosis  and 
stertor.  As  soon  as  the  inhalation  of  the  gas  is  stopped  the  cyanosis  disap- 
pears, the  stertor  ceases,  and  consciousness  returns.  Mtrous  oxide  gas  is 
contraindicated  in  alcoholic  subjects  or  in  those  having  marked  atheroma 
of  the  arteries,  as  apoplexy  may  occur,  or  in  conditions  of  obstructed 
respiration. 

The  shortness  of  the  period  of  antesthesia  induced  by  nitrous  oxide  gas, 
and  the  absence  of  complete  muscular  relaxation  and  the  muscular  tremor 
often  observed,  unfortunately  prevent  its  employment  in  the  majority  of 
surgical  operations.  An  abscess  may  be  opened,  teeth  extracted,  a  finger 
amputated,  or  a  superficial  tumor  removed,  but  any  operation  occupying 
more  than  a  few  minutes  cannot  be  undertaken  under  this  variety  of  anaes- 
thesia. It  is,  as  before  stated,  the  safest  and  most  i^rompt  in  its  action  of 
the  anaesthetics  known  at  the  present  time. 

Nitrous  Oxide  Gas  and  Oxygen. — The  administration  of  nitrous 
oxide  gas  with  oxygen  has  been  found  by  Hewitt  to  diminish  the  asphyxial 
symj)toms,  so  that  a  more  prolonged  and  tranquil  anaesthesia  can  be  safely 
obtained.  The  anaesthetic  state  is  not  produced  as  rapidly  as  by  nitrous 
oxide  gas  alone,  but  it  may  be  prolonged  by  a  skilful  anaesthetizer  for 
an  hour  or  more.  It  is  administered  by  a  sj)ecial  apparatus  by  which 
the  administrator  can  increase  or  diminish  the  amount  of  oxygen,  according 
to  the  symptoms  presented.  Cyanosis,  stertor,  and  muscular  twitching  call 
for  an  increase  in  the  oxygen,  whereas  symptoms  of  excitement  call  for  its 
diminution.  In  children  and  aged  and  anaemic  subjects  the  amount  of  oxygen 
can  be  increased  rapidly,  whereas  in  strong  full-blooded  subjects  the  quantity 
of  oxygen  must  be  increased  cautiously. 


208  ETHER. 

Ether. — Ether  is  at  the  present  time  the  substance  which  is  most  widely 
employed  in  North  America  for  the  induction  of  general  anaesthesia.  Its 
effects,  according  to  Hare,  result  from  the  action  of  the  drug,  first  on  the 
brain,  then  on  the  sensory  tracts  of  the  spinal  cord,  then  on  the  motor  tracts, 
then  on  the  sensory  side  of  the  medulla  oblongata,  and  finally  upon  the  motor 
side  of  the  medulla,  and  it  thereby  produces  death  from  respiratory  failure 
if  given  to  excess.  If  carefully  and  intelligently  administered,  its  use  is 
attended  with  com]3arative  safety,  and  there  are  few  conditions  which  contra- 
indicate  its  employment.  The  accidents  which  we  have  seen  occur  during 
its  use  have  been  largely  the  results  of  carelessness  on  the  part  of  the  anses- 
thetizer,  and  have  generally  been  due  to  mechanical  asphyxia  from  the 
accumulation  of  mucus  or  vomited  matters  in  the  pharynx,  or  from  falling 
back  of  the  tongue,  or  from,  crowding  a  wet  and  softened  ether  cone  over 
the  nose  and  mouth,  suffocating  the  patient ;  the  latter  condition  might  be 
produced  by  a  similar  use  of  a  towel  which  contained  no  anaesthetic  substance. 

Ether  is  a  comparatively  safe  anaesthetic,  but  its  use  is  attended  with 
risk  in  the  following  class  of  cases  :  1.  In  infants  where  it  causes  irritation 
of  the  bronchial  mucous  membrane  and  a  profuse  secretion  of  mucus,  and 
may  also  cause  bronchox^neumonia.  2.  In  aged  persons  profuse  secretion 
of  mucus  and  bronchopneumonia  may  follow  its  use.  It  is  also  coutraindi- 
cated  in  these  subjects  by  the  rigidity  of  the  chest  and  lessened  respiratory 
power.  3.  In  cases  of  extensive  atheroma  of  the  arteries  its  use  is  attended 
with  danger,  because  of  the  vascular  excitement  in  the  primary  stage  of  its 
administration,  which  may  cause  rupture  of  an  artery  from  increased  tension. 
4.  In  advanced  organic  disease  of  the  kidneys,  aad  especially  in  nephritis  of 
the  interstitial  form,  with  urine  of  a  low  specific  gravity,  and  in  diabetic 
subjects.  5.  In  diseases  of  the  heart  its  administration  is  more  dangerous 
in  myocardial  than  in  valvular  lesions.  6.  In  cases  of  obstructed  respira- 
tion from  swelling  of  the  pharynx,  in  fixatiou  of  the  tongue  in  cancer  and 
in  cellulitis  of  the  neck,  and  in  empyema  and  abdominal  distention,  its 
employment  is  attended  with  danger.  7.  lu  cases  in  which  examination  of 
the  blood  shows  that  the  haemoglobin  is  diminished  to  less  than  fifty  per  cent. 
8.  The  bronchial  irritation  following  its  use  may  impair  the  result  in  the 
operation  for  hernia  and  in  laparotomy. 

The  extremely  inflammable  character  of  the  vapor  of  ether  should  be 
borne  in  mind  in  using  the  actual  cautery  and  in  bringing  lights  near  a 
patient  when  operating  at  night ;  it  should  be  x-emembered  that  the  vaj)or 
of  ether  is  heavier  than  the  air  and  falls,  so  that  lights  may  be  brought  near 
the  wound  with  safety  if  they  are  held  above  the  level  of  the  ether  inhaler. 

Administration  of  Ether. — It  may  be  administered  by  the  open  or 
by  the  closed  method  ;  in  the  former  there  is  allowed  free  access  of  air,  and 
in  the  latter  the  patient  breathes  out  of  and  into  a  bag  containing  vapor  of 
ether,  getting  a  more  or  less  imperfect  supply  of  air.  By  the  latter  method 
asphyxiation  is  more  likely  to  occur,  so  that  the  open  method  of  adminis- 
tration is  the  safer  and  the  one  generally  employed  iu  this  country. 

Ether  may  be  administered  by  means  of  a  towel  folded  in  the  shape  of  a 
cone.  (Pig.  124. )  A  few  layers  of  stiff  paper  interposed  between  the  outer 
layers  of  the  towel  will  keep  the  cone  in  shape  and  will  prevent  the  evapo- 


ADMINISTRATION   OF  ETHEE. 


209 


ration  of  ether  from  its  external  surface.  Ether  ]uay  be  administered  by 
one  of  the  ordinary  inhalers,  and  of  these  we  have  found  AUis's  inhaler 
(Fig.  125)  the  most  satisfactory.  It  consists  of  a  metallic  framework,  which 
contains  a  number  of  folds  of  a  roller  bandage,  presenting  a  large  surface  for 


Fig.  125. 


Etlier  cone  made  from  a  towel. 


Allis's  inhaler. 


the  rapid  evaporation  of  the  drug,  covered  with  a  soft-  rubber  or  leather 
sleeve.  The  i^atient  being  prepared  as  previously  described,  and  the  head 
being  turned  to  one  side,  half  an  ounce  of  ether  is  poured  into  the  cone  or 
inhaler,  and  it  is  placed  over  the  nose  and  mouth  of  the  patient.  He  is 
then  requested  to  take  deep  breaths,  or  to  blow  the  ether  away,  which  latter  • 
procedure  causes  him  to  take  deep  inspirations.  In  the  beginning  of  ether- 
ization the  patient  will  resist  the  inhalation  much  less  if  the  ether  is  given 
slowly,  with  a  ijlentiful  admixture  of  air.  The  first  effect  of  the  inhalation 
of  ether  is  acceleration  of  the  pulse  and  respiration  ;  the  mucous  membrane 
of  the  air-passages  is  irritated,  and  coughing  often  occurs,  and  the  patient 
complains  of  a  sense  of  suffocation.  In  the  early  stage  of  etherization  there 
is  a  disposition  to  muscular  movements,  so  that  frequently  it  becomes  neces- 
sary to  restrain  the  patient ;  the  brain  is  also  excited,  and  the  patient  is  apt 
to  talk  or  cry  out.  These  symptoms  call  for  a  continuance  of  the  adminis- 
tration of  ether,  and  not  for  its  withdrawal.  Succeeding  this  stage,  if  the 
ether  be  pushed,  profound  antesthesia  takes  place,  as  is  evidenced  by  the  loss 
of  consciousness,  relaxation  of  the  muscular  system,  moist  skin,  loss  of  spe- 
cial senses,  contracted  pux)ils,  and  slow  and  deep  respiration,  tending  to 
become  stertorous.  When  the  conjunctiva  is  insensitive  to  the  touch  of  the 
finger  anesthesia  is  usually  complete. 

When  the  anaesthesia  is  profound  the  amount  of  ether  inhaled  should  be 
diminished,  and  the  patient  given  only  so  much  as  will  keep  him  well  under 
its  influence.  It  is  surprising  how  small  a  quantity  of  ether  a  careful  and 
watchful  ansesthetizer  will  require  to  keep  the  patient  fully  under  its  effects 
for  a  very  considerable  time.  The  time  required  to  produce  complete  anaes- 
thesia by  ether  varies  in  different  cases  :  antesthesia  is  i^roduced  in  children 
in  a  few  minutes  ;  in  adults  from  ten  to  fifteen  minutes  are  usually  required  ; 
alcoholic  subjects  require  a  large  amount  of  ether  and  take  a  long  time  to 
come  under  its  influence.  When  the  aduninistration  of  the  drug  is  stopped, 
the  patient  may  continue  for  some  time  in  an  unconscious  condition,  resem- 

14 


210  ACCIDENTS  DURING  ETHERIZATION. 

bling  a  quiet  sleep,  or  lie  may  awake  and  exhibit  more  or  less  symptoms  of 
cerebral  excitement. 

First  Insensibility  from  Ether. — There  exists  early  in  the  course  of 
the  administration  of  ether  a  stage  of  primary  ausesthesia,  which  lasts  for  a 
minute  or  more,  and  which  may  be  taken  advantage  of  to  perform  such  a 
minor  sui'gical  operation  as  the  opening  of  an  abscess,  the  reduction  of  a 
dislocation,  or  the  extraction  of  a  tooth.  The  recovery  from  this  condition 
is  usually  very  prompt,  and  is  not  followed  by  nausea  and  the  after-effects 
which  attend  the  prolonged  administration  of  ether. 

Accidents  during  Etherization. — During  the  administration  of 
ether,  particularly  in  the  early  stage,  the  patient  may  suddenly  stop 
breathing,  the  face  at  the  same  time  becoming  cyanosed.  This  condition 
calls  for  the  withdrawal  of  the  ether,  and  if  an  inspiratory  effort  does  not 
quickly  follow,  pressure  should  be  made  upon  the  front  of  the  chest,  and 
when  this  is  relaxed  a  deep  inspiration  usually  takes  place  and  no  further 
difficulty  is  experienced.  This  condition  should  not  be  confounded  with  the 
very  common  effort  to  hold  the  breath,  the  latter  occurring  with  the  chest 
fully  expanded,  the  former  with  the  chest  empty. 

Vomiting  may  occur  during  etherization,  and  the  vomited  matter  may 
accumulate  in  the  pharynx  or  the  mouth  and  obstruct  the  breathing,  or  may 
enter  the  larynx  or  the  trachea  and  cause  a  like  result.  Vomiting  is  more 
apt  to  take  place  if  solid  food  has  been  taken  shortly  before  the  administra- 
tion of  the  ansesthetic.  If  this  accident  occurs  and  interferes  with  the 
breathing,  the  jaws  should  be  opened  and  the  head  turned  to  one  side,  when 
the  vomited  matter  will  usually  escape  without  difficulty.  If,  however,  food 
has  entered  the  larynx,  and  is  not  ejected  by  coughing,  it  may  be  necessary 

to  open  the  trachea  and  hold  the  tracheal 
Fis-  126.  wound  open,  or  to  introduce  a  tube  and 

practise  artificial  respiration.  The 
breathing  may  also  be  obstructed  by  the 
accumulation  of  mucus  and  saliva  in 
the  pharynx,  which  is  less  likely  to  occur 
if  the  head  is  kept  on  one  side  during  the 
administration  of  the  drug  ;  if  it  occurs, 
the  head  should  be  turned  to  one  side,  the 
jaws  opened,  and  the  mucus  and  saliva 
removed  by  small  sponges  securely  fixed 
to  sponge-holders.     When  muscular  re- 

PusMng  the  jaw  forward.  .         .  -,,-,■  ^n        ■ 

laxation  is  complete  during  anaesthesia, 
the  tongue  may  fall  backward  and  obstruct  the  breathing  ;  this  accident 
also  is  less  likely  to  occur  if  the  head  is  kept  on  one  side  during  the  ether- 
ization. If  asphyxia  results  from  this  accident,  the  tongue  may  be  brought 
forward  by  placing  the  fingers  on  each  side  beneath  the  angles  of  the  inferior 
maxillary  bone  and  ijushing  the  jaw  forward,  at  the  same  time  over-extend- 
ing the  neck  by  bending  the  head  backward  (Fig.  126),  or  the  mouth  should 
be  opened  and  the  tongue  drawn  forward  by  tongue. forceps.  Either  of  these 
maniiiulations  is  usually  sulficieut  to  re-establish  the  respiratory  movements. 
If,  however,  in  any  of  these  forms  of  mechanical  asphyxia  resiiiratory  action 


ETHER  AND  NITROUS  OXIDE   GAS.  211 

is  not  promptly  restored,  some  form  of  artificial  respiration  should  be  resorted 
to,  either  Laborde's,  the  direct,  Silvester's,  or  forced  respiration  ;  and  of 
these  Laborde's  method,  by  i-hythmical  traction  of  the  tongue,  and  forced 
respiration  have  yielded  the  most  satisfactory  results.  Failure  of  respira- 
tion may  also  occur  from  paralysis  of  the  respiratory  centi-es  or  spasm  of 
the  respiratory  muscles ;  the  former  maj'  occur  from  an  overdose  of  the 
antesthetic  or  from  intercurrent  asphyxia,  syncoije,  or  morbid  states  of  the 
respiratory  system. 

Spasmodic  respiratory  failure  may  occiu' before  complete  anaesthesia, 
and  it  is  liable  to  arise  in  muscular  and  emphysematous  subjects.  Respira- 
tory failure  from  either  of  these  causes  should  be  promijtly  ti-eated  by  arti- 
ficial respiration  and  the  hypodermic  use  of  strychnine,  atropine,  or  digitalis. 

After-Effects  of  Ether.— After  complete  anaesthesia  from  ether, 
nausea  and  A'omiting  are  very  common  :  they  may  last  for  only  a  short  time 
or  may  persist  for  hours.  The  inhalation  of  the  vapor  of  vinegar  has  been 
recommended  to  prevent  the  nausea  and  vomiting  after  the  administration 
of  ether.  Its  inhalation  should  be  begun  as  soon  as  the  ether  has  been 
withdrawn  and  should  be  continued  for  some  minutes.  We  have  seen  its 
employment  satisfactory  for  this  purpose.  If  persistent,  the  swallowing  of 
a  few  mouthfuls  of  hot  water  will  often  relieve  the  condition,  or  the  admin- 
istration of  cocaine  hydrochlorate,  gr.  },  with  crushed  ice,  repeated  two  or 
three  times,  or  the  use  of  crushed  ice  with  champagne  or  brandy,  may  be 
followed  by  satisfactory  results.  Patients  often  complain,  for  from  twelve 
to  twenty-four  hours  after  the  adinmistration  of  ether,  of  dull  pain  in  the 
lumbar  region  or  of  pain  in  the  thighs  ;  this  has  recently  been  explained  as 
being  due  to  congestion  of  the  bone-marrow. 

Ether  and  Nitrous  Oxide  Gas.— The  production  of  anesthesia  by 
the  combined  use  of  nitrous  oxide  gas  and  ether  has  been  quite  extensively 
employed  both  in  England  and  in  this  country.  Hewitt  considers  this 
method  of  producing  ansesthesia  far  superior  to  any  other  method  which  we 
possess  at  the  present  time.  A  special  apparatus,  which  controls  definitely 
the  amount  of  nitrous  oxide,  ether,  and  air,  is  convenient,  but  the  ordinary 
gas  apparatus  and  an  Allis  inhaler  may  be  employed.  Anaesthesia  is  first 
produced  by  the  use  of  nitrous  oxide  gas,  and  as  soon  as  this  is  developed 
the  anaesthetic  state  is  maintained  by  substituting  the  vapor  of  ether  for  the 
nitrous  oxide  gas.  The  air  is  given  with  the  gas  until  antesthesia  is  com- 
plete, which  should  be  in  from  two  to  three  minutes  ;  the  breathing  at  this 
time  is  stertorous  and  cyanosis  is  marked  ;  after  this  time  air  is  administered 
with  the  ether  vapor.  Antesthesia  by  this  method  is  rapidly  induced,  there 
is  less  struggling  and  spasm,  the  quantity  of  ether  employed  is  smaller  and 
the  after-effects  are  less  marked,  especially  the  nausea,  and  recovery  from 
the  anaesthetic  state  is  more  rapid  than  when  ether  is  used  alone. 

Ether  and  Oxygen. — The  administration  of  ether  with  oxygen  gas 
has  been  employed  to  a  considerable  extent.  In  employing  this  combination 
to  produce  antesthesia  the  patient  is  first  allowed  to  inhale  a  small  amount 
of  ether  from  an  inhaler,  and  a  tube  connected  with  au  oxygen  receiver  is 
then  introduced  into  the  inhaler  and  oxygen  gas  is  turned  on,  so  that  the 
patient  is  allowed  at  the  same  time  to  inhale  the  vapor  of  ether  and  oxygen 


212  ADMINISTRATION   OF  CHLOROFORM. 

gas.  A  special  apijaratus  may  also  be  employed  whicli  regulates  definitely 
the  amouut  of  ether  and  oxygen  furnished.  Anaesthesia  produced  by  this 
combination  is  accompanied  by  less  cyanosis,  vomiting  is  rare,  and  the  patient 
recovers  very  jjromptly  from  the  antesthetic  state.  As  the  combination  of 
ether  vapor  and  oxygen  forms  a  highly  explosive  mixture,  care  should  be 
exercised  not  to  bring  a  flame  near  the  patient  during  its  administration. 

Chloroform. — Chloroform  has  been  shown  to  be  a  more  dangerous 
antesthetic  than  ether,  and,  although  it  is  widely  employed  in  Great  Britain 
and  upon  the  Continent,  it  is  not  generally  iised  in  this  country  except  in 
certain  districts,  the  South  and  Southwest,  and  here  its  use  is  followed  by 
fewer  fatalities  than  in  Iforthern  climates,  so  that  it  has  been  suggested  that 
it  is  safer  in  warm  climates.  In  Germany  it  is  rapidly  being  superseded  by 
ether.  Chloroform,  according  to  Hare,  first  affects  the  brain,  then  the  sen- 
sory part  of  the  spinal  cord,  then  the  motor  area  of  the  cord,  then  the 
sensory  paths  of  the  medulla  oblongata,  and  finally  the  motor  portions  of 
the  medulla,  and  produces  death  from  failure  of  the  vasomotor  centre  and 
of  the  respiratory  centre,  unless,  as  rarely  occurs,  the  heart  has  succumbed 
to  the  drug. 

Clinical  experience  has  demonstrated  the  fact  that  chloroform  can  be 
used  in  children  and  aged  subjects  and  in  puerperal  cases  with  comparative 
safety.  It  is  also  to  be  preferred  to  ether  in  patients  suffering  with  advanced 
renal  disease,  emphysema  of  the  lungs,  and  chronic  bronchitis.  It  is  pre- 
ferred to  ether  by  some  surgeons  in  operations  about  the  mouth  where  the 
actual  cautery  is  employed,  on  account  of  its  less  inflammable  character. 

Administration  of  Chloroform. — Chloroform  may  be  administered 
by  pouring  from  half  a  drachm  to  a  drachm  upon  a  folded  towel,  which 
should  be  held  at  first  a  few  inches  from  the  mouth  and  nose,  and  then 
gradually  brought  nearer,  but  should  not  be  allowed  to  come  in  contact 
with  the  skin,  as  its  irritating  action  will  blister  the  surface.  In  admin- 
istering chloroform  the  anissthetizfer 
Fjg.  127.  shoiild  remember  that  one  of  the  dan- 

gers in  its  use  is  the  too  great  concen- 
tration of  its  vapor,  and  should  there- 
fore be  careful  to  see  that  there  is  a 
sufficient  admixture  of  atmospheric  air. 
The  drop  method  may  also  be  used. 

4 Xy^^  Chloroform  may  also  be  administered 

Esmarch'schiorofon.i  iiihakT.  -with    Esmarch's    inhaler    (Fig.    127), 

which  consists  of  a  wire  frame  covered 
with  gauze,  or  by  the  use  of  Clover's  inhaler,  the  object  of  the  latter  inhaler 
being  to  regulate  the  amount  of  chloroform  inhaled  and  to  secure  a  proper 
admixture  of  atmospheric  air.  During  the  administration  of  chloroform  the 
anffisthetizer  should  watch  carefully  the  character  of  the  respiration,  the 
pulse,  and  the  pupils,  and  should  not  for  a  moment  have  his  attention 
diverted  from  the  patient. 

Profound  chloroform  anaesthesia  is  manifested  by  insensibility  of  the 
conjunctiva  to  the  touch,  absence  of  the  reflexes,  complete  muscular  relax- 
ation, and,  usually,   contracted  pupils.      When  this  stage  is  reached  the 


ACCIDENTS  DURING  CHLOROFORM   ANAESTHESIA.  213 

inhalatio2i  should  be  stopped,  and  after  this  time  only  so  much  chloroform 
should  be  administered  as  is  sufficient  to  keep  the  patieiit  fully  under  its 
influence. 

Complete  anesthesia  should  be  produced  before  any  operation  is  begun  : 
if  undertaken  before  that  time,  syncope  may  be  produced  by  reflex  inhi- 
bition of  the  heart.  If  convulsive  movements  take  place  before  the  patient 
is  fully  anaesthetized,  and  the  face  becomes  cyanosed,  the  inhalation  should 
be  discontinued  until  these  symptoms  disappear.  The  pupils  should  also 
be  carefully  watched,  to  see  if  they  res^Dond  to  light  or  if  they  are  con- 
tracted. If  the  anaesthesia  is  not  comx^lete,  insensibility  to  light  or  wide 
dilatation  is  a  sign  of  danger  which  calls  for  the  removal  of  the  antesthetic 
and  active  treatment  to  stimulate  the  circulation  and  respiration.  If  the 
inhalation  of  chloroform  has  been  stopped  and  is  again  in  a  short  time 
resorted  to,  it  should  be  given  very  carefully  and  slowly,  for  syncope  may 
suddenly  develop  from  the  fact  that  the  heart  or  the  i-espiratiou  may  feel 
the  effect  of  the  previous  use  of  the  drug.  The  after-effects  of  chloroform 
anaesthesia  are  less  mai'ked  than  those  following  the  use  of  ether,  nausea  is 
less  common,  and  the  recovery  from  the  anaesthetic  state  is  much  more 
prompt. 

Accidents  during  Chloroform  Anaesthesia.  —  Mechanical  as- 
phyxia may  occur  during  antesthesia  produced  by  chloroform,  as  well  as  that 
by  ether,  by  the  obstruction  of  the  respiratory  passages  by  blood,  mucus, 
foreign  bodies,  or  the  tongue  falling  backward  over  the  epiglottis.  These 
accidents  should  be  treated  in  the  same  manner  as  similar  accidents  occur- 
ring during  etherization.  Considerable  diversity  of  opinion  exists  among 
different  observers  as  to  whether  death  resulting  from  chloroform  is  due  to 
failure  of  the  heart  or  failure  of  the  respiration.  Although  it  has  been 
demonstrated  that  chloroform  is  a  direct  depressant  and  jjaralyzant  to  the 
heart-muscle  or  its  contained  ganglia,  yet  clinical  experience  shows  that 
paralysis  of  the  respiratory  centres  is  probably  the  most  important  factor  in 
causing  death  during  chloroform  anaesthesia,  for  circulatorj'-  failure  in  these 
cases  is  due  to  embarrassed  or  suspended  breathing,  and  the  only  method  of 
treatment  which  has  been  found  of  value  is  that  which  tends  to  bring  about 
respiratory  action, — namely,  some  one  of  the  various  forms  of  artificial 
respiration.  Death  from  the  administration  of  chloroform  results  from  car- 
diac failure  or  from  respiratory  arrest,  and  the  dangerous  symptoms  de\'elop 
so  raijidljr  that  the  greatest  promptness  is  required  to  meet  them. 

Syncope  developing  during  the  administration  of  chloroform,  manifested 
by  pallor,  fluttering  or  arrested  pulse,  and  cessation  of  respiration,  should 
be  treated  by  lowering  the  patient's  head,  the  use  of  a  rapidly  inter- 
rupted electric  current,  the  hyj)odermic  injection  of  digitalis,  atrojjine,  or 
strychnine,  and  the  employment  of  artificial  respiration,  either  the  direct 
method  or  Laborde's  method,  and,  as  in  cases  of  threatened  death  from 
ether,  the  treatment  should  not  be  desisted  from  for  some  time,  as  by  per- 
sistent employment  of  these  means  apparently  hopeless  cases  have  been 
resuscitated. 

Chloroform  and  Oxygen. — The  combined  use  of  chloroform  and 
oxygen  is  sometimes  employed  to  i^roduce  anaesthesia.     A  small  amount  of 


214  SCHLEICH'S  ANJ3STHETIC  MIXTURE. 

chloroform  is  first  administered,  and  then  oxygen  gas  is  introduced  into  the 
inhaler,  and  the  two  gases  are  inhaled  at  the  same  time ;  or  a  special  apparatus 
may  be  employed  by  means  of  which  a  definite  amount  of  each  drug  may  be 
administered. 

Chloroform  and  Ether. — Chloroform  may  also  be  administered  in 
conjunction  with  ether,  or  nitrous  oxide  gas  and  ether.  Anesthesia  is  first 
produced  by  ether  or  nitrous  oxide  gas,  and  the  anaesthesia  is  then  main- 
tained by  chloroform.  The  stimulating  effect  of  ether  is  thus  obtained,  and 
the  danger  of  cardiac  or  respiratory  failure  is  thus  diminished. 

Ethyl  Bromide. — Ethyl  bromide  produces  a  loss  of  sensibility  before 
consciousness  is  completely  lost,  and  does  not  produce  complete  relaxation 
of  the  muscles.  Its  prompt  action  and  the  brevity  of  the  narcosis  would  recom- 
mend it  in  many  cases,  but  the  fact  that  its  use  is  not  devoid  of  danger — for 
a  number  of  deaths  have  followed  its  employment  as  an  anaesthetic — will,  we 
think,  prevent  its  general  use  as  an  anaesthetic.  Its  mode  of  administration 
is  similar  to  that  of  ether. 

A.  C.  E.  Mixture. — Various  mixtures  of  chloroform,  ether,  and  alcohol 
have  been  used  to  produce  anaesthesia,  but  that  which  has  been  most  widely 
employed  is  known  as  the  A.  C.  E.  mixture,  consisting  of  chloroform,  3 
parts ;  ether,  1  part ;  alcohol,  1  part.  Some  surgeons  employ  this  mix- 
ture with  the  idea  that  the  dangers  of  chloroform  are  diminished  by  its 
combination  with  ether  and  alcohol,  but  clinical  experience  has  not  proved 
this  view  to  be  correct.  It  should  therefore  be  used  with  the  same  care  as 
chloroform.  It  should  be  administered  upon  a  towel,  or  with  an  inhaler, 
in  the  same  manner  as  chloroform,  and  the  patient  should  be  watched  as 
carefully  during  its  inhalation  as  during  the  administration  of  the  latter 
drug,  and  accidents  occurring  during  its  use  should  be  treated  in  the  same 
manner  as  those  arising  during  the  administration  of  chloroform.  Those 
who  have  had  a  large  experience  with  this  anaesthetic  recommend  its  use 
in  the  case  of  children  and  in  stout,  flabby  subjects  suffering  from  shortness 
of  breath,  in  jjatients  suffering  from  advanced  disease  of  the  heart  or  blood- 
vessels, and  in  operations  upon  the  neck,  mouth,  or  pleura. 

Schleich's  Anaesthetic  Mixture.— Schleich  has  introduced  an  anes- 
thetic mixture,  composed  of  chloroform,  5iss,  petroleum  ether,  gss,  and  sul- 
phuric ether,  3  vi,  which  he  considers  safer  than  ether  or  chloroform.  This 
surgeon  maintains  that  the  absorj)tion  of  a  general  anaesthetic  is  chiefly 
regulated  by  the  boiling-point  or  point  of  maximum  evaporation  of  the  anaes- 
thetic. This  anaesthetic  can  be  given  upon  a  towel  or  with  an  inhaler.  It 
is  claimed  that  by  its  use  little  excitement  is  produced  and  cyanosis  rarely 
occurs,  that  there  is  no  hypersecretion  of  mucus  and  no  consecutive  bron- 
chitis or  ijneumonia.  The  anaesthetic  state  is  quiet,  reaction  is  rapid,  and 
vomiting  occurs  in  less  than  half  the  cases. 

Hypnotism. — The  ansestlietio  state  of  hypnotism  has  been  utilized  for 
the  performance  of  surgical  operations.  Schmeltz  and  others  have  recorded 
operations  done  under  this  influence,  the  patients  apparently  suffering  no 
pain.  While  there  is  no  doubt  that  an  anaesthetic  state  may  be  obtained  by 
hypnotism  which  might  be  serviceable  in  surgical  operations,  yet  we  do  not 
believe  that  it  will  be  of  general  utility. 


•AFTER-EFFECTS   OF  GENER.'VL  ANyESTPIESIA.  215 

After-Effects  of  General  Anaesthesia.— The  temperature  is  usually 
notably  lowered  by  ansesthetics,  so  that  it  is  always  well  to  api^ly  artiiicial 
heat  and  keep  the  patient  well  covered.  Retention  of  urine  is  not  un- 
common, and  this  condition  should  not  be  overlooked.  A  forni  of  mental 
disturbance  known  as  covfusional  insanity  is  often  attributed  to  the  use  of 
anaesthetics,  but,  as  it  does  not  usually  develop  until  some  time,  often  two 
or  three  weeks,  after  their  employment,  H.  C  Wood  is  of  the  opinion  that 
the  relation  between  the  mental  symjitoms  and  the  anaesthesia  has  not  been 
clearly  proved  in  these  cases,  and  that  it  is  rather  the  outcome  of  a  peculiar 
depression  of  the  cerebral  cortex  jiroduced  by  the  shock  of  the  operation 
itself,  or  by  the  emotional  strain  due  to  the  surgical  illness.  This  view 
seems  to  be  confirmed  by  the  fact  that  many  of  the  cases  of  confusional 
insanity  which  are  observed  follow  injuries  in  which  no  ausesthetic  has  been 
given.  Albumimuia  and  glycosuria  may  follow  the  administration  of  ether 
or  chloroform,  but  are  usually  only  temporary  conditions. 

Paralysis  of  Nerves. — Paralysis  of  the  nerves  of  the  brachial  plexus 
may  follow  prolonged  anjesthesia  when  the  arm  is  drawn  high  above  the 
head,  and  is  not  due  to  the  anaesthetic,  but  results  from  stretching  of  the 
nerves  over  the  head  of  the  humerus  or  their  compression  between  the 
clavicle  and  the  first  rib.  The  musculo-spiral  nerve  may  also  be  paralyzed 
from  compression  of  the  nerve  against  the  edge  of  the  table  if  the  arm  is 
allowed  to  hang  over  the  table. 


CHAPTER    XV I. 

AMPUTATIONS. 
By  Henry  E.  Whaeton,  M.D. 

The  term  amputation  is  generally  restricted  to  tlie  operation  for  the 
removal  of  a  part  or  the  whole  of  a  limb.  A.  limb  may  be  amputated 
through  its  bones  or  through  its  joints  ;  the  former  operation  is  known  as  an 
amputation  in  the  continuity  of  the  limb,  the  latter  as  an  amputation  in  the 
contiguity,  or  as  a  disarticulation.  Amputation  is  now  much  less  frequently 
resorted  to  than  formerly,  since  the  general  introduction  of  asepsis  in  the 
treatment  of  wounds,  and  also  fiom  the  fact  that  in  many  injuries  involving 
joints  the  more  conservative  oi^eration  of  excision  is  practised  with  success. 
In  the  lower  extremity  amx^utation  is  more  frequently  required  than  in  the 
upper  extremity  ;  in  the  latter  the  very  free  collateral  circulation  and  the 
limited  disability  which  follows  shortening  render  excision  and  resection 
often  more  advisable  than  amputation. 

Conditions  requiring  Amputation. — Compound  Fractures  and 
Dislocations. — These  injuries  often  demand  amputation.  Extensive  com- 
minution and  loss  of  bone,  especially  in  the  lower  extremity,  is  an  indica- 
tion for  amputation.  Avulsion  of  a  Limb. — Although  a  limb  may  have 
been  torn  off  or  may  be  only  hanging  by  a  few  shreds  of  skin,  muscle,  or 
tendon,  amputation  is  indicated  to  promote  the  healing  of  the  wound  and 
insure  the  formation  of  a  \Tseful  stump.  Gangrene. — Gangrene  involving 
the  extremities,  when  not  localized  or  superficial,  is  usually  a  cause  for  am- 
putation. Effects  of  Cold  and  Heat. — Amputation  hiay  be  required  for 
the  conditions  ai'ising  from  exposure  to  cold  or  the  destruction  of  a  portion 
of  the  limb  arising  from  scalds  or  burns.  Lacerated  and  contused 
wounds  and  gunshot  injuries  may  demand  amputation.  Inflammatory- 
Affections  of  Bones  and  Joints. — Although  amj^utations  are  less  frequently 
required  in  these  cases  than  formerly,  owing  to  the  substitution  of  excision 
or  arthrectomy,  there  are  still  cases  in  which,  from  the  extent  of  the  bone 
involved  and  the  implication  of  the  soft  tissues,  amputation  is  required. 
Injuries  of  Blood-Vessels. — Amputation  is  sometimes  required  for  inju- 
ries of  the  larger  arteries  and  veins,  as  well  as  for  aneurisms  which  have 
become  diffused.  Malignant  Growths. — These,  when  involving  the  bones 
of  the  extremities,  or  when  extensive  and  situated  in  the  soft  parts  and 
closely  attached  to  important  blood-vessels  and  nerves,  so  that  their  removal 
is  dangerous  or  impossible,  often  demand  amputation.  Deformities. — 
Amputation  may  be  required  for  the  relief  of  deformities,  either  natural  or 
acquired ;  but  since  the  introduction  of  osteotomy  many  deformities  of  the 
bones  which  were  formerly  subjected  to  amputation  can  be  satisfactorily 
corrected  by  this  procedure. 

Instruments  required  for  Amputation.— These  are  a  tourniquet 
or  other  means  of  controlling  the  circulation  during  the  operation,  knives 
216 


INSTRUMENTS  FOR  AMPUTATION. 


217 


Petit's  tourniquet. 


of  varions  shapes  and  sizes,  a  saw,  bone-forceps,  artery  or  hseniostatic  for- 
ceps, i-etractors,  scissors,  ligatures,  sutures,  and  needles. 

Tourniquets. — The  control  of  the  bleeding  during  amputation  is  a  very 
important  pnvt  of  the  procedure.  This  may  be  accomplished  by  the  use  of 
the  ordinary  toui^niquet,  known  as  Petit's  tour- 
niquet (Fig.  128),  which  consists  of  two  metal 
plates,  the  distance  between  which  is  regulated 
by  a  screw,  with  a  strong  linen  or  silk  strap 
provided  with  a  buckle.  In  applying  this,  a 
firm  pad  or  compress  is  secured  immediately 
over  the  main  artery  by  a  few  turns  of  a  band- 
age passed  around  the  limb  ;  upon  this  pad  is 
l^laced  the  lower  plate  of  the  tourniquet,  so 
that  the  artery  is  held  between  this  plate  and  | 
the  bone ;  the  strap  is  then  buckled  tightly  ''^ 
enough  to  keep  the  instrument  in  place.  The 
compress  is  next  forced  down  upon  the  artery 
by  turning  the  screw  and  separating  the  plates, 
until  the  circulation  is  comijletely  arrested. 
Other  forms  of  tourniqiiets,  such  as  the  horse- 
shoe tourniquet,  or  Skey's  abdominal  tourniquet,  are  sometimes  emjiloyed. 

Esmarch's  Hgemostatic  Apparatus.— This  haemostatic  apparatus  is 
now  generally  emploj^ed,  and  consists  of  a  rubber  bandage  and  an  elastic 
tube  or  strap.  The  bandage  is  applied  to  the  parts  from  the  lowest  ex- 
tremity of  the  limb  to  a  jjoint  some  distance  above  the  seat  of  the  proposed 
amputation.  (Fig.  129.)  The  elastic  tube  or  strap 
is  then  firmly  wound  about  the  limb  at  the  upper 
end  of  the  bandage,  and  the  rubber  bandage  is  re- 
moved. This  renders  the  limb  bloodless,  prevent- 
ing the  loss  of  blood  during  the  operation,  and  adds 
to  the  bulk  of  the  circulation  the  amount  of  blood 
which  was  in  the  limb  before  it  was  rendered  aniemic. 
The  elastic  bandage  is  often  dispensed  with,  the  con- 
strictor only  being  emjployed.  The  bandage  should 
not  be  employed  when  the  tissues  are  septic  or  over 
malignant  growths.  Esmarch'  s  apparatus  has  proved 
a  most  valuable  means  of  controlling  hemorrhage 
and  of  saving  blood  during  the  operation,  but  cau- 
tion should  be  observed  in  its  use.  The  elastic  con- 
stricting band  should  be  applied  for  as  short  a  time 
as  possible  and  only  firmly  enough  to  control  the 
circulation,  for  damage  to  the  blood-vessels,  nerves, 
and  muscles  may  occur  from  its  too  prolonged  and 
tight  application.  The  principal  disadvantage  in 
the  use  of  elastic  constriction  consists  in  the  fact  that  very  troublesome 
oozing  or  consecutive  hemorrhage  follows  its  removal  by  reason  of  a  vaso- 
motor paralysis,  which  results  from  the  pressure  of  the  strap.  This  may  be 
in  a  measure  prevented  by  the  removal  of  the  elastic  constricting  band  as 


Fig.  129. 


Esmarch's  bandage  applied. 


218 


INSTRUMENTS  FOE.  ABIPUTATION. 


soon  as  the  larger  vessels  have  been  secured.  In  operating  upon  the  hands 
and  feet  an  ordinary  rubber  drainage-tube  may  be  employed  instead  of  the 
elastic  straj),  to  control  the  bleeding.  In  emergencies,  where  an  ordinary 
elastic  tube  cannot  be  obtained,  a  pair  of  elastic  suspenders  may  be  employed 
in  place  of  the  elastic  strap  of  Esmarch. 

Amputating  Knives. — Formerly,  when  transfixion  was  the  favorite 
method  of  amputation,  very  long  amputating  knives  were  used,  but  at  the 
present  time  a  stout  scaljael  having  a  blade  three  inches  in  length,  or  an 
amputating  knife  with  a  blade  from  six  to  eight  inches  in  length,  is  usually 
employed.    (Fig.  130.)    A  double-edged  knife,  known  asacatlin  (Fig.  130), 


Amputating  knife  and  catlin. 


is  sometimes  employed  for  dividing  the  interosseous  tissues  in  operations 
where  there  are  parallel  bones.     In  amj)utations  through  the  tarsus  or  of 

Fig.  131. 


Neill's  finger  knife. 

the  metacarpal  bones,  or  of  the  fingers  or  toes,  a  short,  strong,  narrow- 

bladed  bistoury,  known  as  Neill's  finger  knife,  will  be  found  a  most  useful 

instrument.     (Fig.  131.) 

Fig.  1.32. 


Amputating  saw. 

Saw. — An  amputating  saw  should  have  a  blade  about  ten  inches  in 
length  and  two  or  two  and  a  half  inches  in  width,  or  a  bow-saw  with  a  nar- 
row blade  (Fig.  132)  which  is  reversible  and  can  also  be  used  for  excisions 

Fig.  133. 


is'^frequently  employed.      For  amputations  about  the  hands  and  feet  a 
narrow-bladed  metacarpal  saw  will  often  be  useful. 


INSTRUMENTS  FOR  AMPUTATION.  219 

Bone-Forceps. — Bone-forceps  may  be  used  for  dividing  the  phalanges 
in  amputations,  or  for  smoothing  off  any  rough  edges  of  the  bone  which  have 
been  left  by  the  saw.     (Fig.  133.) 

Periosteotome. — A-  periosteotome  is  sometimes  employed  before  the 

bone  has  been  divided,  to  loosen  and  turn  up  a  cuff  of  periosteum,  which, 

after  the  bone  has  been  divided,  is  drawn  down  and  sutured  over  the  sawed 

surface  of  the  bone.     (Pig.  134.) 

Tu     1",4 


Artery  or  Heemostatic  Forceps.— Artery  or  haemostatic  forceps  are 
also  requii-ed.  These  instruments  should  be  self-retaining,  so  that  if  the 
bleeding  is  profuse  from  small  vessels  after  the  tourniquet  is  removed,  a 
number  of  vessels  may  be  clamped  rapidly  and  the  forceps  allowed  to  remain 
in  place,  and,  finally,  when  all  bleeding  has  been  arrested,  the  arteries  can 
be  twisted  or  ligated  before  the  forceps  are  removed. 

Retractors. — These  consist  of  pieces  of  sterilized  muslin  from  six  to 
eight  inches  in  width  and  twenty-four  inches  in  length,  one  end  of  which  is 
split  into  two  or  three  tails.  The  former  variety  of  retractor  is  employed 
where  one  bone  is  divided,  as  in  amputations  of  the  arm  and  thigh ;  the 
latter  in  cases  where  two  bones  are  divided,  as  in  amputations  of  the  forearm 
and  leg. 

Ligatures. — Sterilized  catgut  or  silk  ligatures  are  usually  employed  to 
secure  the  vessels  after  amijutation. 

Sutures  and.  Needles. — A  great  many  different  materials  are  em- 
ployed for  sutures  in  bringing  together  the  flaps  in  amputations.  Silk- 
worm-gut, catgut,  silk,  and  silver  wire  may  be  employed,  the  principal 
requirement  being  that  the  material  shall  be  one  which  can  be  easily  steril- 
ized, and  is  sufficiently  strong  to  hold  the  flaps  together  until  union  has 
occurred.  Personally  we  prefer  catgut  for  buried  sutures,  and  either  silk 
or  silkworm-gut  for  approximation  of  the  flaps.  The  needles  employed  in 
closing  the  stump  may  be  either  curved  or  straight,  according  to  the  choice 
of  the  surgeon. 

Methods  of  Amputating. — Amputations  may  be  performed  by  the 
circular,  flap,  transfixion,  oval  or  modified  circular,  and  elliptical  methods, 
or  Teale's  method  by  rectangular  flaps.  In  forming  flaps  in  amputation  the 
operator  should  allow  for  the  contraction  of  the  skin  and  retraction  of  the 
muscles  ;  the  old  rule  was  to  allow  one  finger-breadth  for  contraction  of  the 
skin  and  two  for  retraction  of  the  muscles. 

Circular  Method. — In  performing  an  amputation  by  this  method  the 
incision  of  the  skin  is  made  at  some  distance  below  the  point  where  the  bone 
is  to  be  divided.  An  assistant  grasps  the  limb  and  draws  the  skin  evenly 
and  firmly  towards  the  root  of  the  part,  and  the  surgeon  passes  the  heel  of 
the  knife  well  into  the  tissues  and  makes  a  circular  sweep  around  the  limb, 
completing  the  division  of  the  skin  and  cellular  tissue  with  one  motion 
of  the  knife.     The  second  incision  in  amputation  by  the  circular  method 


220 


METHODS  OF  AMPUTATION. 


consists,  after  retraction  of  tlie  skin,  in  making  a  circular  cut  througli  all 
the  tissues  down  to  the  bone.     (Fig.  135.)     The  third  step  in  this  form  of 


Amputation  by  the  circular  metliod.     (After  Esmarch.) 


amj)utation  consists,  after  retracting  the  skin  and  muscles  and  holding  them 
back  by  retractors,  in  the  division  of  the  bone  with  a  saw. 

Flap  Method. — This  method  of  amputation  is  susceptible  of  many 
variations  :  there  may  be  one  or  two  flaps  of  equal  or  unequal  length  ;  the 
flaps  may  be  cut  antero-posteriorly,  laterally,  or  obliquely ;  thej^  may  also 
be  made  by  transfixing  the  limb  and  cutting  outward,  or  may  be  cut  from 
without  inward,  or  may  be  formed  so  as  to  include  the  whole  thickness  of 
the  tissues  down  to  the  bone,  or  merely  the  skin  and  superficial  fascia,  the 
deep  structures  being  divided  by  a  circular  incision.  The  flaps  may  have  a 
curved  outline,  or  may  be  rectangular  in  shape. 

Transfixion  Method. — In  amputation  by  transfixion  (Fig.  136)  the 
surgeon  grasj)S  the  limb  and  enters  the  point  of  a  long  knife  into  the  tissues 

Fig.  136. 


Forming  flaps  by  transfision.    (Agnew.) 


at  the  side  nearest  himself,  pushing  it  across  and  around  the  bones,  bringing 
it  out  through  the  skin  diametrically  opposite  its  point  of  entrance.  He 
then  shapes  the  flap  by  cutting  downward  with  a  rapid  sawing  motion  until 
a  flap  of  sufficient  length  has  been  formed,  and  next  cuts  obliquely  outward 
until  all  the  tissues  are  divided.  The  flap  being  turned  up  and  held  out 
of  the  way,  he  re-enters  his  knife  at  the  same  point  and  passes  it  to  the 


METHODS   OF  AMPUTATION. 


221 


opposite  side  of  the  bone  or  boues,  and  cuts  a  second  flap  of  eqnal  length 
in  the  same  manner. 

Modified .  Circular  or  Oval  Method.— In  this  method  of  ampntatiou 
t-«-o  oval  skin-flaps,  antero-posterior  or  lateral,  are  turned  up  (Pig.  137),  and 


Fig.  137. 


^^ 


Fig.  138. 


Amputation  by  oval  flaps. 

the  muscles  are  next  divided  down  to  the  bone  by  a  circular  sweep  of  the 
knife.  This  form  of  amputation  is  at  the  present  time  very  widely  employed, 
and  is  especially  to  be  recommended  in  amputation  in  muscular  limbs. 

Elliptical  Method. — This  is  a  form  of  the  oval  method  of  amputation 
which  is  employed  in  amputations  at  the  knee-  and  elbow-joints.  The 
incision  forms  a  perfect  ellipse,  coming  below  the  joint  on  the  fi-ont  or 
outside  of  the  limb,  the  resulting  flap,  folded  upon  itself,  making  a  curved 
cicatrix  and  furnishing  an  excellent  covering  for  the  stump. 

Teale's  Method  by  Rectangular  Flaps. — In  this  method  of  ampu- 
tation two  flaps  are  made  of  unequal  length,  and  the  incisions  are  so  planned 
that  the  shorter  flap  contains  the  more 
important  vessel  or  vessels.  The  flaps 
are  cut  of  equal  widths ;  the  length  of 
the  long  flap  should  be  one-half  the 
circumference  of  the  limb  at  the  jDoint 
where  the  bone  is  to  be  divided,  and 
that  of  the  short  flap  should  be  one- 
eighth  of  the  circumference  of  the  limb. 
The  flaps  are  cut  from  without  inward, 
and  embrace  all  the  tissues  of  the  limb 
down  to  the  bone.  After  the  flaps  have 
been  dissected  up,  the  bone  is  divided 
with  a  saw,  and  after  the  bleeding  has 
been  arrested  the  long  flaj)  is  folded 
over  and  sutured  to  the  short  flap.  (Fig. 
138.)  The  disadvantages  of  this  method  of  amputation  are  that  in  muscular 
limbs  it  requires  the  bone  to  be  divided  at  a  higher  point  than  would  other- 
wise be  necessary,  and  there  is  also  liability  to  sloughing  of  the  long  flap. 

Bier's  Osteoplastic  Method. — This  method  is  designed  in  amputations 
of  the  leg  to  secure  a  stump  capable  of  sustaining  direct  pressure  upon  its 
extremity.  It  may  be  employed  at  the  time  of  the  amx^utation  or  after  the 
stump  has  healed.  When  employed  as  a  i^rimary  operation  a  thin  section 
of  the  tibia  with  the  periosteum  attached  is  sawed  from  the  tibia  and  turned 
over  the  sui'faces  of  the  tibia  and  fibula  at  their  point  of  section  (page  251). 
When  ajjplied  to  stumj^s  a  wedge-shaped  section  is  removed  from  the  soft 
parts,  the  tibia  and  fibula,  the  base  of  the  wedge  being  anterior.    The  opera- 


Amputation  of  leg  by  Teale's  method.   (Bryant.) 


222 


PERIOD   OF  AMPUTATION. 


Fig.  139. 


Osteoplastic  amputation  of  stump. 


tion  is  modified  according  as  it  is  applied  to  long  or  short  stumps ;  in  the 
former  the  portion  of  bone  removed  is  a  little  distance  from  the  end  of  the 
stump,  and  in  the  latter  the  wedge  begins  at  the  end  of  the  bone,  to  prevent 

marked  shortening  of  the  stump.  (Fig. 
139.)  The  disadvantages  of  this  method 
are  the  shortening  of  the  stumi?,  the  time 
required,  and  the  difficulty  of  maintaining 
the  bone-flap  in  position. 

Periosteal  Flaps.  —  In  any  of  the 
methods  of  amputation  previously  described 
the  xDeriosteum  may  be  dissected  up  in  two 
flaps  attached  to  the  muscles,  or  pushed  uj) 
as  a  sleeve  by  means  of  a  director  or  peri- 
osteotome  before  the  boue  is  sawed.  This 
procedure  is  most  easily  accomplished  in 
young  subjects.  When  periosteal  flaps  have  been  made,  before  closing  the 
wound  they  should  be  brought  down  over  the  end  of  the  boue  and  their 
edges  approximated  by  a  continiious  catgut  suture.  In  this  way  the  peri- 
osteum covers  the  cut  surface  of  the  bone,  to  which  it  soon  forms  adhesions. 
Relative  Value  of  the  Different  Methods.— It  is  well  for  the 
surgeon  to  have  in  mind  the  different  methods  of  amputation,  for  he  should 
not  coufine  himself  to  any  one  method,  but  should  iiractise  the  procedure 
which  seems  to  him  best  adapted  for  the  special  case.  In  many  cases  the 
laceration  of  the  tissues  or  other  conditions  may  prevent  the  performance 
of  any  typical  operation,  and  in  such  cases  the  surgeon  may  have  to  cut  his 
fla^js  and  modify  the  operation  according  to  the  conditions  x>resented.  In 
amputations  just  above  the  ankle  or  in  the  forearm,  the  circular  method  is 
quite  satisfactory.  In  the  leg,  some  form  of  the  flap  or  the  modifled  circular 
method  can  be  practised  with  the  best  results  ;  while  in  the  arm  and  thigh 
the  modified  circular  method  is  the  one  generally  employed.  At  the  knee 
or  elbow  the  o\  al  or  the  elliptical  method  is  usually  practised. 

Period  of  Amputation. — Amputations  demanded  by  injury  of  the 
tissues  may  be  done  in  the  primary,  the  intermediary,  or  the  secondary 
period.  The  primary  period  is  the  time  before  traumatic  fever  has  devel- 
oped. In  cases  of  injury  the  surgeon  should,  if  possible,  amputate  during 
this  period,  but  he  will  often  have  to  delay  the  operation  for  some  hours 
until  reaction  has  occurred,  if  the  patient  is  suffering  from  shock.  The  inter- 
mediary period  is  that  after  traumatic  or  septic  fever  has  developed  :  this  is 
not  considered  a  favorable  period  in  which  to  undertake  amputation.  The 
secondary  period  is  that  after  sui>i)uration  or  septic  inflammation  has 
developed  and  has  gradually  subsided :  this  is  a  comparatively  favorable 
period  for  amputation.  These  various  periods  are  not  now  so  clearly  de- 
fined as  formerly,  since  the  inti-oduction  of  antiseptic  methods  ;  the  primary 
period  is  often  much  prolonged,  and  the  intermediary  and  secondary  some- 
times do  not  exist.  Extensive  experience  has  shown  that  the  primary 
period  is  the  most  favorable  for  amputation. 

Preparation  of  the  Patient  for  Amputation. — Many  patients 
suffering   from   injuries  which  demand   ajuputatiou  are  not   in   condition 


AMPUTATIONS  DURING  SHOCK.  223 

to  bear  the  operation  when  they  come  under  the  care  of  the  surgeon.  Such 
patients  are  usually  suffering  markedly  from  shock,  and  the  first  indication 
in  their  treatment  is  to  bring  about  reaction.  (See  page  93.)  In  am^ju- 
tations  for  injuries,  if  there  is  no  active  bleeding  from  the  wound,  it  should 
be  carefully  irrigated  with  a  solution  of  bichloride,  and  the  surrounding 
skin  gently  rubbed  over  with  tuj-peutine,  which  should  be  followed  by  the 
use  of  soap  and  water,  and  finally  thoroughly  irrigated  with  a  1  to  2000 
bichloride  solution,  and  the  part  wrapped  in  several  towels  wrung  out  of 
bichloride  solution.  If  it  is  found  that  there  is  a  moderate  amount  of 
bleeding,  and  the  bleeding  A'^essels  can  be  seen  by  carefully  exploring  the 
wound,  they  should  be  secured  by  ligatures.  If  the  bleeding  arises  from  a 
number  of  small  vessels  aud  constitutes  a  continuous  oozing,  the  wound 
should  be  firmly  packed  with  strips  of  bichloride  or  sterilized  gauze,  and  a 
comjjress  of  gauze  should  be  placed  over  the  wound  and  held  in  position  by 
a  firmly  applied  bandage.  If,  however,  the  bleeding  is  free,  the  application 
of  a  tourniquet  may  be  necessary.  The  elastic  strap  of  the  Esmarch  apparatus 
is  the  appliance  which  will  usually  control  the  bleeding  most  jiromptly  and 
perfectly.  We  think  that  in  many  cases  the  elastic  tube  or  strai^  is  used 
improperly,  from  the  fact  that  it  is  often  applied  high  uj)  upon  the  limb 
away  from  the  wound,  is  applied  too  tightly,  and  is  allowed  to  remain  for 
too  long  a  time.  A  tightly  applied  Esmarch  elastic  strap  soon  becomes 
painful  to  the  patient,  and  for  this  reason  we  prefer  not  to  use  it  where  the 
bleeding  can  be  controlled  by  simple  packing  of  the  wound  and  the  use  of  a 
compress  and  a  bandage.  If  the  Esmarch  strap  is  required  to  control  hemor- 
rhage, we  apply  the  strap  over  the  wound,  or  as  near  the  wound  as  iDOSsible, 
preferring  to  apply  it  to  the  contused  and  lacerated  tissues  of  the  wound 
itself,  which  are  not  to  be  included  in  the  flaps  when  the  amjjutation  is 
done,  for  we  are  certain  that  sloughing,  which  sometimes  occurs  in  the  flaps 
after  amputation,  is  often  due  to  the  injury  done  to  the  tissues  by  the  pro- 
longed use  of  elastic  constriction.  When  reaction  has  been  established,  as 
is  evidenced  by  the  improvement  in  the  pulse  and  the  rise  of  temperature 
to  or  a  little  above  the  normal,  the  patient  may  be  considered  in  condition 
for  the  operation. 

Amputations  during  Shock. — The  question  of  amputating  while 
the  patient  is  suffering  from  shock  is  one  which  has  received  a  great  deal 
of  attention,  and  at  the  present  time  the  weight  of  surgical  opinion  is 
decidedly  against  the  operative  j)rocedure  in,  this  condition.  There  are, 
however,  cases  in  which  the  condition  of  shock  is  probably  kept  up  by 
the  presence  of  the  lacerated  tissues,  and  in  which,  in  spite  of  treatment, 
reaction  is  not  established.  In  such  cases  it  seems  scarcely  humane  to  allow 
the  patient  to  die  without  attempting  operative  treatment.  In  these  cases 
we  often  administer  an  anaesthetic,  aud  if  the  patient's  condition  improves 
under  its  use  we  continue  it  until  anaesthesia  is  produced,  and  then  rapidly 
perform  the  amputation ;  a«d,  although  many  cases  subsequentlj'  die  of  shock, 
recovery  follows  in  a  sufficient  niunber  to  justify  the  procedure. 

Details  of  an  Amputation. — The  parts  having  been  previously 
thoroughly  sterilized,  the  x^atieut  is  anfesthetized  and  is  placed  upon  the 
operating-table.     The  surgeon  should  first  consider  the  means  of  controlling 


224 


DETAILS   OF  AN  AMPUTATION. 


the  bleediug  during  tlie  operation.  If  the  patient  has  lost  a  considerable 
quantity  of  blood  it  is  important  that  as  much  as  possible  be  saved,  and, 
with  this  end  in  view,  an  elastic  bandage  shou.ld  be  applied  from  the  lowest 
portion  of  the  limb  to  the  point  at  which  the  constricting  band  or  tourniquet 
is  to  be  applied.  We  prefer  to  use  for  the  control  of  hemorrhage  during 
the  operation  an  elastic  strap,  which  is  wrapped  several  times  around  the 
limb  at  a  point  where  the  large  nerves  are  not  close  to  the  surface.  This 
having  been  secured,  we  next  apply  an  ordinary  Petit's  tourniquet  a  short 
distance  above  it,  so  that  when  the  constricting  band  is  removed  this  can 
be  screwed  down  and  control  any  bleeding  which  is  present.  Having  con- 
trolled the  circulation  of  the  part,  an  assistant  should  hold  the  limb  firmly 
some  distance  above  the  seat  of  operation,  and  a  second  assistant  should  hold 
the  limb  below  the  seat  of  operation.  The  surgeon  then  decides  upon  the 
method  of  amputation  he  desires  to  employ,  and  makes  his  incisions  accord- 
ingly, care  being  taken  to  make  the  flaps  sufficiently  long.  After  the  flaps 
have  been  cut  and  the  soft  parts  over  the  bones  have  been  divided,  a 
retractor  is  applied  to  hold  the  soft  parts  back,  while  the  bone  or  bones 
are  divided  with  a  saw.     (Fig.  140.)     After  the  limb  has  been  removed, 

the  surgeon  first  seizes  the  main 
artery  or  arteries  with  hfemostatio 
forceps  and  then  searches  for  the 
smaller  vessels,  and  when  as  many 
as  possible  have  been  seized  with 
forceps,  they  are  tied  off  in  turn 
with  ligatures  and  the  forceps  are 
removed.  After  securing  the  prin- 
ciijal  vessels  the  elastic  tube  shoiild 
be  removed,  and  if  any  arteries 
spurt  after  its  removal  they  should 
be  grasped  with  haemostatic  for- 
ceps and  ligated.  If  free  bleeding 
occurs  from  a  number  of  points, 
the  Petit's  tourniquet,  which  has  been  secured  around  the  limb  above,  should 
be  screwed  down  so  as  to  control  the  hemorrhage.  After  all  vessels  have  been 
secured,  any  nerves  which  are  exposed  in  the  wound  should  be  drawn  out 
for  a  short  distance  and  resected,  and  tendons  which  project  in  the  stump 
should  also  be  retrenched.  The  flaps  and  the  surface  of  the  stump  may  now 
be  irrigated  with  hot  bichloride  solution  or  with  hot  sterilized  water ;  the 
latter  application  is  especially  useful  if  there  is  considerable  oozing  from 
the  muscles.  If  the  surgeon  does  not  wish  to  use  antiseptic  solutions  he  may 
simply  sponge  or  mop  off  the  surface  of  the  flaps  with  pads  of  sterilized  gauze, 
and  the  question  of  drainage  should  next  receive  attention.  If  one  is  sure 
of  his  asepsis  during  the  operation  and  the  bleeding  has  been  absolutely  con- 
trolled, it  is  possible  in  many  cases  to  close  the  stump  without  drainage,  and 
this  procedure  is  recommended  by  many  surgeons.  A  drainage-tube  is  useful 
if  consecutive  bleeding  occurs  after  reaction,  allowing  the  blood  to  escape 
from  the  stump,  and  not  stuff  the  stump  and  cause  tension  upon  the  flaps. 
We  therefore  consider  it  wiser  before  closing  the  flaps  to  introduce  a  short 


Retractor  and  saw  applied.     (After  Esmarch 


DETAILS  OF  AMPUTATION. 


225 


rubber  drainage-tube  or  a  gauze  drain  at  the  most  dependent  portion  of  the 
wound.  Where  it  is  possible,  the  muscles  and  tendons  should  be  sutured 
over  the  face  of  the  stump  by  continuous  or  interrupted  sutures  of  catgut, 
which  makes  a  good  cushion  and  tends  to  lessen  subsequent  muscular  atro- 
phy (Fig.  141)  ;  a  second  layer  of  sutures  is  then  introduced  to  approximate 


Fig.  142. 


Fig.  141. 


Application  of  deep  sutures. 
Esmareh.) 


(After 


Approximation  of  edges  of  flaps.    (After 
Esmareli. ) 


the  edges  of  the  flaps.  (Fig.  142.)  The  suturing  material  for  this  purpose 
may  be  catgut,  silk,  or  silkworm-gut.  The  stump  having  been  closed,  the 
cavity  may  or  may  not  be  irrigated  through  the  drainage-tube,  according  to 
the  judgment  of  the  surgeon,  with  sterilized  water  or  with  bichloride  solu- 
tion. The  surface  of  the  stump  should  then  be  irrigated  and  cleansed,  and 
the  line  of  sutures  may  be  covered  with  loose  pads  of  bichloride  or  sterilized 
gauze.  When  a  number  of  these  layers  have  been  applied,  larger  pieces  of 
gauze,  composed  of  a  number  of  layers,  are  laid  upon  the  stump,  covering  it 
thoroughly  in  all  directions,  and  over  the  gauze  are  applied  a  few  layers  of 
sterilized  or  sublimated  cotton.  This  dressing  is  held  in  position  by  a  recur- 
rent gauze  bandage.  Compression  of  the  tissues  of  the  stump  by  a  firmly 
applied  bandage  prevents  oozing  and  controls  muscular  spasm.  The  appli- 
cation of  a  sjjlint  often  conduces  to  the  iiatient's  comfort.  When  the  stump 
has  been  dressed  in  this  manner  it  is  placed  in  a  moderately  elevated  jposi- 
tion  upon  a  soft  jjillow. 

After-Treatment  of  Amputations.— The  after-treatment  in  cases 
of  amputation,  if  shock  does  not  occui'  after  the  operation,  is  usually  very 
simple.  The  patient  should  be  kept  in  the  recumbent  position  with  the 
head  low,  and  should  be  given  opium  if  pain  is  present,  and  for  the  first 
few  days  liquid  diet. 

Dressing  of  Stumps. — If  the  patient  has  no  elevation  of  temijerature 
and  no  other  evidence  that  the  wound  is  not  running  a  perfectly  aseptic 
course,  we  are  not  in  the  habit  of  di'essing  the  stumji  until  the  seventh  day, 
even  if  drainage  has  been  introduced.  At  this  time  the  materials  for  dress- 
ings should  be  prepared  ;  a  rubber  blanket  covered  with  sterilized  towels 
should  be  slipped  under  the  stump,  and  the  bandage  should  be  divided  with 
scissors  before  the  stump  is  lifted  from  its  pillow.  The  stump  then  being 
carefully  raised  by  an  assistant,  the  dressings  and  the  drainage-tube  are 
removed,  and  if  the  appearance  of  the  stump  is  satisfactory,  there  being 
no  tension  from  the  sutures,  a  sterilized  or  antiseptic  dressing  is  applied  in 

15 


226  COMPLICATIONS  AFTER  AMPUTATION. 

the  same  manner  as  the  primary  dressing,  after  which  the  stump  is  allowed 
to  rest  for  a  week  without  dressing.  Of  course,  the  greatest  possible  care 
should  be  exercised  as  regards  asepsis  in  the  redressing  of  stumps.  At  the 
expiration  of  the  second  week  the  dressings  are  removed,  and  by  this  time 
union  is  usually  so  far  advanced  that  the  sutures  may  be  removed.  A  light 
antiseptic  dressing  is  then  applied,  and  the  patient  is  allowed  to  sit  up  in 
bed,  or,  in. case  of  amputation  of  the  hands  or  feet,  may  even  be  allowed  to 
leave  his  bed. 

This  description  applies  to  a  case  which  runs  an  aseptic  course  after 
amputation  ;  but,  unfortunately,  in  spite  of  the  greatest  care,  cases  may  run 
a  different  course,  and  numerous  complications  may  be  developed. 

Complications  after  Amputation.— Shock.— This  is  an  impor- 
tant and  serioTis  complication  which  may  follow  amputation.  The  treat- 
ment of  the  condition  has  already  been  described.     (See  page  94. ) 

Intermediary  or  Consecutive  Hemorrhage. — In  spite  of  the  great- 
est care  in  securing  the  blood-vessels  at  the  time  of  operation,  often  a  num- 
ber of  small  vessels  escape  observation,  which  do  not  bleed  at  the  time  of 
operation,  but  bleed  after  reaction  has  been  established,  and  as  a  result  of 
this  blood  escapes  through  the  drainage-tubes,  and  if  drainage  has  not  been 
employed  the  stump  becomes  stuffed  with  blood-clots  and  bloody  serum 
escapes  between  the  flaps.  The  presence  of  consecutive  hemorrhage  is 
shown  by  the  soaking  of  the  dressings  with  blood  and  serum,  or  occasionally 
the  dressings  contain  blood-clots.  Treatment. — This  consists  in  elevating 
the  stump  and  applying  pressure  by  means  of  a  compress  and  a  bandage. 
If  in  spite  of  this  treatment  the  stump  becomes  painful  and  the  oozing  con- 
tinues, it  is  wiser  to  etherize  the  patient,  remove  the  dressings,  ojien  the 
stump,  turn  out  the  clots,  and  irrigate  the  stumj)  with  hot  sterilized  water. 
If  bleeding  vessels  can  be  discovered  they  should  be  ligated,  but  if  the 
oozing  is  capillary  the  application  of  hot  water  will  often  check  it.  After 
the  bleeding  has  ceased  the  flaps  should  be  approximated  by  sutures  and 
the  stump  dressed  as  previously  described. 

Secondary  Hemorrhage. — This  complication  is  fortunately  very  in- 
frequent after  amputations  where  due  regard  to  asepsis  has  been  observed. 
If  secondary  hemorrhage,  however,  does  occur,  warning  is  usually  given 
by  one  or  two  slight  preliminary  bleedings.  These  should  piit  the  surgeon 
upon  his  guard,  and  the  j)atieut  should  be  carefully  watched  by  a  skilled 
assistant  who  is  able  to  apply  a  tourniquet  or  compress  the  main  artery  in 
case  the  hemorrhage  becomes  profuse.  Treatment. — When  free  hemor- 
rhage occurs,  the  tourniquet  should  be  applied,  the  dressings  removed,  the 
stumj)  opened,  and  the  bleeding  vessels  sought  for  in  the  wound  and  secured 
by  a  ligature ;  the  stump  should  then  be  closed  and  dressed.  If  hemor- 
rhage again  occurs,  the  same  procedure  should  be  repeated,  and  the  vessel 
should  be  secured  in  the  wound  if  possible.  If,  however,  it  is  impossible 
to  secure  the  vessel  in  the  wound,  or 'if  the  hemorrhage  again  recurs  after 
the  vessel  has  been  secured,  the  main  artery  should  be  ligated  above  the 
wound  at  the  point  of  election. 

Gangrene  of  the  Stump. — This  complication  sometimes  occurs  in 
stumps  after  amputations,   and  may  result  from  impaired  nutrition  of  the 


MORTALITY   AFTER  AMPUTATIONS.  227 

flaps  due  to  the  primary  injury,  from  thrombosis  or  embolism,  or  may  be 
caused  bj^  the  presence  of  infective  organisms.  All  surgeons  of  exi>erience 
recognize  the  fact  that  in  amputations  for  traumatism  it  is  extremely  difficult 
to  differentiate  accurately  vitalized  from  partially  devitalized  tissues,  aud  in 
spite  of  the  greatest  care  tissue  may  be  included  in  the  flaps  which  does  not 
possess  sufficient  vitality.  Gangrene  may  also  result  from  infection,  and 
may  occur  in  the  form  of  traumatic  spreading  gangrene.  Treatment. — 
Limited  gangrene  of  a  flap  or  a  portion  of  a  flap  resiilting  from  the  original 
traumatism  is  not  a  very  serious  complication  ;  the  dead  tissue  in  time 
separates  and  leaves  a  healthy  granulating  surface,  and  in  many  cases  a 
satisfactory  stump  results  after  cicatrization  has  occurred.  Extensive  gan- 
grene involving  the  whole  stump  is  a  very  seiious  condition,  and  is  often 
followed  by  a  fatal  termination.  If  this  does  occur,  as  soon  as  the  gan- 
grene is  well  established  and  a  line  of  separation  has  formed  amputation 
should  be  performed  at  a  higher  point.  In  traumatic  spreading  gangrene, 
prompt  ampntation  at  a  higher  point  alone  gives  the  patient  a  chance  of 
recovery.     (See  p.  109.) 

Septic  Infection. — Septic  infection,  resulting  in  osteomyelitis,  septicce- 
mia,  or  pytemia,  is  also  a  complication  which  may  occur  after  amputation, 
and  is  often  a  fatal  one.  If  recovery  takes  place  after  osteomyelitis,  more 
or  less  necrosis  of  the  bone  usually  results.  Erysipelas  may  also  occur  in 
stumps,  and  may  result  in  serious  consequences.  Treatment. — In  the 
case  of  osteomyelitis  involving  the  stump,  the  treatment  which  offers  the 
patient  the  best  chance  of  recovery  consists  in  opening  the  stump  and 
exposing  the  bone  by  a  lateral  incision  from  the  angle  of  the  flaps  ;  the  bone 
should  then  be  freely  opened  with  a  gouge  and  the  medullary  cavity  thor- 
oughly exposed,  and  all  diseased  tissues  should  be  removed  with  the  gouge 
and  curette. 

Mortality  after  Amputations.— This  is  influenced  by  various  con- 
ditions, among  which  may  be  mentioned  the  nature  of  the  injury,  the  age 
of  the  patient,  and  the  various  constitutional  conditions  which  affect  unfa- 
vorably other  operations  as  well  as  amputations.  The  locality  of  the  ampu- 
tation is  important  in  this  connection,  amputations  of  the  lower  extremities 
being  more  fatal,  as  a  rule,  than  those  of  the  upper  extremity,  and  all 
amputations  increasing  in  gravity  as  the  point  of  amj)utation  approaches 
the  trunk.  Amijutations  for  acute  affections  of  the  bones  are  more  fatal 
than  those  for  chronic  diseases.  Formerly  many  deaths  after  amputation 
were  due  to  septic  infection,  which,  however,  at  the  present  time  has  been 
reduced  to  a  minimum  by  the  improved  methods  of  wound  treatment.  The 
loss  of  blood  in  certain  amputations,  as  those  of  the  hip-  and  shoulder-joints, 
was  frequently  a  cause  of  death,  but  the  mortality  following  these  opera- 
tions has  been  very  much  diminished  by  the  use  of  some  of  the  recently 
introduced  methods  of  controlling  hemorrhage,  and,  indeed,  in  all  ampu- 
tations the  general  introduction  of  the  method  of  controlling  bleeding 
during  the  operation  by  elastic  constriction  has  done  much  to  reduce  the 
mortality.  If  after  amputation  the  patient  escapes  the  primary  danger 
from  shock,  and  if  due  care  has  been  taken  as  regards  asepsis,  the  prognosis 
is  good. 


228 


AFFECTIONS   OF  STUMPS. 


Affections  of  Stumps. — After  the  cicatrization  of  tlie  stump  it  con- 
tinues to  undergo  cliauges  in  structure  for  a  long  time ;  the  muscles  waste 
and  are  converted  into  deuse  fibro-cellular  tissue ;  the  same  changes  occur  in 
the  tendons  ;  the  bone  is  rounded  off  and  its  medullary  cavity  becomes  filled 
up  ;  the  vessels  are  obliterated  to  a  certain  distance  and  are  converted  iuto 
fibrous  cords  ;  the  nerves  become  thickened  or  bulbous  at  their  extremities, 
and  in  time  the  whole  stump  becomes  more  or  less  wasted. 

Spasm  of  Muscles. — This  affection  is  sometimes  observed  after  ampu- 
tation, and  usually  occurs  shortly  after  the  operation.  The  most  marked 
cases  of  this  condition,  however,  occur  where  amputations  have  been  per- 
formed in  patients  suffering  from  chorea ;  in  other  cases  persistent  or 
choreic  spasms  have  developed  after  stumps  have  permanently  healed. 

Mechanical  Ulcer. — This  consists  in  a  chronic  form  of  ulceration  at 
the  end  of  a  stump,  and  generally  results  from  insufficient  flaps  or.  from 
undue  retraction  of  the  muscles  after  amputation  has  been  performed. 
Mechanical  ulcer  may  be  treated  by  bandaging,  by  the  application  of  an 
extension  apparatus,  or  by  reamputation. 

Conical  Stump. — This  is  chiefly  seen  in  amj)utations  of  the  upper  part 
of  the  arm  or  leg  in  children,  and  does  not,  as  a  rule,  result  from  the  flaps 
having  been  of  insufficieut  length,  but  is  accounted  for  by  the  physiological 
fact  that  the  princiijal  growth  of  the  arm  is  from  the  upper  epiphysis  of  the 


Fig.  143. 


f 


Conical  stump  after  amputation  of  the  arm. 


Conical  stumps  after  amputation  of  the 


humerus,  and  that  of  the  leg  from  the  upper  epiphysis  of  the  tibia,  and, 
as  the  growth  of  the  bone  from  these  epiphyses  is  more  active  than  that 
of  the  surrounding  soft  parts,  the  bone  is  projected  through  the  parts  and 
produces  a  typical  conical  stump.  (Figs.  143  and  144.)  A  conical  stump 
generally  requires  reamputation. 

Neuromata. — A  painful  enlargement  of  the  nerves  of  a  stump  is  not 
infrequent,  and  the  pain  is  said  to  depend  not  so  much  upon  the  bulbous 
enlargement  of  the  nerves  as  on  a  sclerotic  condition  of  the  same,  giving 
rise  to  neuritis,  which  results  from  inflammatory  changes.  If,  however, 
any  distinct  painful  enlargements  of  the  nerves  can  be  felt  in  the  stump. 


MULTIPLE  AMPUTATIONS.  229 

they  slionld  be  removed  by  incision,  or  reamputation  of  the  stump  may  be 
necessai-y  if  the  condition  gives  the  patient  great  discomfort. 

Contraction  of  Tendons. — Occasionally  in  certain  amputatious  about 
the  foot  the  stump  is  distorted  by  the  contraction  of  tendons  and  is  rendered 
practically  useless.  In  such  cases  subcutaneous  division  of  the  tendons  may 
be  required.  After  Chopart's  amputation  of  the  foot,  contraction  of  the 
muscles  attached  to  the  os  calcis  by  the  tendo  Achillis  may  cause  distortion 
of  the  stump,  so  that  the  cicatrix  is  pressed  upon  and  becomes  painful,  or 
may  jDroduce  so  much  distortion  that  a  shoe  cannot  be  worn.  In  such  a 
case  tenotomy  of  the  tendo  Achillis  may  be  required. 

Necrosis. — This  condition  may  be  present  after  amputation,  and  results 
from   osteomyelitis.     The  amount  of 
bone  destroyed  may  be  extensive,  and 
a   long    tubular    sequestrum    forms, 
which   may   require   removal   subse- 
quently.    (Fig.  145.)     On  the  other  -^.y-jir^ 
hand,  a  limited  amount  of  necrosis         Tub^aTs^q^to^  from  stump. 
may    result,    unattended    with    any 

marked  constitutional  disturbances,  which  is  probably  due  to  the  injury 
produced  by  the  saw  at  the  time  of  the  division  of  the  bone. 

Multiple  Amputations. — In  multiple  injuries  of  the  extremities  it 
may  become  necessary  to  remove  two  or  more  limbs  at  the  same  time 
by  primary  amputation.  The  majority  of  cases  receiving  injuries  of  suffi- 
cient gravity  to  demand  multiple  amputation  usually  die  of  hemorrhage, 
or  are  in  so  profound  a  condition  of  shock  when  they  come  under  the  care 
of  the  sm-geou  that  no  operative  treatment  can  be  undertaken ;  reaction 
in  these  cases  is  vm usual,  the  patient  generally  dying  of  shock.  In  excep- 
tional cases,  where  little  blood  has  been  lost  as  the  result  of  the  accident, 
and  reaction  has  been  established,  primary  amputation  should  be  per- 
formed. Eecovery  following  double  amputation  is  not  uncommon,  a  num- 
ber of  cases  in  which  parts  of  three  limbs  have  been  removed  simultaneously 
have  been  reported,  and  a  few  cases  in  which  quadruj)le  amputation  has 
been  practised  have  terminated  successfully.  The  nearer  the  damage  to 
the  limbs  approaches  the  trunk  the  less  is  the  chance  of  reaction.  Ash- 
hurst's  remarkable  case  of  primary  simultaneous  amputation  at  the  hip- 
joint  and  of  the  leg,  in  which  recovery  followed,  shows  that  if  reaction 
from  shock  in  these  cases  takes  place,  a  successful  result  need  not  be 
despaired  of. 

In  multiple  amputations  required  for  the  results  of  frost-bites,  burns,  a.nd 
scalds,  or  for  gangrene,  synchronous  amputation  is  not  always  demanded, 
and  the  parts  may  be  removed  at  intervals  of  a  few  days  or  weeks.  The 
shock  of  the  operation  is  thus  very  much  lessened,  and  the  results  in  these 
cases  are  naturally  more  favorable  than  in  cases  where  multiple  synchronous 
amputations  are  demanded. 

Multiple  Simultaneous  or  Synchronous,  or  Consecutive  Ampu- 
tations.— Some  difference  of  ox^iuion  exists  among  surgeons  as  to  the  best 
method  of  procedure  in  these  cases  to  diminish  the  shock  of  the  operation 
itself     It  has  been  recommended  that  the  amputation  be  done  synchro- 


230 


AMPUTATIONS   OF  THE  UPPER  EXTRE:\IITY. 


^^ 


nously  or  simultaneously, — that  is,  two  or  more  surgeons  each  removing  a 
limb  at  the  same  time  ;  this  method  certainly  diminishes  the  time  required, 
but  in  our  judgment  does  not  diminish  the  amount  of  shock,  but  rather 
aggravates  it  for  a  short  time  during  the  operative  procedure.  We  have  in 
these  cases  adoi^ted  the  consecutive  method,  which  is  that  recommended  by 
Ashhurst,  and  consists  in  performing  first  the  amputation  which  is  likely  to 

be  followed  by  the  most  shock,  and  if  the 
patient's  condition  after  this  has  been 
done  warrants  it,  the  next  most  serious 
amputation  is  performed,  and  after  this 
the  third  or  fourth  amputation  may  be 
undertaken.  For  instance,  in  a  case  of 
crush  of  the  thigh,  leg,  and  arm,  the 
thigh  should  be  amputated  first,  next  the 
leg,  and  lastly  the  arm.  This  method  of 
procedure  we  employed  in  a  case  of  triple 
amijutation  for  railroad  crush,  which 
ended  in  recovery.  (Fig.  146.)  The 
time  occupied  in  the  operations  should 
be  as  short  as  possible,  to  avoid  the  de- 
velopment of  shock  and  the  disadvan- 
tages of  prolonged  ansesthesia.  With 
this  end  in  view,  after  removing  the  first 
limb,  the  main  vessels  should  be  secured 
by  ligatures  and  the  stump  wrapped  in  a 
bichloride  towel,  and  the  same  procediu-e 
repeated  for  the  next  operation ;  when  all  have  been  amputated,  any  re- 
maining vessels  are  secured,  and  the  stumj)S  are  closed  and  dressed.  If  after 
removing  one  or  more  limbs  the  surgeon  finds  that  the  patient's  condition 
has  markedly  failed,  as  evidenced  by  the  condition  of  the  iiulse  and  tempera- 
ture, it  is  wise  to  postpone  furtlier  operative  procedure  and  treat  the  i^atient 
actively  for  the  relief  of  shock,  adopting  rather  the  consecutive  than  the 
synchronous  method  of  am]putation.  When  reaction  has  occurred,  even  if 
it  be  after  some  hours,  the  remaining  amputation  or  amputations  may  be 
undertaken  with  a  much  more  favorable  prosj)ect.  We  have  successfully 
adopted  this  method  in  multiple  amputations. 


Triple  amputation. 


AMPUTATIONS  OF  THE  UPPER  EXTREMITY. 

In  all  amxjutatious  involving  the  phalanges  and  metacari^al  bones  the 
rule  is  observed  to  save  as  nuich  of  the  part  as  i)ossible,  as  no  mechanical 
contrivance  can  possibly  equal  the  natural  utility  of  the  hand.  The  possi- 
bility of  saving  badly  damaged  portions  of  the  hand  has  also  been  greatly 
increased  by  the  modern  methods  of  wound  treatment.  The  fingers  are 
very  seldom  amputated  unless  their  destruction  by  the  injury  is  complete  ; 
a  small  amount  of  vitalized  tissue  will  often  in  these  cases  keep  ^^p  the 
nutrition  of  the  finger,  and  ultimately  recovery  with  a  more  or  less  useful 
finger  may  result.  It  was  formerly  the  rule  in  the  case  of  the  middle  fingers, 
when  it  became  necessary  to  go  as  high  as  the  proximal  iuterphalangeal 


AMPUTATION   OF  THE   FINGERS. 


231 


joint,  as  there  is  bo  special  flexor  teudon  for  the  proximal  phalanx,  to 
amputate  at  the  nietacarpo-phalaugeal  joint.  At  the  ijresent  time,  when 
it  is  recognized  that  the  interossei  flex  the  proximal  phalanx,  the  old  rule 
is  disregarded,  and  amputations  at  the  proximal  interphalangeal  joint  may 
be  undertaken  with  satisfactory  results. 

Amputation  of  the  Phalanges  of  the  Fingers.— The  phalanges 

may  be  amputated  in  their  coutinuity  or  in  their  contiguity.  As  it  is 
imxjortant  to  save  as  much  as  possible  of  the  finger,  the  former  method 
is  generally  to  be  employed  instead  of  disarticulation.  Amputations  for 
necrosis  of  the  distal  phalanx  are  now  seldom  performed ;  it  is  found 
better  in  these  cases  to  expose  the  dead  bone  and  enucleate  it,  leaving  the 
soft  parts  and  the  nail,  which  procedure,  although  it  leaves  a  somewhat 
misshapen  finger,  retains  the  length  of  the  finger,  and  thus  preserves  its 
usefulness.  Amputation  in  the  continuity  of  the  phalanx  may  be  performed 
by  making  antero-posterior  flaps  ;  a  short  dorsal  flap  is  first  cut  from  with- 
out inward,  and  a  long  palmar  flap  is  cut  in  the  same  manner  ;  the  bone  is 
then  divided  with  a  small  metacarpal  saw  or  with  bone-ciitting  forceps.  Am- 
putations in  the  contiguity  are  performed  by  making  a  short  posterior  flaj), 
opening  the  joint,  and  then  making  a  long  anterior  flap.  (Fig.  147.)  In 
disarticulations  of  the  phalanges  the  position 
of  the  joint  may  always  be  recognized  by  re- 
membering that  when  the  finger  is  flexed  the 
knuckle  is  the  upper  boundary  of  the  articu- 
lation. (Fig.  148. )  In  amputating  the  fingers 
very  little  hemorrhage  occurs,  and  the  bleed- 

FiG.  148. 


Amputation  of  finger  by  long  anterior  flap.   (After  Esmarch.)  Position  of  phalangeal  joints.   (Smith.) 


ing  may  be  satisfactorily  controlled  by  an  assistant  making  digital  compres- 
sion upon  the  radial  and  ulnar  arteries,  or  a  rubber  drainage-tube  may  be 
wrapijed  several  times  around  the  wrist,  which  will  satisfactorily  control  the 
bleeding.  After  the  finger  has  been  removed  the  digital  arteries  usually 
require  the  application  of  ligatures,  or,  if  hemorrhage  is  not  free  from  these 
vessels,  the  surgeon  may  control  bleeding  from  them  by  the  stitches  which 
hold  the  flaps  in  apposition.  After  controlling  the  bleeding,  the  flaps  are 
brought  together  by  sutures  ap])lied  at  three  or  four  points. 

Amputations  of  the  phalanges  of  the  thumb  are  performed  in  the 
same  manner  as  amputations  of  those  of  the  fingers. 

Metacarpo-Phalangeal  Amputations.— In  amputating  at  the 
metacarpo-phalangeal  joints  the  hand  should  be  pronated,  and  the  sound 
fingers  held  out  of  the  way  by  an  assistant ;  the  surgeon  then  grasps  the  in- 
jured finger,  and,  entering  the  iioint  of  the  knife  directly  in  front  of  the  middle 


232 


AMPUTATIONS  OF  THE  METACARPAL  BONES. 


of  the  knuckle,  carries  it  at  once  to  the  bone,  making  his  incision  directly 

forward  for  a  short  distance,  then  diverging  to  one  side  and  passing  through 

the  interdigital  cleft  to  the  palm.     A  similar  cut  is  made  on  the  opposite 

side,  the  two  incisions  meeting  on  the  palmar  surface  of  the  finger  opposite 

the  point  of  starting.     (Fig.  149.)     The  lateral  aspect  of  the  joint  is  next 

opened  by  the  point  of  the  knife,  the 

finger  being  carried  strongly  to  the  -^'°-  ^'^^■ 

opposite  side,  to  make  the  ligaments 

tense  and  the  articulation  gape.    The  , 

Fig.  149.  1^^"  ^^ 


Incision  of  metacarpo-phalangeal  amputation. 


Amputation  of  finger  at  metacarpo-plialangeal 
joint.    (After  Rotter.) 


lateral  ligaments  of  the  opposite  side  are  next  divided,  and  the  disarticula- 
tion is  completed.  The  wound  resulting  after  disarticulation  is  represented 
in  Pig.  150.  To  make  the  deformity  less  after  disarticulating  a  finger  at 
this  joint,  it  has  been  recommended  that  the  head  of  the  metacarpal  bone 
be  also  removed  with  bone-forceps,  so  that  the  remaining  metacarpal  bones 
may  come  closer  together  ;  this  has  the  disadvantage,  however,  of  weaken- 
ing the  hand,  and,  as  the  head  of  the  metacarpal  bone  in  time  atrophies  to 
a  certain  extent,  causing  the  gap  between  the  fingers  to  be  less  marked,  the 
procedure  is  not  to  be  recommended. 

Amputations  of  the  Metacarpal  Bones. — The  removal  of  the 
whole  or  a  jpart  of  a  metacarpal  bone,  with  its  corresponding  finger,  may  be 
required  in  consequence  of  injury  or  disease.  The  operation  is  done  by 
making  a  dorsal  incision,  commencing  at  the  carpal  extremity  of  the  meta- 
carpal bone  and  carrying  it  forward  to  the  knuckle ;  at  this  point  the  direc- 
tion of  the  knife  is  changed,  and  it  is  carried  towards  the  interdigital  cleft 
into  the  palm,  where  it  joins  a  similar  cut  made  upon  the  opposite  side  ;  the 
soft  parts  should  next  be  dissected  free  from  the  dorsal  and  lateral  aspects 
of  the  bone,  and  the  ligaments  uniting  the  anterior  extremity  of  the  bone 
to  the  adjoining  metacarj)al  bones  should  be  divided,  when  the  finger  can 
be  drawn  backward,  which  raises  the  metacarpal  bone  from  its  bed  and 
allows  it  to  be  detached  from  the  soft  parts  connected  with  its  anterior  sur- 
face.    In  amputating  the  metacarpal  bones  it  is  advisable  to  divide  the 


AMPUTATIONS  OF  THE  METACARPAL  BONES. 


233 


bones,  leaving  the  carpal  ends  in  place  in  order  to  avoid  opening  the  wrist- 
joint,  except  in  the  case  of  the  first  and  fifth  metacarpal  bones,  which  do  not 
commnnicate  with  the  others  and  with  the  synovial  sacs.  In  dividing  or 
disarticnlating  the  carj)al  ends  of  the  bones,  great  care  should  be  taken  to 
avoid  injury  of  the  vessels  of  the  palm. 

Amputations  of  the  Thumb  and  its  Metacarpal  Bone. — 
In  performing  this  amputation  care  should  be  taken  to  preserve  the  entire 
mass  of  muscles  on  the  thenar  aspect  of  the  hand,  to  leave  a  surface  against 
which  the  fingers  may  impinge.  An  incision  is  started  at  the  junction  of 
the  metacarpal  bone  with  the  carpus,  on  the  dorsal  surface  of  the  thumb, 
and  is  carried  down  through  the  web  between  the  thumb  and  the  forefinger. 
A  corresponding  incision  is  made  upon  the  opposite  side,  which  joins  the 
first  incision,  and  the  bone  is  cleared  and  raised  from  its  bed  and  is  dis- 
articulated at  its  proximal  extremity.  (Fig.  151.)  Another  method  of  per- 
forming this  amputation  is  to  make 

first  a  dorsal  incision  and  carry  it  Fig.  152. 

down  to  the  web  between  the  thumb 


Fig.  151. 


Amputation  of  thumb  and  metacarpal  bone, 
racket-shaped  incision. 


Amputation  of  thumb  by  transfixing  anterior 


and  the  forefinger  ;  the  palmar  flap  is  then  made  by  thrusting  the  knife  up- 
ward to  its  point  of  entrance  and  cutting  downward  and  outward.  In  ampu- 
tating the  right  thumb  with  the  metacarpal  bone,  it  is  better  to  make  the 
palmar  flap  first  by  transfixion,  the  dorsal  flap  being  made  subsequently. 
(Fig.  152.)  In  this  operation  it  is  also  necessary  to  keep  the  point  of  the 
knife  close  to  the  bone. 

Amputation  of  the  Little  Finger  and.  its  Metacarpal  Bone. 

— In  amputating  the  fifth  metacarpal  bone  an  incision  should  be  made  along 
the  inner  border  of  the  hand,  and  carried  down  to  the  bone  between  the  skin 
and  the  abductor  minimi  digiti  muscle  ;  the  lower  end  of  the  incision  passes 
over  the  knuckle  to  the  web  of  the  finger,  and  backward  under  the  palmar 
surface  to  join  the  first  incision.  .  The  ligaments  attaching  the  bone  to  its 
fellow  should  next  be  divided,  and  the  bone  should  be  raised  from  its  bed  and 
separated  from  the  soft  parts  and  disarticulated  at  its  proximal  extremity. 


234 


ATYPICAL   AMPUTATIONS   OF  THE   FINGERS  AND  HAND. 


Amputation  of  hand  at  earpo-mctacarpal  joint. 
(Agnew.) 


Amputation  of  the  Hand  at  the  Carpo-Metacarpal  Joint. 

— Amputation  of  the  hand  at  the  carpometacarpal  joint  or  between  the 
rows  of  the  carpal  bones  is  occasionally  resorted  to.  When  this  operation  is 
performed,  the  hand  should  be  placed  in  a  state  of  extreme  supination,  and 

the  point  of  a  naiTOw  knife  should  be 
Fig.  153.  entered  on  the  x^almar  aspect  of  the 

hand,  opposite  the  articulation  of  the 
metacarpal  bone  of  the  little  finger 
with  the  unciform  bone,  and  pushed 
directly  across  the  hand,  between  the 
bones  and  the  soft  parts,  until  its 
point  emerges  below  the  thumb  (Fig. 
153) ;  the  knife  should  then  be  carried 
downward,  close  to  the  metacarpal 
bones,  and  an  elliptical  flap  should  be 
cut ;  the  hand  being  turned  into  a  state 
of  pronation,  a  semicircular  incision 
should  be  made  across  its  dorsal  sur- 
face, three-fourths  of  an  inch  below 
the  carpo-metacarj)al  articulation,  joining  the  anterior  incision  at  the  inner 
and  outer  margins  of  the  hand.  The  flaps  are  next  turned  back  and  the 
metacarpal  bones  are  disarticulated. 

Atypical  Amputations  of  the  Fingers  and  Hand.— It  is  well  for 
the  surgeon  to  bear  in  mind  the  typical  amxjutations  of  the  fingers  and  hand, 
but,  owing  to  the  A^ery  irregular  manner  in  which  the  soft  parts  and  the 
bones  of  the  fingers  and  hand  are  injured  in  wounds,  it  is  often  impossible 
to  practise  any  of  these  typical  amputations.  In  such  cases  the  surgeon  has 
an  opportunity  of  displaying  his  ingenuity  in  the  method  of  securing  flaps 
to  cover  the  bones  after  the  removal  of  the  injured  parts.  Partial  amputa- 
tions of  the  hand,  removing  several  of  the  fingers  with  their  metacarpal 
bones,  often  leave  a  most  useful  member.  If  the  thumb  and  index  finger 
can  be  saved,  the  portion  of  the  hand  remaining  is  much  more  useful  than 
any  artificial  apparatus.  In  the  same  way,  if  the  fingers  are  removed  at  the 
metacarpo-phalangeal  articulation  and  the  thumb  can  be  saved,  a  very  use- 
ful hand  results.  In  cases  w^here  the  thumb  and  little  finger  can  be  saved, 
and  the  rest  of  the  fingers  require  removal,  a  satisfactory  result  is  obt^iined. 
In  extensive  laceration  of  the  hand,  accompanied  by  injuries  of  the  fingers, 
where  a  number  of  fingers  require  amputation,  if  any  sound  skin  is  present 
upon  the  fingers,  this  should  be  stripped  off  to  form  a  fiap  to  cover  the  raw 
surface  upon  the  hand.  Occasionally  also  it  is  possible  to  shift  a  finger  to 
a  sound  metacarpal  bone  where  a  finger  has  been  amputated  and  an  injured 
metacarpal  bone  has  required  removal.  No  fixed  rule  for  these  various  pro- 
cedures can  be  given  ;  the  surgeon  has  simjily  to  exercise  his  judgment  as 
to  the  best  disposition  of  the  material  he  has  before  him. 

After  all  amputations  of  the  fingers  or  of  the  metacarpal  bones  the  flaps 
should  be  loosely  brought  together  with  sutures,  and  a  gauze  dressing  should 
be  applied  and  the  parts  placed  at  rest  u]3on  a  palmar  splint.  Eepair  after 
operations  upon  the  hand,  by  reason  of  its  great  vascularity,  is  usually  rapid. 


AMPUTATIONS  AT  THE  WRIST. 


235 


Amputations  at  the  Wrist.— The  hand  should  be  removed  at  the 
radio-carpal  joint,  where  it  is  possible,  rather  than  by  amputation  above 
this  joint,  for  by  amputation  at  the  wrist  the  motions  of  pronation  and 
supination  may  be  preserved,  although  this  is  not  invariably  the  case.  In 
disarticulating  at  the  wrist  it  should  be  remembered  that  the  styloid  pro- 
cesses of  the  ulna  and  the  radius  form  the  inner  and  outer  borders  of  the 
carpal  arch,  and  that  the  bones  of  the  first  row  of  the  carpus,  the  scaphoid, 
semilunar,  and  cuneiform,  are  arranged  so  as  to  present  a  convex  surface 
adapted  to  the  concavity  of  the  bones  of  the  forearm.  (Fig.  154.)  In  am- 
putations at  the  wrist  or 
those  of  the  forearm,  the 
bleeding  is  controlled  by  the 

Fig.  154. 


Fig  155 


Radio-carpal  articulation. 


Disarticulation  at  the  wrist. 


application  of  a  tourniquet  or  an  elastic  strap  to  the  brachial  artery  at 
the  middle  of  the  arm.  In  amputating  at  the  wrist-joint  antero-posterior 
flaps  are  usually  employed.  The  hand  should  be  held  in  the  iironated  posi- 
tion and  somewhat  flexed  ;  a  curved  incision  is  made  from  one  styloid  pro- 
cess to  the  other,  and  a  convex  flap  an  inch  and  a  half  in  length  is  turned 
up  from  the  back  of  the  hand.  The  hand  is  then  strongly  flexed,  and  the 
posterior  radio-carpal  ligament  is  divided.  The  joint  being  exposed,  the 
knife  is  next  applied  to  the  lateral  ligaments,  and  when  the  joint  is  freely 
opened,  the  knife  is  carried  through  it  and  made  to  shape  an  anterior  or 
palmar  flap  by  cutting  downward  and  outward.  (Fig.  155.)  The  anterior 
or  palmar  flap  should  be  longer  than  the  posterior  flap.  After  disarticula- 
tion of  the  hand  the  tips  of  the  styloid  processes  may  be  removed  with  a 
saw  or  with  bone-forceps,  although  their  removal  is  not  absolutely  necessary. 
The  vessels  requiring  ligature  in  amputations  at  the  wrist  are  the  radial, 
ulnar,  and  interosseous  arteries. 

Amputations  of  the  Forearm. — The  forearm  may  require  ampu- 
tation at  aii>'  point  between  the  wrist  and  the  elbow,  and  the  circular,  the 
modified  circular  or  oval  method,  or  the  method  by  rectangular  flaps 
(Teale's)  may  be  emj)loyed.  At  the  lower  portion  of  the  forearm  the  circu- 
lar method  is  that  usually  employed.  In  the  upj)er  portion  of  the  forearm 
the  modified  circular  method  is  most  satisfactory. 


236 


AMPUTATIONS  AT  THE  ELBOW. 


Circular  Method. — In  performing  this  operation  a  circular  incision  of 
the  skin  and  cellular  tissue  is  made,  and  a  cuff  is  dissected  up  for  about  two 
inches,  the  miiscles  and  interosseous  membrane  being  out  through  ;  a  three- 
tailed  retractor  is  next  ai^ijlied,  and  the  bones  are  diyided  with  a  saw.    (Fig. 

Fig.  156. 


Circular  method  of  amputation.    (After  Esmarch.) 


156.)  The  tendons  are  apt  to  laroject  from  the  surface  of  the  stump,  and 
they  should  be  drawn  down  and  retrenched.  The  principal  arteries  re- 
quiring ligatures  are  the  ulnar,  radial,  and  anterior  and  posterior  interos- 
seous :  a  few  muscular  branches  may  also  require  ligation.  The  median, 
radial,  and  ulnar  nerves  should  also  be  drawn  out  and  retrenched. 

Modified  Circular  or  Oval  Method. — Amputation  of  the  forearm  by 
this  method  is  very  frequently  resorted  to.  It  consists  in  first  dissecting  up 
two  oval  antero-posterior  flaps  of  skin  and  cellular  tissue,  and  then,  having 

Fig.  157. 


Amputation  of  the  forearm  by  modified  circular  method.     (Bryant.) 

retracted  these,  the  muscles  are  cut  through  by  a  circular  incision  (Fig. 
1.57),  and  the  bones  are  subsequently  divided  with  a  saw. 

Teale's  Method. — Teale's  method  (see  page  221)  is  sometimes  emijloyed 
in  amputations  of  the  forearm,  but  possesses  no  advantage  over  the  methods 
previously  described. 

Amputations  at  the  Elbow.— The  methods  of  amputating  at  the 
elbow  are  the  anterior  flap,  the  elliptical  incision,  the  lateral  flap,  and  the 
circular  method. 

Anterior  Flap  Method.— A  flap  three  inches  in  length,  its  base  par- 
allel to  and  half  an  inch  below  the  condyles  of  the  humerus,  is  cut  by  trans- 
fixion or  from  without  inward.  (Fig.  158.)  The  joint  is  next  opened  and 
the  lateral  ligaments  are  divided.     The  olecranon  is  then  exposed,  the  at- 


AJVIPUTATIONS  AT  THE  ELBOW. 


237 


tacliments  of  the  triceps  are  separated,  and  a  posterior  flap  is  cut  from  witli- 
out  inward  or  ffoni  within  outward  a  little  below  the  line  of  the  condyles. 


Amputation  at  the  elbow,  anterior  flap  metlioa. 


Fig.  160. 


Fig  161 


The  Elliptical  Method. — In  this  method  of  amputating  at  the  elbow 
an"  incision  is  carried  from  the  olecranon  process  downward  and  forward  to  a 
point  a  little  above  the  middle  of  the  forearm.  The  incision 
is  then  continued  across  the  anterior  aspect  of  the  limb,  and 
is  carried  back  to  the  olecranon  process.  (Fig.  159.)  The 
incision  involves  only  the  skin  and  the  cellular  tissue.  The 
flap  having  been  dissected  up  for  a  short  distance,  the  soft 
parts  close  to  the  joint  are  transfixed  ;  the  muscles  are  cut 
obliquely,  so  that  an  anterior  flap  is 
formed.  This  flap  is  held  up,  the 
bones  are  disarticulated,  the  attach 
ment  of  the  triceps  tendon  to  the 
olecranon  is  divided,  and  any  tissues 
which  have  escaped  division  along 
the  posterior  as 
j)ect  of  the  limb 
are  severed.  Af 
ter  the  vessels 
have  been  se- 
cured, the  flap  is 
turned  over  and  sutured,  and  a 
curved  cicatrix  on  the  posterior 
aspect  of  the  limb  results. 

Lateral  Flap  Method. — 
Amputations  at  the  elbow  may 
also  be  performed  by  the  lateral 
flap  method,  in  which  the  flaps 
are  cut  either  from  without  in- 
ward or  by  transfixion.  An  ex- 
ternal flap  three  Inches  in  length 
is  made  on  the  outer  side  of  the 
arm,  starting  from  a  point  a 
finger-breadth  below  the  bend  of  the  elbow,  by  transfixion  or  by  cutting  fi-om 
without  inward.    A  shorter  internal  flap  is  next  cut  in  the  same  manner,  and 


Incision  fcr  ellip- 
tical amputation  at 
the  elbow.  (After 
Treves. ) 


Circular   amputation    at   the 
elbow.    (After  Esmarch.) 


Stump  after  circular 
amputation  at  the  el- 
bow.   (After  Esmarch.) 


238  AMPUTATIONS  OF  THE  ARM. 

the  joint  is  opened  and  the  disarticulation  effected.     The  circular  method 
may  also  be  employed  in  this  amputation.     (Figs.  160  and  161.) 

Amputations  of  the  Arm. — The  arm  may  be  amputated  at  any  point 
below  the  attachment  of  the  muscles  at  the  axilla  by  the  circular,  the  oval, 
the  transfixion,  or  Teale's  method.  Although  these  various  systematic 
methods  of  removing  the  arm  are  often  practised,  it  is  sometimes  found  im- 
possible, from  the  character  of  the  injury,  to  employ  any  of  them,  and  in 
such  eases  flaps  have  to  be  fashioned  according  to  the  tissue  which  is  pres- 
ent, the  rule,  however,  being  to  save  as  much  of  the  arm  as  possible.  It  is 
always  considered  advisable  to  save  even  a  small  portion  of  the  bone,  which 
may  consist  only  of  the  head  and  the  upper  portion  of  the  humerus,  as 
by  so  doing  the  rotundity  of  the  shoulder  is  preserved,  and  the  deformity  is 
not  so  marked  as  it  would  be  if  the  arm  were  amjiutated  at  the  shoulder- 
joint.  An  artificial  arm  can  also  be  better  adapted  to  a  stumij  of  some 
length. 

To  control  hemorrhage  during  amputation  of  the  arm  at  its  middle  or 
lower  third  the  tourniquet  with  a  compress  should  be  applied  along  the 
inner  edge  of  the  biceps  or  coraco-brachialis  muscle,  or  the  elastic  strai)  of 
Esmarch's  apparatus  may  be  employed.  "When,  however,  the  arm  is  ampu- 
tated in  its  upper  third,  to  control  the  bleeding  a  bandage  should  be  placed 
in  the  axilla  over  the  artery,  and  a  tourniquet  applied  over  this,  resting 
upon  the  acromion  process.  Hemorrhage  in  high  amputations  of  the  arm 
may  also  be  controlled  by  the  application  of  a  compress,  with  the  elastic 
strap  of  Esmarch's  apparatus  applied  over  it,  the  strap  being  crossed  high 
over  the  shoulder  and  fastened  in  the  opposite  axilla,  or  Wyeth's  pins  and 
an  elastic  strajD  maj^  be  emxiloyed.     (Fig.  164.) 

Circular  Method. — This  method  is  usually  employed  in  amputations 
in  the  lower  third  of  the  arm.  The  arm  is  abducted,  and  the  surgeon, 
with  a  circular  sweep  of  the  knife,  divides  the  skin  and  cellular  tissue  for 
about  three-fourths  of  the  circumference  of  the  arm ;  the  remaining  undi- 
vided skin  is  then  severed,  and,  as  the  skin  upon  the  anterior  and  internal 
surface  of  the  arm  retracts  more  than  that  upon  the  posterior  surface, 
the  circular  incision  should  extend  somewhat  lower  upon  the  anterior  than 
upon  the  posterior  surface.  The  skiu  and  cellular  tissue  having  been  di- 
vided, an  assistant  retracts  them  forcibly,  and  the  surgeon  makes  a  circular 
incision  of  the  muscles  down  to  the  bone  on  a  line  with  the  upper  edge  of 
the  divided  skin.  The  bone  is  then  thoroughly  cleared,  and  great  care 
should  be  taken  that  the  musculo-spiral  nerve,  which  lies  in  a  groove  in  the 
bone,  is  cleanly  divided.  Having  incised  the  muscles  and  cleared  the  bone, 
a  two-tailed  retractor  is  applied,  the  muscles  and  skin-flaps  are  held  back, 
and  the  bone  is  divided  with  a  saw.  The  vessels  which  require  ligatures  in 
amputation  of  the  lower  third  of  the  arm  are  the  brachial  artery,  which  lies 
to  the  inner  side  with  the  median  nerve  ;  the  superior  profunda,  which  lies 
upon  the  posterior  external  aspect  of  the  bone  with  the  musculo-spiral 
nerve ;  and  the  inferior  i^rofunda,  to  the  inner  side  of  the  brachial  with  the 
ulnar  nerve.  In  muscular  arms,  in  addition,  several  muscular  branches 
will  also  require  ligatures.  In  all  amputations  of  the  arm  it  is  well  to 
remember  the  possibility  of  a  high  division  of  the  brachial  artery,  and  to  see 


AMPUTATIONS   AT  THE    SHOULDER-JOINT. 


239 


Modified  circular  amputation  of  the  arm.     (After  Esmarch.) 


that  the  auomalons  vessel  is  properly  secured  if  present.  The  nerves  should 
be  drawn  out  and  retrenched.  After  all  bleeding  has  been  controlled  a 
drainage-tube  is  introduced,  and  the  flaps  are  brought  together  vertically,  to 
secure  free  drainage. 

Modified  Circular  or  Oval  Method. — In  this  method  of  amputation 
of  the  arm,  antero-posterior  oval  flaps  of  skin  and  cellular  tissue  are  made, 
the  anterior  flaj)  being  slightly  longer  than  the  posterior  one.    ,  These  flaps 
are  dissected  up  for  a  suffi- 
cient distance,  when  a  circu-  ^^^'-  162. 
lar  incision  is  made,  dividing- 
all  the  tissues  down  to  the 
bone  ;  a  retractor  is  next  ap- 
plied, and  the  bone  is  divided 
with  a  saw.    (Pig.  162.)  Lat- 
eral flaps  as  well  as  antero- 
posterior flails  may  be  em- 
ployed in  this  amputation. 

Transfixion  Method. 
— Owing  to  the  central  posi- 
tion of  the  bone  in  the  arm,  the  method  by  transfixion  is  preferred  by  many 
operators  ;  it  is  also  the  method  by  which  amijutation  can  be  most  rapidly 
performed.     (Fig.  163. )     The  arm  being  grasped  with  the  hand,  the  point 

of   a    medium-sized    ampiitating- 
'''■      ■  ■  knife  is  thrust  through  the   arm 

so  as  to  pass  over  the  humerus 
and  make  its  exit  at  a  corre- 
sponding point  on  the  skin  of  the 
oijposite  side  ;  a  flap  of  sufficient 
length  is  next  cut  from  within 
outward.  The  knife  is  then  passed 
behind  the  bone,  and  a  posterior 
flap  is  cut  in  the  same  manner. 
The  bone  is  next  cleared  of  any 
muscular  tissue  which  remains, 
the  flaps  are  retracted,  and  it  is 
divided  with  a  saw. 
Teale's  rhethod  is  sometimes  employed  in  amputations  at  the  middle 
and  lower  thirds  of  the  arm.  The  incisions  forming  the  long  anterior  flap 
should  be  made  in  such  a  manner  that  the  inner  one  clears  the  margins  of 
the  biceps  muscle  so  as  not  to  involve  the  brachial  artery  ;  the  short  flap  is 
taken  t'vonx  the  posterior  aspect  of  the  arm. 

Amputations  at  the  Shoulder-Joint. — The  disarticulation  of  the 
arm  at  the  shoulder-joint  may  be  effected  by  the  following  methods :  the 
oval,  or  Larrey's;  the  flap,  or  Dupuytren's ;  the  double  flap,  or  Lisfranc's, 
and  Spence's. 

The  greatest  risk  which  formerly  accompanied  amputations  at  the  shoul- 
der-joint arose  from  the  difficulty  in  controlling  the  hemorrhage  during  the 
oiieration.     This  was  effected  by  a  padded  kej'  pressed  upon  the  subclavian 


Amputation  of  the  arm  by  transfixion.     (Bryant.) 


240 


AMPUTATIONS  AT  THE  SHOULDER-JOINT. 


artery  above  tlie  clavicle,  or  by  an  assistant  grasping  the  axillary  vessels  in 
the  axillary  flap  before  their  final  division  was  accomplished.  At  the  present 
time  the  use  of  Wyeth's  pins  and  an  elastic  strap  is  found  the  most  satis- 
factory method  of  controlling  hemorrhage  during  amputation  at  the  shoul- 
der-joint. When  this  method  is  employed,  stout  steel  x)ins  or  skewers  about 
ten  inches  in  length  should  be  used  ;  the  anterior  pin  is  passed  through  the 
tissues  in  front  of  the  acromion  process,  and  is  brought  out  through  the 
anterior  fold  of  the  axilla ;  the  posterior  pin  is  passed  behind  the  acromion 
process,  and  is  brought  out  through  the  posterior  fold  of  the  axilla.  The 
rubber  strap  or  tube  is  then  wrapx^ed  around  the  shoulder  behind  the  pins 
and  secured.     (Fig.  164.)    If  this  method  of  controlling  hemorrhage  is  not 

Fig.  164. 


Pins  and  elastic  strap  applied  for  amputation  at  tlie  shoulder-joint. 

employed,  a  compress  in  the  axilla,  held  by  an  elastic  strap,  the  ends  of 
which  are  crossed  high  up  upon  the  shoulder  and  passed  to  the  opposite 
axilla,  may  be  used. 

Oval,  or  Larrey's  Method. — In  this  method  of  amputation  the  arm 
should  be  held  a  short  distance  from  the  body ;  the  point  of  the  knife  is  • 

entered    just    below    the 
^^'^-  ^^^-  acromion  process,  and  a 

deep  incision  three  inches 
in  length  is  made  down 
to  the  head  of  the  bone 
along  the  axis  of  the  arm  ; 
from  the  middle  of  this 
incision  two  others  are 
made,  one  on  each  side, 
obliquely  downward  to 
the  point  where  the  ante- 
rior and  posterior  folds  of  the  axilla  end  in  the  tissues  of  the  arm  (Fig.  165)  ; 
the  latter  incisions  should  be  only  deep  enough  to  divide  the  skin  and  super- 
ficial fascia.  The  median  incision  is  deepened  until  the  head  of  the  bone 
is  well  exposed,  and  after  opening  the  capsule  and  dividing  the  muscles 
inserted  into  the  neck  and  the  tuberosity  of  the  humerus,  which  ipay  be 
facilitated  by  rotating  the  head  of  the  bone  outward  and  inward,  the  dis- 


lucisions  for  Larrey's  amputation  at  the  shoulder-joint. 


AMPUTATIONS  AT  THE  SHOULDER-JOINT. 


241 


Fig    166 


Larrey's  amputation  at  the  shoulder-joint. 


Fig.  167. 


articulation  is  effected  by  adducting  the  elbow  and  passing  the  knife  down- 
ward behind  the  bone  and  cutting  outward  in  the  line  of  the  cutaneous 
incisions.  (Fig.  166.)  After  securing 
the  axillary  artery  and  axillary  vein, 
the  anterior  and  posterior  circumflex 
arteries,  and  any  muscular  brandies 
which  bleed,  the  flaps  should  be  brought 
together  vertically. 

The  Flap,  or  Dupuytren's  Method. 
— In  this  amputation,  the  arm  being  ab- 
ducted to  a  right  angle  with  the  body, 
the  flaps  may  be  cut  by  transfixion  or 
from  without  inward  ;  the  external  or 
large  flap  embraces  the  greater  i>art  of 
the  deltoid  muscle,  and  the  smaller  or 
short  flap  is  cut  from  the  inside  of  the 
arm  after  the  head  of  the  bone  has  been 
disarticulated.      When  amputating  by 

transfixion,  the  surgeon  pinches  up  the  thick  cushion  of  flesh  overlying  the 
shoulder ;  the  point  of  a  narrow  knife  should  be  entered  an  inch  in  front  of 
the  acromion  process  and  pushed  across  the  outer 
aspect  of  the  head  of  the  humerus,  shaving,  if 
possible,  the  capsule,  and  brought  out  at  the  pos- 
terior fold  of  the  axilla  ;  the  knife  is  then  made 
to  cut  downward  until  a  large  deltoid  flap  is 
formed ;  this  flap  is  turned  up  and  the  head  of 
the  bone  is  disarticulated ;  the  knife  is  then 
placed  behind  the  bone  and  a  short  flap  is  cut, 
keeping  close  to  the  bone  so  that  the  vessels  are 
divided  with  the  last  cut  of  the  knife.  (Fig.  167.) 
Double  Flap,  or  Lisfranc's  Method. — In 
this  amputation  the  point  of  the  knife  is  entered 
at  the  outer  side  of  the  coracoid  process  and  is 
cari'ied  across  the  outer  aspect  of  the  head  of  the 
humerus,  being  brought  out  a  little  below  the 
posterior  border  of  the  acromion  process,  and  a 
long  flap  is  cut  with  its  apex  below.  This  flap 
is  turned  up,  the  attachments  to  the  head  of  the  bone  are  severed,  and  it  is 
disarticulated.  The  knife  is  again  entered  behind  the  bone,  and  a  long 
posterior  flap  is  cut  from  within  outward. 

Spence's  Method. — In  this  amiautation  an  incision  is  made  down  to  the 
head  of  the  humerus,  immediately  in  front  of  the  coracoid  process,  and  is 
continued  downward  through  the  clavicular  fibres  of  the  deltoid  and  pec- 
toralis  major  muscles  until  the  attachment  of  the  latter  to  the  humerus  is 
reached  ;  the  incision  is  next  carried  backward  to  the  posterior  fold  of  the 
axilla ;  an  incision  including  only  the  skin  and  the  cellular  tissue  is  next 
made  from  the  anterior  portion  of  the  first  incision  across  the  inside  of  the 
arm  to  meet  the  incision  on  the  outer  side ;  the  outer  flap  thus  formed  is 

16 


Dupuytren'9  amputatioD  at  the 
shoulder-joint. 


242 


AMPL'TATIONS   ABOVE   THE   SHOrLDEE-JOIXT. 


turned  up,  aud  the  head  of  the  bone  is  disarticulated.    The  operation  is  com- 
pleted by  dividing  the  remaining  tissues  on  the  axillary  asj^ect  of  the  arm. 

In  securing  the  dressing  to  the  wound  after  ami^utations  at  the  shoulder- 
joint,  a  few  recurrent  and  circular  turns  of  a  bandage  are  applied,  aud  the 
turns  of  the  bandage  are  carried  over  the  stumj)  and  to  the  opposite  axilla, 
a  number  of  these  turns  being  emxjloyed,  and  the  bandage  is  finished  with  a 
few  circular  turns. 

Amputations  above  the  Shoulder-Joint.— Interscapulo-Tho- 
racic. — Tliis  form  of  amputation  is  sometimes  required  in  extensive  lacera- 
tions of  the  arm  and  the  region  of  the  shoulder,  or  in  cases  of  growths 
which  involve  the  shoulder  joint  and  the  tissues  above,  and  consists  in  the 
removal  of  the  arm  with  a  part  or  the  whole  of  the  scapula,  and  sometimes 
a  portion  of  the  clavicle.  When  the  operation  is  done  for  injury,  no  defi- 
nite lines  of  incision  can  be  laid  down,  the  practice  being,  as  far  as  possible, 
to  make  the  incisions  in  such  a  manner 
that  the  least  possible  amount  of  skin 
shall  be  sacrificed,  so  that  a  sufficient 
covering  for  the  wound  can  be  obtained. 
When  done  for  the  removal  of  growths 
involving  the  shoulder-joint,  the  inci- 
sions recommended  by  Treves  may  be 
employed.  The  patient  should  be  placed 
on  his  back  close  to  the  edge  of  the  oper- 
ating-table. An  incision  should  be  made 
over  the  clavicle,  extending  from  the 
inner  extremity  outward  to  a  point  a  little 
beyond  the  acromioclavicular  articula- 


FiG.  169. 


Lines  of  incision  for  amputation  above  the  shoulder- 
joint      (Tre-s  es  ) 


Interscapulo-thoracie  amputation.    (Le  Conte.) 


tion,  which  should  be  carried  down  to  the  bone  ;  the  clavicle  being  exposed, 
it  should  be  divided  in  its  middle  third  or  disarticulated  from  the  sternum, 
and,  its  outer  portion  being  lifted  up,  it  is  disarticulated  at  its  acromial  ex- 
tremity. The  subclavian  vessels  are  thus  exposed,  and  should  be  tied  by 
two  ligatures,  about  an  inch  apart,  and  the  vessels  should  finally  be  divided 
between  the  ligatures.    The  axillary  plexus  of  nerves  should  next  be  divided. 


AMPUTATIONS   OF  THE  LOWER  EXTREMITY. 


243 


The  second  incision  is  made  at  the  centre  of  the  first  incision,  and  the  knife 
is  carried  directly  across  the  anterior  x^art  of  the  axilla  and  inner  bordor 
of  the  arm  to  the  inferior  angle  of  the  scapnla ;  from  the  outer  extremity 
of  the  first  incision  over  the  clavicle  a  third  incision  should  be  made  poste- 
riorly, across  the  dorsum  of  the  scapula  to  its  inferior  angle,  joining  the 
termination  of  the  second  incision.  (Fig.  168.)  Upon  turning  back  the 
posterior  flap  thus  formed  and  severing  the  connections  of  the  scapula  with 
the  trunk  and  the  musciTlar  attachments  which  remain  anteriorly,  the  upper 
extremity  will  be  entirely  freed  from  the  trunk.  Any  small  vessels  which 
bleed  should  be  secured,  and,  after  introducing  a  ■  drainage-tube,  the  flaps 
should  be  brought  together  with  sutures  ;  the  wound  when  closed  forms  an 
oblique  line  running  from  above  downward,  outward,  and  backward ;  a 
coijious  gauze  dressing  should  be  applied  and  held  in  position  by  a  bandage. 
The  result  of  an  amputation  above  the  shoulder-joint  is  shown  in  Pig.  169. 


Fig.  170. 


Fig.  171. 


AMPUTATIONS   OP   THE    LOWEPv   EXTREMITY. 

Amputations  of  the  Toes.— The  amputation  of  a  toe  may  be  accom- 
plished through  the  continuity  of  the  phalanx,  or  an  interphalangeal  dis- 
articulation may  be  effected  ;  the  latter  is  the  preferable  operation.  Phalanges 
of  the  toes  may  be  removed  in  the  same  manner  as  those  of  the  fingers,  by 
a  racket-shaped  incision.  (Pig.  170.)  It  is  better  to  amputate  at  the  meta- 
tarso-phalangeal  articulation 
than  to  attempt  to  remove 
them  in  front  of  this  articula- 
tion, except  in  the  case  of  the 
great  toe,  as  the  pi-eservation 
of  a  portion  of  the  other  toes 
is  often  a  discomfort  rather 
than  an  advantage.  Care 
should  be  taken  to  make  the 
incision  in  such  a  manner  that 
the  resulting  cicatrix  shall  not 
occupy  the  i^lantar  surface  ;  if, 
however,  it  is  desired  to  am- 
putate a  toe  in  the  continuity 
of  the  phalanx,  this  is  accom- 
plished in  the  same  manner  as 
in  the  case  of  the  fingers,  by 
a  short  oval  flap  from  the 
dorsal  surface,  and  a  long  one 
from  the  plantar  aspect  of  the 
toe.  (Pig.  170).  It  is  well  to  remember  that  the  web  of  the  toes  is  consid- 
erably below  the  position  of  the  metatarso-ijhalangeal  joint.     (Pig-  171.) 

Metatarso-Phalangeal  Amputation  of  the  Toes. — A  single  toe  is 
usually  removed  by  an  incision  on  the  dorsal  surface,  beginning  a  little  above 
the  joint,  and  carried  downward  for  about  an  inch  ;  the  incision,  which  is 
made  down  to  the  bone,  then  diverges  into  the  web,  and  is  carried  under  the 
toe  and  back  on  the  other  side  to  the  point  of  divergence.     (Pig.  170.) 


Amputation  ol  toes  by 
racket  shaped  incibion  and 
flap  method.    (After  Rotter.) 


Relation  of  the  metatarso- 
phalangeal joint  to  web  of 
the  toes.    (Stimson.) 


244 


AMPITTATIONS   OF  THE  TOES. 


Amputation  of  Two  Adjoining  Toes.— A  dorsal  incision  should  be 
made  in  the  intermetatarsal  space,  just  below  the  level  of  the  joint,  and 
carried  down  to  the  beginning  of  the  web,  then  over  the  toe  to  the  begin- 
ning of  the  adjoining  web,  then  under  the  plantar  surface  of  both  toes  in 
the  line  of  the  digito-plantar  fold,  through  the  web,  and  back  to  the  point 
of  divergence ;  the  disarticulation  of  the  toes  is  then  effected,  and,  after 
controlling  bleeding  by  the  use  of  ligatures,  the  flaps  are  brought  together 
with  sutures. 

Amputation  of  the  Great  Toe. — Amputation  of  the  great  toe  may 
be  accomplished  by  means  of  the  racket-shaped  incision  employed  in  ampu- 
tation of  the  other  toes  (Fig.  170),  or  by  means  of  the  lateral  flap.  In  the 
latter  case  the  knife  is  made  to  enter  the  joint  by  cutting  through  the  com- 
missure, and  the  operation  is  completed  by  carrying  the  knife  through  the 
joint  and  along  the  outer  side  of  the  toe,  forming  a  flap  of  the  required  size. 
The  great  toe  may  also  be  amputated  by  means  of  a  short  dorsal  flap  and  a 
long  plantar  flap.  In  amputating  the  great  toe,  unless  care  is  taken  to  make 
the  flaps  sufficiently  voluminous,  difficulty  may  be  found  in  providing  suf- 
ficient covering  for  the  expanded  anterior  extremity  of  the  metatarsal  bone  ; 
this  should  be  covered  by  the  flaps  without  making  tension  upon  them,  for 
it  is  better  not  to  resect  the  end  of  this  bone,  as  it  interferes  with  the  base 
of  sujjport  for  the  foot. 

Amputation  of  all  the  Toes.— It  sometimes  happens  that  by  reason 
of  crushes,  frost-bites,  or  burns  the  removal  of  all  the  toes  is  required. 
This  is  accomplished  by  grasping  the  toes  with  the  hand 
and  making  an  incision  across  the  phalangeal  portion  of 
the  foot,  from  its  outer  to  its  inner  border,  as  nearly  as  pos- 
sible on  a  line  with  the  free  edge  of  the  interdigital  webs 
of  the  toes.  This  flap  is  next  dissected  back  as  far  as  the 
articulations,  each  of  which  is  opened  upon  its  dorsal  sur- 
face. (Fig.  172.)  When  all  the  bones  have  been  disarticu- 
lated the  toes  are  flexed,  and  the  knife  is  carried  behind 
the  articulations  to  the  plantar  aspect  of  the  foot  and  made 
to  cut  a  flap  from  the  under  surface  of  the  phalanges  as 
far  forward  as  the  web  of  the  toes.  A  number  of  metatarsal 
branches  of  the  plantar  arch  will  require  ligatures. 

Amputation  of  the  Metatarsal  Bones.— In  am- 
putating the  metatarsal  bones  it  is  better  to  leave  the  tarsal 
lieads  of  the  metatarsal  bones  in  place  and  divide  the  bones 
with  bone-pliers  or  a  saw  ;  in  other  words,  to  do  an  opera- 
tion in  continuity  to  prevent  opening  the  tarsal  articula- 
tions. In  amputating  through  the  metatarsus,  a  short  dorsal 
flaj),  slightly  convex  downward,  is  cut  from  one  side  of  the 
foot  to  the  other,  and  is  dissected  up  ;  a  long  plantar  Aap 
is  next  cut  in  the  same  manner,  and  when  this  has  been 
freed  from  the  bones  a  saw  is  applied  and  the  bones  are 
divided.     After  securing  any  bleeding  vessels  the  flaps  are 

brought  together  with  sutures,  and  the  cicatrix  will  be  upon  the  dorsum  of 

the  foot. 


Fig.  172. 


Amputation  of  all 
tbe  toes.  (After  Es- 
mareli.) 


AMPUTATIONS   OF  THE  FOOT. 


245 


Fig.  173. 


Amputation  of  the  Great  Toe  and  Metatarsal  Bone. — In  re- 
moving the  great  toe  with  its  metatarsal  bone  an  incision  is  made  upon 
the  dorsal  surface  of  the  metatarsal  bone,  a  little  below  the  point  at  which 
the  bone  is  to  be  divided,  and  is  carried  downward  below  the  meta- 
tarso- phalangeal  joint ;  it  then  diverges,  passes  under  the  toe,  and  comes 
back  again  to  the  jjoint  of  divergence.  The  bone  is  then  exposed  and 
cut  through  with  bone-cutting  forceps  and  a  saw,  or  is  disarticulated  at 
the  tarso-metatarsal  joint  and  then  lifted  up  and  dissected  loose  from  the 
tissues. 

Amputation  of  the  Fifth  Metatarsal  Bone.— The  incision  for  the 
removal  of  the  fifth  metatarsal  bone  is  made  over  the  bone  a  little  below 
the  tarso-metatarsal  articulation,  is  carried  down  and  curved  around  the 
toe,  and  after  the  bone  is  exposed  by  dissecting  back  the  flaps  it  is  divided 
or  disarticulated,  and  dissected  out. 

AMPUTATIONS   OP   THE    FOOT. 

At  the  present  time  some  surgeons  are  inclined  to  question  the  utility  of 
partial  amputations  of  the  foot,  and  consider  it  a  wiser  procedure,  where  an 
amputatioa  is  required  through  the  tarsal  bones,  to  go  above  the  ankle  and 
amputate  the  leg,  claiming  that  better  functional  results  follow  this  opera- 
tion. We  do  not  consider  this  opinion  a  sound  one,  and  think  that  those 
surgeons  who  have  had  large  experience  with  partial  amputations  of  the  foot 
are  convinced  that  these  are  better  procedures,  as 
shown  by  the  excellent  results  that  follow  these  oper- 
ations. In  amputating  through  the  foot  it  has  also 
been  advised  by  Hancock  to  consider  the  foot  as  com- 
posed of  one  bone,  and,  after  having  made  sufficient 
flaps,  to  saw  through  the  bones  of  the  foot,  disregard- 
ing the  articulations.  Where  it  is  possible,  however, 
we  prefer  the  systematic  oiierations  through  the  ar- 
ticulations, although  almost  every  surgeon  has  found 
in  actual  work  that  some  of  these  procedures  have  to 
be  modified  by  sawing  the  bones  at  certain  points. 
In  all  amputations  of  the  foot  involving  the  tarsus 
the  surgeon  should  be  thoroughly  familiar  with  the 
surgical  landmarks  of  the  different  articulations. 
(Pig.  173.)  We  refer  to  those  laid  down  by  Bryant, 
which  are  as  follows  :  On  the  inner  side  of  the  foot, 
not  far  from  the  inner  malleolus,  the  tubercle  of  the 
scaphoid  bone  is  to  be  felt  (A)  as  a  marked  promi- 
nence. About  half  an  inch  in  front  of  this  will  be 
found  the  articulation  with  the  cuneiform  bone  (B), 
and  one  inch  in  front  of  this  the  joint  which  the  sur- 
geon will  have  to  open  in  Lisfranc's  or  Hey's  opera- 
tion (0).    Just  above  the  tubercle  of  the  scaphoid  will 

be  found  the  articulation  with  the  astragalus,  the  line  of  Ch opart's  amputa- 
tion (i>).  On  the  outer  side  of  the  foot,  one  inch  below  the  external  malle- 
olus, a  sharply  defined  projection  will  be  felt,  which  is  the  peroneal  tubercle 


Surgical  landmarks  to  the 
articulations  of  the  foot.  (Brj'- 
ant.) 


246  TARSO-jMETATAESAL  AMPUTATIOX. 

(JE)  ;  half  au  inch  in  fi-ont  of  this  will  be  foiiud  the  joint  which  separates  the  os 
calcis  from  the  cuboid  (F),  this  joint  forming  the  outer  circle  of  Choi^art's 
amputation.  Half  an  inch  in  front,  or  one  inch  from  the  tubei'cle,  the 
l^rominence  of  the  iifth  metatarsal  bone  is  to  be  felt  (S),  a  line  above  this 
prominence  indicating  the  articulation  of  the  cuboid  bone,  which  forms  the 
outer  boundary  for  Hey's  or  Lisfranc's  amj)utation. 

Hemorrhage  during  tarsometatarsal  or  tarsal  am^^utations  is  controlled 
by  the  application  of  a  tourniquet  to  the  femoral  artery,  or,  better,  by  the 
application  of  Esmarch's  elastic  strap  to  the  fleshy  jjart  of  the  leg. 

Tarso-Metatarsal  Amputation  (Lisfranc's).— The  incision  for 
this  amputation  is  a  curved  one,  carried  across  the  dorsum  of  the  foot,  from 
the  base  of  the  fifth  to  the  base  of  the  first  metatarsal  bone.  The  incision 
should  involve  the  skin  only,  its  centre  lying  half  an  inch  or  more  below 
the  centre  of  the  line  of  the  articulations,  and  it  should  begin  and  end  at 
the  sides  of  the  foot  at  their  junction  with  the  sole.  A  plantar  flap  should 
be  marked  out  by  a  curved  incision  crossing  the  sole  of  the  foot  near  the 
articulations  of  the  toes  with  the  metatarsal  bones,  starting  and  ending  at 
the  same  points  as  the  dorsal  incision.  Having  cut  the  dorsal  flap  as  above 
described,  it  should  be  dissected  back  to  the  line  of  the  articulations ;  the 
tendons,  muscular  fibres,  and  fascia  being  divided,  the  joints  between  the 
tarsal  and  the  metatarsal  bones  are  next  opened  with  a  stout,  narrow-bladed 
knife.  Difdculty  is  sometimes  experienced  in  opening  the  joint  between  the 
head  of  the  second  metatarsal  bone  and  the  second 
^^°  ^"^^     «.  cuneiform  bone,  which  occupies  a  position  higher 

in  the  foot  than  the  other  articulations.  The  dis- 
articulation may  be  facilitated  by  forcibly  depress- 
ing the  anterior  i^ortion  of  the  foot.  After  all  the 
ioints  have  been  opened,  the  plantar  ligaments  are 
divided,  the  knife  is  passed  behind  the  ends  of  the 
metatarsal  bones,  and  a  plantar  flap  is  cut  from 
within  outward,  following  the  line  of  the  incision 
previously  marked  out.  (Fig.  174).  The  plantar 
fla]3  may  be  cut  from  without  inward  if  preferred. 
MOfea^  The  vessels  requiring  ligatures  are  the  dorsal  and 

Lisfranc's  amputation  of  the  foot,  intcrosseous  artcrics  and  the  plantar  branch  of  the 
dorsalis  pedis  ;  in  the  j)lantar  flaj)  the  plantar  digital 
branches  of  the  external  plantar,  as  well  as  the  internal  plantar  arterj-, 
usually  require  ligatures.  Care  should  be  taken  that  the  dorsal  incision  is 
not  carried  too  far  back,  or  the  joint  between  the  scaphoid  and  cuneiform 
bones  may  be  opened  on  the  inner  margin  of  the  foot. 

Tarso-Metatarsal  Amputation  (Hey's).— In  this  amputation  a 
curved  incision  is  made  from  the  base  of  the  fifth  metatarsal  bone,  across  the 
dorsum  of  the  foot,  to  the  base  of  the  first  metatarsal  bone.  The  line  of 
incision  and  the  steps  of  the  amputation  are  similar  to  those  in  Lisfranc's 
amputation,  with  the  exception  that  the  projecting  portion  of  the  internal 
cuneiform  bone  is  sawed  off  after  disarticulating  the  metatarsal  bones. 
This  modification,  although  it  imxJroves  the  appearance  of  the  stump,  pos- 
.sesses  no  other  advantage. 


CHOPART'S   AMPUTATION.  247 

Medio-Tarsal,  or  Chopart's  Araputation.— In  this  amputation 
the  whole  of  the  tarsus  except  the  asti-agalus  and  the  calcaneum  is  removed, 
the  disarticulation  being  through  the  joints  formed  by  the  astragalus  and 
OS  calcis  behind  and  the  scajihoid  and  cuboid  in  front.  In  performing 
Chopart's  amputation  an  incision  is  made  from  the  tubercle  of  the  scaphoid 
bone  across  the  dorsum  of  the  foot,  an  inch  in  front  of  the  head  of  the 
astragalus,  to  the  lower  and  outer  border  of  the  cuboid  bone.  A  plantar 
flap  is  next  marked  out  by  an  incision  beginning  and  ending  at  the  same 
points  as  the  first  incision  and  crossing  the  sole  of  the  foot  four  or  five  finger- 
breadths  nearer  the  toes  ;  the  dorsal  flap  is  next  dissected  up,  and  after  the 
tendons  and  fascia  and  ligaments  have 

been  divided  the  j oints  are  opened.   The  ^^'^-  ^''^• 

disarticulation  may  be  much  facilitated 
by  forcibly  bending  the  foot  downward, 
so  as  to  make  the  anterior  ligaments  of 
the  joints  tense.  The  plantar  flap  is 
next  cut  from  within  outward,  follow- 
ing the  line  of  the  previously  marked- 
out  plantar  incision.  (Fig.  175).  If, 
on  adjusting  the  flaps,  it  is  found  that 
any  tension  is  present  from  the  draw- 
ing  upward   of   the   heel   by   the  tendo         Choiait's  amputation  ot  Uie  foot       (Brjant.) 

Achillis,  the  extensor  tendons  may  be 

sutured  to  the  face  of  the  stump,  or  the  former  tendon  should  be  divided. 
The  stump  resulting  fi-om  Chopart's  amputation  is  a  useful  one,  but  in  some 
cases  the  subsequent  retraction  of  the  heel  by  the  action  of  the  muscles 
inserted  through  the  tendo  Achillis  causes  pressure  upon  the  cicatrix,  which 
interferes  with  the  use  of  the  stump.  In  these  cases  division  of  the  tendo 
Achillis  may  be  of  service. 

Subastragaloid.  Amputation.— In  this  operation  all  the  bones  of 
the  foot  are  removed  excejit  the  astragalus.  In  performing  this  amputation 
an  incision  is  made  beginning  an  inch  below  the  tip  of  the  external  malle- 
olus, and  is  carried  forward  to  the  base  of  the  fifth  metatarsal  bone,  then 
carried  across  the  dorsum  of  the  foot  to  the  calcaneo-cuboid  articulation,  on 
a  line  with  which  a  transverse  incision  is  made  through  the  tissues  of  the 
sole  of  the  foot.  The  joints  between  the  scaphoid  bone  and  the  astragalus, 
and  between  the  astragalus  and  the  os  calcis,  are  opened,  and  the  os  calcis  is 
carefully  dissected  out,  the  point  of  the  knife  being  kept  close  to  the  bone 
during  dissection  to  avoid  injury  of  the  vessels  ;  the  ligaments  are  divided, 
and  the  astragalus  only  is  allowed  to  remain  in  place. 

Tripier  has  modified  the  subastragaloid  amputation  by  leaving  the  upper 
part  of  the  calcaneum,  which  he  saws  through  on  an  angle  with  the  susten- 
taculum tali  and  at  right  angles  to  the  axis  of  the  leg.  The  incisions  are  the 
same  as  in  Chopart's  amputation. 

Amputations  at  the  Ankle-Joint.— Syme's  Amputation.— 
In  performing  this  anqiutatiou  the  foot  should  be  at  a  right  angle  to  the  leg, 
and  an  incision  should  be  made  from  the  centre  of  one  malleolus,  directly 
across  the  sole  of  the  foot,  to  the  centre  of  the  opposite  malleolus ;  the  tissues 


248 


AMPUTATIONS  AT  THE  ANKLE-JOINT. 


of  the  heel  are  next  carefully  dissected  from  the  bone  by  keeping  the  knife 
close  to  the  osseous  surface  until  the  tuberosity  of  the  os  calcis  is  fairly 
turned.  (Fig.  176.)  The  two  extremities  of  the  first  incision  are  then 
joined  by  a  transverse  one  across  the  instep,  and,  the  joint  being  opened, 
the  lateral  ligaments  are  divided  to  complete  the  disarticulation ;  the  knife 

Fig.  176.  Fig.  177. 


Syme's  amputation  of  the  foot.    (Bryant.) 


Stump  after  b\  me  s  amputation.     (Agnew.) 


Fig.  178. 


is  next  used  to  clear  the  malleoli,  and  these  with  the  articulating  surface 
of  the  tibia  are  removed  with  a  saw.  In  dissecting  out  the  os  calcis  and 
making  the  heel-flap,  great  care  should  be  taken  to  keep  close  to  the  bone,  so 
as  not  to  destroy  the  vascular  connections  of  the  flap.  The  stump  resulting 
from  this  amputation  is  an  excellent  one.     (Fig.  177.) 

Pirogoff's  Amputation. — In  this  amputation  all  the  tarsal  bones 
are  removed  except  the  posterior  portion  of  the  os  calcis.  In  performing 
Pirogoff's  ami^utation  an  incision  is  carried  from  the  tij)  of  the  inner  mal- 
leolus, over  the  instep,  half  an  inch  in  front  of  the  anterior  edge  of  the 

tibia  to  a  point  half  an  inch  in  front 
of  the  tip  of  the  outer  malleolus.  A 
second  incision  crossing  the  sole  of  the 
foot  and  carried  down  to  the  bone, 
uniting  the  extremities  of  the  first  in- 
cision, is  next  made.  The  plantar  flap 
thus  made  is  dissected  back  for  a  quar- 
ter of  an  inch,  the  joint  being  opened 
by  dividing  the  lateral  ligaments,  the 
astragalus  is  disarticulated,  and  the 
malleoli  are  exposed.  A  narrow  saw 
is  next  applied  to  the  upper  and  pos- 
terior part  of  the  calcaneum  behind  the 
astragalus,  and  it  is  divided  obliquely 
downward  in  the  line  of  the  plantar 
incision.  (Fig.  178.)  The  malleoli 
and  a  thin  slice  of  the  tibia  are  next 
removed  with  a  saw,  as  in  Syme's  amputation.  Some  surgeons  do  not  re- 
move the  malleoli,  but  press  the  sawed  surface  of  the  os  calcis  between  them 


Pirogoff's  amputation  of  the  foot.    (After  Es- 
march.) 


EOrX'S  AMPUTATION. 


249 


X 


> 


\ 


Line  of  intr 


1  V  -  imputation  at  the  ankle   a,  dorsal, 
h,  plantar,  incision. 


when  it  is  possible  to  do  so.  By  this  amputation  an  admirable  stump  may 
be  obtained  ;  the  ealcaneum  being  firmly  attached  to  the  bones  of  the  leg, 
the  length  of  the  limb  is  not  seriously  altered. 

Roux's  Amputation  at  the  Ankle- Joint.— In  this  method  of  am- 
putation an  incision  is  made  at  the  outer  edge  of  the  tendo  Achillis  a  little 
above  its  insertion,  and  is  car- 
ried forward  under  the  outer  Fig.  179. 
malleolus  and  across  the  instep 
and  back  to  a  point  just  in 
front  of  the  inner  malleolus ; 
the  incision  is  carried  from 
this  point  downward  and 
partly  across  the  sole  of  the 
foot,  then  back  to  the  point  of 
origin  of  the  original  incision. 
(Fig.  179.)  The  flaps  are  dis- 
sected up  for  a  short  distance  ; 
the  ankle-joint  is  opened,  dis- 
articulation is  effected,  and 
the  internal  flap  is  carefully 
dissected  from  the  bones. 

Osteoplastic  Resection  of  the  Foot.— As  a  substitute  for  amputa- 
tion at  the  ankle-joint  in  injuries  or  diseases  of  the  os  calcis  or  in  intractable 
ulceration  of  the  heel,  the  Mikulicz- Wladimiroff  operation,  or  osteoplastic 
resection  of  the  foot,  has  been  practised,  consisting  in  the  removal  of  the 
soft  parts  covering  the  heel,  together  with  the  os  calcis 
and  the  astragalus,  and  bringing  into  contact  the  sawed 
surfaces  of  the  tibia  and  fibula  on  the  one  hand  and 
those  of  the  cuboid  and  scaphoid  on  the  other,  the  foot 
thus  being  fixed  in  the  position  of  talipes  equinus,  and 
the  patient  walking  on  the  balls  and  phalanges  of  the 
toes.  (Fig.  ISO.)  A  transverse  incision  is  made  across 
the  sole  of  the  foot  from  the  tuberosity  of  the  scaphoid 
to  a  point  a  little  behind  the  fifth  metatarsal  bone  ;  two 
incisions  are  next  carried  from  the  extremities  of  this 
cut  on  each  side  of  the  foot  obliquely  upward  to  the 
bases  of  the  malleoli ;  the  two  extremities  of  the  cut 
are  finally  joined  by  a  horizontal  incision  which  crosses 
over  the  tendo  Achillis  and  comi^letes  the  wound.  The 
foot  is  nest  flexed,  the  tendo  Achillis  is  divided,  and  the 
ankle-joint  is  opened  from  behind.  The  soft  parts  upon 
the  dorsum  of  the  foot  are  next  separated  from  the 
astragalus  by  an  elevator ;  the  calcaneo-cuboid  and 
astragalo-scaphoid  joints  are  then  opened  from  above, 
and  the  whole  of  the  heel,  together  with  the  os  calcis 
and  the  astragalus,  is  removed ;  the  lower  ends  of  the  tibia  and  fibula  and 
the  joint  surfaces  of  the  scaphoid  and  cuboid  are  next  removed  with  a  saw. 
The  cut  surfaces  of  the  bone  are  then  brought  together  and  held  in  contact 


Fig.  180. 


Result  of  osteoplastic  re- 
section of  the  foot.  (After 
Esmaroh.) 


250  AMPUTATIONS   OF  THE  LEG. 

by  sutures ;   a  gauze  dressing  is  applied,  and  over  this  a  plaster- of- Paris 

dressing,  including  the  foot  and  leg.     The  patient  after  the  wound  is  healed 

is  usually  compelled  to  wear  a  specially  constructed  shoe.     As  the  result  of 

this  operation  the  limb  is  sometimes  a  little  lengthened,  so  that  it  becomes 

necessary  to  wear  a  high  shoe  upon  the  sound  foot  to  equalize  the  length  of 

the  limbs. 

AMPUTATIONS   OP   THE   LEG. 

The  leg  may  be  amj)utated  in  its  lower,  middle,  or  upper  third,  the  rule 
being  to  save  as  much  of  the  limb  as  jDOSsible,  but  as  regards  the  application 
of  artificial  limbs,  the  stumps  resulting  from  amijutatiou  in  the  middle  and 
upiDcr  thirds  will  be  found  more  satisfactory  than  those  from  amputation 
just  above  the  ankle.  In  sawing  the  bones  it  is  of  advantage  to  divide  the 
fibula  at  a  slightly  higher  point  than  the  tibia.  The  leg  may  be  amputated 
by  the  circular,  modified  circular  or  oval,  the  elliptical,  the  rectangular 
flap  method  (Teale),  or  the  external  flap  method  (Sedillot).  The  choice 
of  operation  will  dej)end  somewhat  ujion  the  portion  of  the  leg  at  which  the 
amputation  is  to  be  performed.  In  the  lower  third  of  the  leg  the  circular 
or  the  modified  circular  method  is  usually  employed.  In  the  middle  and 
upper  thirds  the  elliptical  method  or  that  of  Sedillot  may  be  emj)loyed  with 
advantage.  Hemorrhage  is  controlled  during  the  operation  by  applying  the 
tourniquet  or  elastic  strap  to  the  femoral  artery  in  Scarpa's  triangle  or  just 
above  or  below  the  knee. 

Circular  Method. — In  amputating  the  leg  in  the  lower  third  a  circu- 
lar incision  is  made  through  the  skin  and  connective  tissue  just  above  the 
malleoli,  and  a  cuff  is  dissected  up  for  a  suf&cient  distance ;  a  circular  in- 
cision of  the  tendons  and  muscles  is  nest  made,  dividing  all  the  tissues  down 
to  the  bone.  The  interosseous  membrane  is  next  divided  with  a  narrow 
knife,  a  retractor  is  applied  to  hold  back  the  soft  parts,  and  the  bones  are 
divided  with  a  saw. 

The  Modified  Circular  or  Oval  Method. — In  this  method  two 
oval  flaps  of  skin  and  connective  tissue  are  made,  either  antero-posterior  or 
lateral ;  these  are  dissected  up.     A  circular  di^asion  of  the  muscles  is  next 


Moditied  ciicular  amputatiun  of  the  le; 


made  down  to  the  bone,  the  interosseous  membrane  is  divided,  and,  the  soft 
parts  being  held  out  of  the  way  by  a  retractor,  the  bones  are  divided  with  a 
saw.     (Pig.  181.) 

Sedillot's,  or  External  Flap  Method.— In  this  method  the  point 
of  the  knife  is  entered  a  finger-breadth  external  to  the  spine  of  the  tibia  and 
carried  outward  grazing  the  fibula,  and  is  brought  out  as  far  as  possible  to 
the  outer  side.     A  flap  three  or  four  inches  in  length  is  then  cut  from  within 


AMPUTATIO^"S   OF  THE  LEG. 


251 


outward.  Tlie  extremities  of  the  incision  are  next  united  by  an  incision 
across  the  inner  side  of  the  limb  involving  the  skin  and  fascia  only,  and  any 
remaining  muscular  tissue  is  divided  and  the  bones  are  sawed.  (Fig.  182.) 
The  long  external  flap  is  then  brought  over  the  ends  of  the  bones  and  fas- 
tened to  the  edges  of  the  incision  on  the  inner 
side  of  the  limb.  Ashhurst  modified  this  oper- 
ation by  cutting  the  long  external  flap  from 

Fig.  182. 


Scdillot  <;  imputation  of  the  lee 


Stump  after  Sedillot'b  .imijuta- 
tion.     (After  Esmarch.) 


without  inward,  and  made  also  a  short  internal  flap  in  the  same  manner. 
The  resulting  stumj)  is  a  good  one,  with  the  ends  of  the  bones  covered  by 
the  tissues  of  the  external  flap.     (Fig.  183.) 

Rectangular  Flap  Method  (Teale).— In  this  method  of  amputation 
of  the  leg  an  incision  equal  in  length  to  one-half  of  the  circumference  of  the 
leg  is  made  from  the  point  at  which  the  bones  are  to  be  divided,  on  one  side 
of  the  leg,  and  is  carried  across  the  limb  and  back  upon  the  other  side  to  a 
point  opposite  the  point  of  starting.  The  flap  thus  marked  out  is  dissected 
uiJ  to  its  base,  and  a  second  flap  of  one-quarter  of  the  length  is  next  cut 
by  a  transverse  incision  down  to  the  bone,  and  is  dissected  back  to  the  line  of 
origin  of  the  first  incision.  The  bones  are  divided  with  a  saw,  and  the  long- 
flap  is  next  doubled  back  and  its  edges  secured  to  the  posterior  flap.  (Fig. 
181.) 


Teale's  amputation  of  the  leg.     (Bryant.)  Osteoplaitic  amputation  of  the  leg  bj  Bier  s  mLthod. 

Bier's  Osteoplastic  Method.— An  oval  flap  consisting  of  the  skin 
and  cellular  tissue  of  one-half  of  the  limb  is  dissected  back  to  its  base,  care 
being  taken  not  to  injure  the  periosteum.     From  the  ijeriosteum  of  the  tibia 


252 


AMPUTATIONS  AT  THE  KNEE-JOINT. 


a  rectangular  flap  sufficiently  large  to  cover  the  sawed  surface  of  the  tibia 
and  fibula  is  marked  out  by  incisions ;  the  longitudinal  incisions  lie  a 
little  beyond  the  tibial  borders.  From  the  transverse  incision  the  flap  is 
reflected  upward  about  one-half  a  centimetre.  A  lamella  of  bone  is  next 
sawed  in  an  upward  direction,  the  saw  being  tui'ned  towards  the  periosteum 
at  its  ui^per  part  to  complete  the  bone-flap.  The  amputation  is  completed 
by  a  circular  incision  of  the  tissues  on  the  jjosterior  aspect  of  the  limb  and 
sawing  the  tibia  and  fibula  close  to  the  border  of  the  bone-flap.  The  bone- 
flap  is  then  turned  over  the  sawed  surfaces  of  the  bones  and  secured  by 
sutures.     (Fig.  185.) 

The  vessels  which  require  ligature  in  amputations  of  the  leg  are  the 
anterior  and  jjosterior  tibial  and  the  peroneal  and  muscular  branches.  Care 
should  be  taten  to  make  the  flaps  sufficiently  long,  so  that  the  anterior  flap 
shall  not  be  tightly  drawn  over  the  spine  of  the  tibia.  Formerly,  when 
sui^puration  was  common  after  amx^utations,  the  spine  of  the  tibia  often 
came  through  the  anterior  flap,  and  a  limited  necrosis  of  this  portion  of  the 
bone  was  apt  to  occur.  To  avoid  this  accident  it  was  recommended  that 
the  anterior  edge  of  the  spine  of  the  tibia  be  sawed  off  obliquely.  This 
procedure  is  now  rarely  practised.  Before  dividing  the  bones  it  is  often 
possible  in  amputations  of  the  leg,  esiiecially  in  young  subjects,  to  turn 
up  a  periosteal  flap  from  the  tibia.  Before  closing  the  stumxD  this  periosteal 
flap  may  be  stitched  over  the  sawed  surface  of  the  bone. 


AMPUTATIONS   AT   THE   KNEE-JOINT. 
Amputations  at  the  knee-joint  may  be  done  by  the  anterior  flap  method, 

or  by  the  elliptical  or  the  circular  method,  and  the  bones  may  be  dis- 
articulated   or    a    section    may    be 
^^^  ^^^  made  through  the  condyles  of  the 

femur. 

Anterior  Flap  Method.— Tn 
amputating  at  the  knee-joint  by  this 
method  a  long  anterior  cutaneous 
flap  is  formed  :  the  incision,  begin- 
ning half  an  inch  below  the  internal 
condyle  of  the  femur,  is  carried  down 
the  leg  for  five  inches,  then  crosses 
the  anterior  surface  of  the  leg  to  a 
corresponding  iioint  on  the  opposite 
side,  and  is  carried  back  to  a  point 
half  an  inch  below  the  external  con- 
dyle of  the  femur.  This  flaj)  is  dis- 
sected up  and  the  ligament  of  the 
patella  is  divided  ;  the  joint  is  then 
opened,  the  lateral  ligaments  are 
divided,  and  the  disarticulation  is 
effected.     A  short  posterior  flap  is 

next  cut  by  transfixion,  or  from  without  inward.     The  semilunar  cartilages 

and  the  patella  are  not  removed.     (Fig.  186.) 


Amputation  at  the  knee  joint  by  an  anterior  flap. 


A:\IPUTATI0\S   at  the   knee-joint.  253 

Elliptical  or  Oval  Method. — In  the  elliptical  method  an  incision 
crossing  the  spine  of  the  tibia  five  finger-breadths  below  the  lower  extremity 
of  the  patella  is  carried  around  the  back  of  the  leg  three  finger-breadths 
higher  than  in  front ;  the  tissues  in  the  front  of  the  leg  are  dissected  up 
until  the  tendon  of  the  patella  is  exposed ;  the  leg  is  then  flexed  and  the 
ligament  of  the  patella  is  divided ;  the  capsular  ligament  and  the  lateral 
and  crucial  ligaments  are  next  severed,  care  being  taken  not  to  injure  the 
popliteal  vessels  with  the  point  of  the  knife.  The  tibia  is  next  drawn  for- 
ward, the  knife  is  passed  behind  its  posterior  border,  and  the  remaining 
soft  parts  are  divided  from  within  outward. 

Circular  Method. — In  performing  this  ami^utation  the  leg  should  be 
extended,  and  a  circular  incision  should  be  made  around  the  leg  three 
inches  below  the  patella,  dividing  the  skin  and  connective  tissue.  The 
skin  is  next  dissected  up,  on  all  sides,  as  far  as  the  lower  edge  of  the 
patella ;  the  cuff  of  skin  being  turned  back  at  this  point,  the  knee  is 
flexed,  the  ligamentum  patellae  cut  through,  the  joint  opened,  and  the 
disarticulation  is  effected  by  dividing  the  capsular  and  lateral  ligaments 
close  to  the  femur,  so  that  the  semilunar  cartilages  and  the  greater  i^art  of 
the  caj)sular  ligament  shall  remain  attached  to  the  tibia.  The  crucial  liga- 
ments and  remaining  tissues  are  then  divided,  and  the  disarticulation  is 
completed.  After  the  vessels  have  been  ligated,  the  cuff  of  skin  is  turned 
down  over  the  patella  and  cartilages,  and  its  edges  are  brought  together 
transversely  by  sutures. 

Gritti's  Amputation  at  the  Knee-Joint. — In  this  operation  a 
long  anterior  rectangular  flap  is  cut  and  dissected  up,  and  after  the  dis- 
articulation has  been  effected  the  skin  covering  the  posterior  surface  of 
the  knee  is  cut  from  within  outward.  The  condyles  of  the  femur  are 
next  reinoved  by  a  saw,  just  above  the  edge  of  the  articular  cartilage, 
and  the  articular  surface  of  the  patella  is  also  removed  with  the  saw.  The 
patella  is  next  brought  down  so  that  its  sawed  surface  shall  be  in  contact 
with  the  sawed  surface  of  the  condyles,  and  the  flaps  are  approximated. 

Garden's  Amputation. — This  amputation  is  performed  by  making 
an  anterior  flap  whose  lower  extremity  is  three  finger-breadths  below  the 
patella ;  this  is  cut  and  dissected  up,  and  the  disarticulation  is  effected.  A 
short  posterior  flap  similar  to  that  in  amputation  through  the  knee-joint  is 
next  cut ;  the  joint  is  opened,  and  the  disarticulation  is  completed.  The 
patella  is  then  removed  and  the  condyles  of  the  femur  are  sawed  through 
just  above  the  edge  of  the  articular  cartilage. 

The  vessels  requiring  ligature  in  amputations  at  the  knee-joint  are  the 
popliteal  artery  and  popliteal  vein,  the  sural  arteries,  and  a  few  muscular 

AMPUTATIONS   OF   THE   THIGH. 

Amputation  may  be  performed  at  any  portion  of  the  thigh  ;  the  gravity 
of  the  operation  increases  with  the  proximity  of  the  section  to  the  trunk. 
The  methods  employed  in  amputation  of  the  thigh  are  the  circular,  the 
modified  circular,  and  transfixion. 

The  Circular  Method. — This  amputation  is  employed  at  the  lower 
portion  of  the  thigh  and  in  cases  where  the  limb  is  not  very  muscular.     In 


254 


AMPUTATIONS   OF  THE  THIGH. 


this  method  after  drawing  the  skin  upward,  and  while  the  retraction  of 
the  skin  and  cellular  tissue  is  maintained,  a  circular  incision  is  made 
around  the  thigh,  dividing  the  skin  and  cellular  tissue ;  the  surgeon  then 
makes  a  circiilar  sweep  with  the  knife,  dividing  all  the  tissues  down 
to  the  bone ;  a  retractor  is  next  applied,  and  the  bone  is  divided  with 
a  saw. 

The  Modified  Circular  Method. — This  amputation  is  applicable 

to  all  portions  of  the  thigh,  and  consists  in  making  anterior  and  posterior, 

or  lateral  oval  flaps  of  skin  and  con- 
nective tissue  (Fig.  187) ;  these  are 
dissected  uj),  and  a  circular  incision 


Fig.  187 


Amputation  of  the  thigh  by  the  modified  circular 
method. 


Amputation  of  the  thigh  by  transfixion.    (Bryant. ) 


of  the  muscles  down  to  the  bone  is  next  made.   The  soft  parts  being  retracted, 
the  bone  is  divided  with  a  saw. 

Transfixion  Method. — Amputation  of  the  thigh  by  transfixion  was 
formerly  a  popular  operation  on  account  of  the  rapidity  with  which  it  could 
be  performed.  In  this  method  of  amputating  a  long  knife  is  entered  at  the 
outer  portion  of  the  thigh,  carried  over  the  femur,  and  brought  out  at  a  cor- 
responding point  on  the  inner  portion  of  the  thigh ;  a  flap  of  sufficient 
length  is  then  cut  by  carrying  the  knife  downward  and  bringing  it  out  to 
the  surface  of  the  skin  (Fig.  188) ;  the  knife  is  then  entered  behind  the  bone 
at  the  same  point,  and  a  j^osterior  flap  is  cut  from  within  outward.  In  am- 
putations of  the  thigh  the  femoral  artery  and  femoral  vein  require  the 
application  of  ligatures  ;  also,  in  high  amputations,  the  profunda  or  branches 
of  the  profunda,  and  numerous  muscular  branches. 

AMPUTATION   AT   THE   HIP-JOINT. 

The  gravity  of  this  operation  depends  largely  upon  the  amount  of  blood 
that  is  lost  during  the  procedure,  and  various  methods  of  controlling  bleed- 
ing have  therefore  been  devised.  Hemorrhage  during  hip-joint  amputations 
was  formerly  controlled  by  digital  pressure  upon  the  femoral  artery,  by  the 
use  of  the  abdominal  tourniquet,  or  by  Davy's  lever,  which  made  com- 
pression on  the  aorta  or  iliac  artery  through  the  rectum,  or  by  compression 


AMPUTATION   AT  THE  HIP-JOINT.  255 

of  the  abdominal  aorta  by  the  liaiicl  by  Macewen's  method.  Preliminary 
ligation  of  the  external  iliac  artery  has  also  been  practised.  Esmarch's 
elastic  strap  has  also  been  employed  during  amputations  at  the  hip-joint, 
the  strap  being  applied  in  such  a  manner  that  it  occupies  the  position  of  a 
spica  bandage  of  the  groin.  Wyeth's  method  of  controlling  hemorrhage 
during  amputations  at  the  hip-joint  is  described  later.  Jordan  and  Senn 
have  employed  a  method  of  amputating  at  the  hijD-joint,  in  which  the  head 
of  the  bone  is  first  disarticulated  through  the  external  incision,  and  the 
bleeding  is  controlled  before  the  amputation  is  completed  by  passing  an 
elastic  strap  or  tube  around  the  soft  parts  above  the  point  where  they  are  to 
be  divided.  ISTumerous  methods  of  amputation  of  the  hip-joint  liave  been 
devised,  but  those  principally  employed  are  the  oval  method,  the  circular 
method,  and  the  anteroposterior  flap  method.  In  any  of  these  methods  the 
hemorrhage  during  the  operation  maj^  be  controlled  by  the  use  of -Wyeth's 
pins  and  the  elastic  strap. 

Oval  Method. — In  this  method  of  amputation  the  point  of  a  strong 
knife  is  jiassed  into  the  tissues  below  the  anterior  superior  spinous  process 
of  the  ilium,  and  two  oblique  incisions  are  made,  one  forward  and  down- 
ward, the  other  backward,  both  incisions  meeting  on  a  transverse  line  on  the 
inner  side  of  the  thigh.  The  muscles  are  next  divided  on  a  little  higher 
line,  and  when  the  joint  is  exposed  disarticulation  is  effected  from  the  outer 
side,  and  any  remaining  tissue  is  divided. 

Circular  Method. — A  circular  incision  of  the  skin  and  connective 
tissue  of  the  thigh  is  made  six  inches  below  the  spine  of  the  ilium.  The 
muscles  are  next  divided  down  to  the  bone  on  a  higher  level,  the  joint  is 
opened,  and  the  head  of  the  bone  disarticulated. 

Antero-Posterior  Flap  Method. — In  this  method  of  amputation 
the  flaps  may  be  made  by  transfixion,  or  may  be  cut  from  without  inward. 
When  done  by  transfixion  the  point  of  a  long  amputating  knife  is  thrust 
into  the  tissues  about  two  finger- breadths  below  the  anterior  superior  spinous 
process  of  the  ilium,  is  pushed  through  the  tissues,  grazing  the  hij)-joint,  and 
is  then  brought  out  at  the  opposite  side  of  the  thigh  close  to  the  junction  of 
the  scrotum  with  the  thigh.  The  knife  is  next  carried  downward  close  to 
the  bone,  and  an  anterior  flap  of  sulflcient  length  is  cut  from  within  out- 
ward ;  this  flajj  being  held  back  by  an  assistant,  the  head  of  the  bone  is 
disarticulated,  and,  the  knife  being  passed  behind  the  bone,  the  posterior 
flap  of  equal  length  is  cut  from  within  outward. 

Guthrie's  method  of  amputation  at  the  hip-joint  is  also  an  antero- 
posterior flap  method,  and  consists  in  cutting  the  flaps  from  without 
inward,  a  small  knife  being  used  for  this  purpose ;  the  posterior  flap  is 
cut  first. 

In  amputating  at  the  hip-joint  for  the  removal  of  tumors,  it  is  often  im- 
possible to  perform  any  of  the  typical  oi^erations  ;  if  much  tissue  has  to  be 
*  removed  it  may  be  necessary  to  use  a  single  flap,  either  anterior,  jjosterior, 
or  internal,  to  cover  the  wound. 

Wyeth's  Bloodless  Method.— This  method  is  now  very  generally 
employed,  and  its  adoption  has  diminished  in  a  remarkable  degree  the  mor- 
tality following  amputations  at  the  hip-joint.     The  patient  is  brought  well 


256 


AMPUTATION  AT  THE  HIP-JOINT. 


oyer  the  edge  of  the  table,  and  an  Esmarch  bandage  is  applied  to  the  limb 
up  to  the  crotch.  Two  stout  steel  mattress  needles,  or  steel  skewers,  about 
twelve  or  fourteen  inches  in  length,  are  required  ;  the  point  of  one  of  these 
needles  is  jpassed  through  the  skin  one  and  a  half  inches  below  and  slightly 

to  the  inner  side  of  the  an- 
FiG-  189'  terior  superior  spine  of  the 

ilium,  and  carried  through 
the  tissues  about  half-way 
between  the  great  trochanter 
and  the  spine  of  the  ilium, 
external  to  the  neck  of  the 
femur,  its  point  being  made 
to  emerge  just  behind  the 
trochanter  ;  the  second  needle 
is  made  to  enter  the  skin  an 
inch  below  the  crotch,  inter- 
nal to  the  saphenous  open- 
ing, and  its  point  is  made  to 
emerge  about  an  inch  and  a 
half  in  front  of  the  tuber  ischii.  The  points  of  the  needles  are  next  pro- 
tected with  corks,  and  a  long  piece  of  rubber  tubing  or  an  Esmarch  elastic 
strap  is  wound  tightly  five  or  six  times  around  the  limb  above  the  fixation 
needles.  (Fig.  189. )  The  Esmarch  bandage  is  then  removed,  and  a  circular 
incision  of  the  skin  and  cellular  tissue  made  five  inches  below  the  constricting 
band ;  this  cuff  of  skin  and  cellular  tissue  should  be  dissected  up  to  the  level 

Pig.  190. 


Wyeth's  method  of  controlling  hemorrhage  in  amputating  at 
the  hip-joint. 


Disarticulation  of  head  of  bone  in  amputation  at  the  hip-joint.    (After  Esmarch.) 


of  the  lesser  trochanter  ;  a  circular  division  of  all  the  muscles  should  next 
be  made  at  this  point,  and  the  bone'  should  be  divided  with  a  saw.     The 


AMPUTATION   ABOVE  THE   HIP-JOINT. 


257 


femoral  artery  and  femoral  vein,  the  profunda,  and  any  large  muscular 
branches  should  now  be  seized  with  hsemostatic  forceps  and  ligated.  After 
all  vessels  which  can  be  located  have  been  ligated,  the  lubber  tube  is  removed, 
and  any  vessels  which  bleed  should  be  grasped  with  hsemostatic  forceps  and 
secured.  The  sawed  surface  of  the  femur  is  next  seized  with  boue-forceps, 
and  an  incision  is  made  upon  the  outer  side  through  the  muscles  until  the  neck 
and  head  of  the  bone  are  exposed,  when  the  disarticulation  should  be  accom- 
plished. (Fig.  190.)  A  better  method,  which  is  now  generally  employed, 
is  to  disarticulate  the  head  of  the  femur  without  previous  sawing.  A  drain- 
age-tube is  introduced,  and  the  edges  of  the  flaps  are  brought  together  ver- 
tically.    The  appearance  of  the 

stump  resulting  from  am]putation  ^'""'-  ^'^'• 

at  the  hip-joint  is  shown  in  Fig. 
191. 

Amputation    above    the 

Hip- Joint.  —  This  operation, 
which  consists  in  the  removal  of 
the  lower  extremity  with  the  cor- 
responding innominate  bone,  has 
been  j)ractised  in  a  few  cases  of 
malignant  growth  which  involved 
the  ilium  and  extended  to  the 
femur.  The  operation  employed 
by  Girard  and  Baudenhauer  is  as 
follows  :  An  incision  is  made  from 
the  anterior  extremity  of  the  last 
rib  to  the  anterior  suj)erior  pro- 
cess of  the  ilium  and  carried  along 
Poupart's  ligament  to  the  jiubis  ; 

the  common  iliac  artery  and  vein  are  then  exposed  and  ligated.  A  posterior 
oval  flap  is  then  formed  by  making  an  incision  from  the  spine  of  the  pubis 
along  the  cruro-perineal  fold  to  the  tuberosity  of  the  ischium,  and  then  back 
of  the  great  trochanter  to  the  middle  of  the  iliac  crest,  then  forward  to  the 
anterior  superior  spine,  joining  the  first  incision.  The  soft  parts  are  incised, 
the  symphysis  j)ubis  separated,  the  j)Soas  muscle,  anterior  crural  nerve, 
obturator  vessels  and  nerve,  and  sacral  plexus  are  divided.  The  operation 
is  completed  by  dividing  the  sacroiliac  ligament. 

The  mortality  following  this  operation  is  very  high,  and  there  are  few 
cases  which  would  justify  its  employment.  Ssalistschew  reports  a  successful 
case. 

Prosthetic  Apparatus  after  Amputations.— In  performing  am- 
putations the  surgeon  should  bear  in  mind  the  i)ossibility  of  the  patient's 
wearing  an  artificial  limb,  and  for  this  reason  should  jjlan  the  operation  in 
such  a  way  that  a  useful  stump  may  result,  and  should  also  endeavor  to  saA^e 
as  much  of  the  limb  as  possible.  This  is  i>articularly  important  in  amputa- 
tions of  the  thigh,  where  the  longer  the  stump  is  the  more  satisfactory  it  will 
be  for  the  adaptation  of  an  artificial  limb.  In  the  leg,  an  amputation  in  the 
upi^er  or  middle  third  is  better  suited  for  the  adaptation  of  the  prosthetic 

17 


Stump  after  amputation  at  the  hip-Joint.    (Ashhurst.) 


258  PROSTHETIC  APPARATUS. 

apparatus  tlian  one  in  the  lower  third.  The  makers  of  artificial  limbs  hold 
that  a  stump  not  longer  than  half  the  length  of  the  leg  gives  better  results 
with  prosthetic  apparatus  than  a  longer  stump  extending  into  the  lower 
third  of  the  leg.  The  fact  that  partial  amputations  of  the  foot — Ch opart's, 
Pirogolf' s^are  often  difficult  to  fit  with  prosthetic  apijaratus  has  iniiuenced 
many  surgeons  to  recommend  amj)utation  of  the  leg  in  these  cases  rather 
than  partial  amjputation  of  the  foot.  But  it  should  be  borne  in  mind  that 
many  cases  of  partial  amputation  of  the  foot  can  go  about  comfortably  with- 
out any  apparatus  other  than  a  specially  constructed  leather  shoe,  or  one 
with  a  steel  plate  in  the  sole  and  narrow  steel  braces  fastened  to  the  leg  by 
a  flexible  collar.  Prosthetic  apparatus  of  the  upper  extremity,  except  in 
cases  of  amputation  below  the  elbow,  is  usually  of  little  practical  value,  and 
is  serviceable  only  for  cosmetic  purposes. 

Artificial  Arms. — The  artificial  arm  which  is  generally  adapted  to 
amputations  below  the  shoulder  consists  of  a  closely  fitting  leather  socket, 
which  covers  the  stump  for  several  inches,  and  is  secured  to  it  and  the 
body  by  straps.  Light  internal  and  external  steel  rods  jointed  at  the  elbow 
and  containing  a  cogged  wheel  and  ratchet,  which  allow  flexion  and  exten- 
sion at  the  elbow  with  fixation  at  any  angle,  are  attached  to  this  and  secured 
to  a  wooden  block  below  the  elbow,  and  at  the  end  of  this  is  fastened  an 
artificial  hand  to  which  various  implements  may  be  screwed,  such  as  a  knife, 
a  fork,  or  an  iron  hook.  (Fig.  192. )  In  case  of  amj)utation  of  the  fotearm 
a  similar  apparatus  is  made  to  fit  a  portion  of  the  stump  of  the 
forearm,  and  is  secured  to  the  arm  above  by  a  laced  band. 

Fig.  192. 


Artificial  arms. 

Many  complicated  forms  of  artificial  arms  have  been  devised  which  allow 
fiexion  and  extension  of  the  fingers  through  cords  worked  by  movements  of 
the  opposite  arm. 

Artificial  Legs. — In  cases  of  partial  amputations  of  the  foot  a  shoe  with 
a  metal  sole  and  narrow  steel  bands  secured  to  the  leg,  and  with  a  wooden 
block  filling  up  the  anterior  portion  of  the  shoe,  corresponding  to  the 
portion  of  the  foot  removed,  will  constitute  a  satisfactory  apparatus.  In 
amputations  of  the  leg  a  more  complicated  form  of  prosthetic  apparatus  is 
required. 

In  amputations  at  the  knee-joint  or  through  the  upper  part  of  the  leg, 
the  cheapest  form  of  artificial  apparatus  which  is  employed  is  known  as  the 
"  peg  leg,"  or  "  j)oor  man's  leg,"  which  consists  of  a  stout  wooden  stick,  with 
an  expanded  upper  extremity  or  socket  composed  of  a  conical  i^iece  of  light 
wood,  with  two  lateral  splints  embracing  the  thigh,  the  inner  splint  extend- 
ing only  to  the  middle  of  the  thigh,  while  the  external  one  reaches  to  the 


ARTIFICIAL  LEGS. 


259 


pelvis  and  is  fasteued  by  a  padded  pelvic  belt ;  a  strap  passing  around  the 
lower  part  of  the  thigh  holds  the  inner  splint  to  the  outer  one.  (Fig.  193.) 
The  front  of  the  flexed  knee  rests  upon  a  cushion  between  the  two  splints. 
In  adapting  an  artificial  limb  in  a  case  of  amputation  of  the  leg  it  is  im- 
portant that  no  pressure  be  brought  upon  the  surface  of  the  stump,  and 
that  the  weight  of  the  body  be  sui)j)orted  by  the  thigh,  the  circumference 

Fig.  194. 


Fig.  193. 


Peg  leg. 


Artificial  leg. 


of  the  leg,  the  tuberosities  of  the  tibia,  the  condyles  of  the  femur,  and  the 
tuberosity  of  the  ischium.  Many  very  ingenious  forms  of  artificial  legs 
have  been  manufactured  which  allow  a  certain  amount  of  movement  at  the 
ankle  and  flexion  and  extension  at  the  knee-joint.  (Fig.  194.)  Artificial 
legs  with  rubber  feet  are  also  used  with  advantage.  ;N"o  satisfactory  arti- 
ficial apparatus  can  be  adapted  in  cases  of  very  short  thigh  stumps  or  of 
amputations  at  the  hip -joint. 


CHAPTEE    XVII. 

PLASTIC   SURGERY. 
By  Heney  E.  Whaeton,  M.D. 

This  brancli  of  surgery  includes  the  operative  procedures  which  are 
employed  to  repair  defects  in  the  various  tissues  of  the  body.  The  replace- 
ment of  parts  partly  separated  by  injuries,  as  well  as  the  readjustment  of 
parts  entirely  severed,  is  also  sometimes  included  under  plastic  surgery. 

Plastic  operations  are  divided  into  heteroplastic  operations,  in  which  the 
defect  is  repaired  by  tissue  taken  not  from  the  individual  in  whom  the 
defect  exists,  but  from  another  individual  or  one  of  the  lower  animals,  and 
autoplastic  operations,  in  which  the  tissue  to  supply  the  defect  is  taken  from 
the  same  individual. 

Plastic  operations  may  be  required  for  the  repair  of  congenital  defects, 
such  as  harelip,  cleft  palate,  or  exstrophy  of  the  bladder,  for  defects  result- 
ing from  injuries  or  from  the  removal  of  tumors,  or  for  the  distortion  and 
functional  disturbance  resulting  from  the  contraction  following  injuries, 
burns,  and  ulceration  consequent  upon  lupus  and  syphilis  or  other  intrac- 
table forms  of  ulceration.  These  operations  may  be  indicated  for  the  resto- 
ration of  function,  as  is  seen  in  cases  of  harelip,  cleft  palate,  or  contrac- 
tions about  the  joints.  They  are  often  indicated  for  cosmetic  reasons,  when 
they  are  emjjloyed  to  relieve  deformities  resulting  from  congenital  defects, 
injuries,  burns,  or  the  abnormal  development  of  certain  ijarts  of  the  body, 
as  is  seen  in  cases  of  hypertrophy  of  the  nose,  lips,  and  tongue,  and  of  dis- 
placement or  malformation  of  the  ears.  The  tissue  which  is  generally 
employed  to  repair  defects  is  the  skin  with  its  subcutaneous  tissue,  or  the 
sui^erficial  layers  of  the  skin,  as  in  skin-grafting,  although  other  tissues, 
such  as  bone,  bone  chij)s,  muscle,  tendon,  nerve,  and  mucous  membrane, 
are  sometimes  used. 

The  elements  which  conduce  most  to  success  in  plastic  operations  are 
rigid  care  as  regards  asepsis,  perfect  control  of  hemorrhage,  since  the  inter- 
position of  a  blood-clot  may  interfere  with  union,  and  avoidance  of  tension 
upon  flaps,  which  can  be  secured  by  having  the  flaps  of  sufficient  size.  The 
flaps  should  be  cut  about  one-third  larger  than  the  gap  to  be  filled,  to  com- 
pensate for  the  subsequent  shrinkage.  A  flap  which  is  white  in  appearance 
after  it.  has  been  transplanted  is  less  likely  to  slough  than  one  which  is 
purple  and  congested ;  the  latter  is  more  apt  to  develop  moist  gangrene 
from  venous  obstruction. 

Choice  of  Time  for  Plastic  Operations.— This  depends  largely 
upon  the  affection  for  the  relief  of  which  the  operation  is  performed  :  the 
condition  of  the  j)arts  and  the  patient's  general  condition  in  these  cases 
often  call  for  the  exercise  of  the  best  surgical  judgment.  In  congenital 
defects,  such  as  harelip,  it  is  well  to  postpone  the  operation,  if  possible, 
260 


PLASTIC  SURGERY. 


261 


for  a  few  months  after  birth ;  while  in  cases  of  cleft  palate  the  operation 
should  be  deferred  until  the  child  is  two  or  three  years  of  age  ;  and  neither 
operation  should  be  undertaken  if  the  child  is  in  poor  physical  condition. 
"Where  plastic  operations  are  undertaken  for  the  deformity  resulting  from 
the  iilceration  of  lupus  or  syphilis,  the  patient  should  have  had  a  prolonged 
course  of  specific  treatment,  and  the  ulcer  should  be  firmly  cicatrized  before 
the  operation  is  performed. 

Where  plastic  operations  are  performed  to  fill  a  gap  left  by  the  removal 
of  a  tumor  or  of  a  portion  of  a  bone  or  nerve,  the  flaps  may  be  fashioned 
and  approximated  or  the  piece  of  bone  or  nerve  introduced  into  the  gap 
at  the  time  of  operation.  Immediate  suture  of  completely  severed  parts 
should  also  be  practised  even  if  some  little  time  has  elapsed  since  the  injury. 
A  sufficient  number  of  successful  cases  have  been  reported  to  render  this 
procedure  advisable. 

Methods  used  in  Plastic  Surgery.— In  closing  gaps  in  the  tissues 
some  of  the  following  methods  are  generally  employed  :  1.  Direct  approxi- 


FiG.  195. 


Mi.4l:mAm 


li.lH., 1-' 


mmimM^^mm 


Closing  a  gap  by  sliding  flaps :  a,  a,  relaxing  incisions  which  gape  after  the  flaps  are 
brought  together. 

mation  of  the  edges  by  stretching  the  skin  and  deeper  tissues  of  the  wound 
and  securing  them  by  suture.  2.  Approximation  of  the  edges  of  the  skin, 
the  tissues  in  the  immediate  vicinity 
being  utilized  by  dissecting  the  sub- 
cutaneous tissue  from  the  underlying 
tissues  ("undermining  the  edges") 
and  then  stretching  or  sliding  them, 
and,  if  the  gap  to  be  filled  is  a  con- 
siderable one,  relaxing  incisions  (a, 
a)  may  be  made  as  shown  in  Fig. 
195,  the  gaps  of  these  incisions  being 
allowed  to  heal  by  granulation.  In 
closing  a  rectangular  gap  in  the  tissues 
the  method  shown  in  Fig.  196  may 
be  emijloyed,  the  flaps  being  loosened 
on  the  lines  a,  a.     jElliptical  defects 

may  be  closed  by  curved  flaps  which  are  freed  and  displaced  upward  :  the 
flaps  d,  e, /and  d,  e,  g  being  sutured  at  h  (Fig.  197),  or  by  Weber's  method. 


Method  of  closing  a  rectangular  flap. 


262 


PLASTIC  SURGEEY. 


shown  in  Fig.  198,  the  flaps  a,  c,  d  and  b,  e,  f  are  formed,  the  ijart  c  carried 
up  to  b,  and  the  margin  a,  b  sutured  to  a,  c.  The  flap  b,  e,  f  is  used  to  close 
the  gap  left  by  the  displacement  upward  of  the  flap  a,  c,  d.     A  triangular 


Operations  for  closure  of  elliptical  defects. 


gap  may  be  closed  by  loosening  and  sliding  the  tissues  according  to  Dieffen- 
bach's  method,  the  gaps  at  the  ends  of  the  incisions  being  allowed  to  heal 
by  granulation  (Fig.  199),  or  by  making  a  flap  by  a  curved  incision,  as  in 
Fig.  200,  freeing  it  and  suturing  the  part  a  to  b  and  introducing  sutures  at 


Fig.  199. 


Fig.  200. 


|gw;!;'-«.»f>.ij.;i|j 


iiSi'M 


Method  of  closing  a  triangular  gap. 


Kepair  of  triangular  defect  bv  curved  incision. 


other  points.  A  quadrilateral  gap  may  be  closed  bj^  Letenneur's  oi)eration, 
in  which  a  flap,  e,  f,  g,  is  formed,  is  loosened,  and  the  edge  e,  f  is  sutured 
to  a,  b.  (Fig.  201.)  3.  Another  very  common  method  of  closing  a  gap  is 
to  emplojr  a  flap  with  a  pedicle,  which  may  be  brought  fi-om  a  distance  and 
twisted  upon  itself,  or  the  flap  may  be  slid,  the  so-called  Indian  method 


PLASTIC  SURGERY. 


263 


(Fig.  202),  or  may  be  everted  and  covered  by  lateral  flaps  which  are  slid 
and  have  their  raw  surface  in  contact  with  the  raw  surface  of  the  inverted 
flap,  as  is  done  in  Wood's  oj)eration  for  exstrophy  of  the  bladder.  In  cases 
where  it  is  impossible  completely  to  cover  a  large  raw  surface  or  ulcer, 
much  time  may  be  saved  in  the  healing  and  contraction  may  be  avoided  by 
sliding  a  flap  with  a  pedicle  from  each  side  of  the  wound  or  ulcer,  and 

Fic   201 


Fig.  202. 


LetenneuT's  method. 


Method  of  closing  a  gap  by  flap  mth  a 
pedicle. 


suturing  them  so  as  to  form  a  bridge  of  tissue  across  the  gap,  as  shown  in 
Fig.  203.  In  repairing  defects  of  the  ala  of  the  nose,  a  flap  with  a  pedicle 
close  to  the  cheek  is  cut  and  is  swung  iuward  so  as  to  close  the  gap. 

Another  method  consists  in  transplanting  a  flap  to  the  defect  from  a 
distant  part  of  the  body  to  which  it  retains  attachments  (Italian  method). 

Fig.  203. 


Method  of  bridging  a  gap  by  two  flaps. 


Thus  a  flap  from  the  arm  may  be  used  in  a  rhinoplastic  operation,  the  flap 
being  sutured  in  position  and  allowed  to  remain  attached  by  a  broad  ijedicle 
until  its  vitality  is  assured,  when  the  pedicle  is  divided.  This  method  is 
capable  of  very  ingenious  modifications  ;  for  instance,  a  hand  in  which  the 
palmar  tissues  have  been  lost  by  accident  may  be  slipped  under  a  bridge 
flap  of  skin  and  cellular  tissue  in  the  region  of  the  buttock  and  allowed  to 
remain  until  the  raw  surfaces  have  formed  vital  attachments,  and  then  the 
ends  of  the  flap  are  severed. 


264 


SKIN-GEAFTING. 


SKIN-GKAPTING. 

Beverdin's  Method.— This  consists  in  applying  to  a  granulating  sur- 
face small  flat  pieces  of  epidermis ;  small  grafts  not  larger  than  an  eighth 
or  a  twelfth  of  an  inch  in  diameter,  including  only  the  superficial  epithelium 
of  the  skin,  should  be  emi^loyed,  being  taken  from  the  skin  of  a  recently 
amputated  limb,  or  from  the  skin  of  the  patient  himself,  or  from  another 
subject.  The  grafts  may  be  cut  with  a  sharp  scalpel  or  razor,  and  should 
be  directly  transferred  to  the  granulating  surface  and  placed  with  their  raw 
surface  in  contact  with  the  granulations.  To  insure  success,  the  granulating 
surface  should  be  in  a  healthy  condition  ;  if  there  is  profuse  discharge  of  pus 
from  the  surface  the  grafts  are  apt  to  be  floated  off,  and  the  j)rocedure  is 
likely  to  fail.  The  use  of  antiseptics  also  prevents  the  successful  taking  of 
the  grafts,  and  therefore  in  this  procedure  asepsis  should  be  practised.  In 
employing  this  method  of  skin-grafting,  if  there  is  purulent  discharge  upon 
the  granulating  surface  it  should  be  freely  irrigated  with  normal  salt  solu- 
tion, and  a  number  of  grafts  should  be  applied  to  the  granulating  surface, 
after  which  the  surface  should  be  covered  with  a  piece  of  sterilized  pro- 
tective or  rubber  tissue,  a  sterilized  gauze  and  cotton  dressing  being  applied 
over  this  and  allowed  to  remain  in  place  for  a  week.  Upon  the  removal  of  the 
dressing  at  this  time  it  will  often  be  found  that  a  portion  of  the  outer  layers 
of  the  grafts  has  been  cast  off,  but  usually  sufficient  epithelial  structure 
remains,  from  which  subsequent  proliferation  occurs,  forming  islands  of  epi- 
thelium upon  the  granulating  surface.  The  part  should  be  again  dressed  in 
the  same  manner,  and  at  the  end  of  two  weeks  the  growth  of  epithelium  at 
the  site  of  the  grafts  is  usually  very  marked,  and  the  granulating  surface 
soou  becomes  covered. 

Thiersch's  Method. — This  consists  in  covering  the  prepared  granu- 
lating or  raw  surface  with  strips  of  skin  consisting  of  the  epidermal  and 

Fig.  204. 


Application  of  McBurney's  skin-stretcliing  hooks. 


papillary  layers,  from  two  to  four  centimetres  wide  and  of  variable  length, 
which  are  cut  from  the  skin  of  the  patient  or  another  individual  or  from  a 
recently  amputated  limb.  In  cutting  these  strips  the  skin  should  be  made 
tense  at  the  point  of  removal,  and  this  can  be  best  accomplished  by  the  use 
of   McBurney's  skin-stretching  hooks.      (Fig.  204.)      In  employing  this 


TRANSPLANTATION   OF  MUCOUS  MEMBRANE.  265 

method  of  skin-grafting,  the  granulating  surface  should  be  first  irrigated 
with  warm  salt  solution,  and  the  surface  curetted,  or  the  granulations  may 
be  shaved  oflf  with  a  sharp  knife,  the  bleeding  being  arrested  by  the  pressure 
of  an  aseptic  comijress.  When  the  hemorrhage  has  been  controlled  the  sur- 
faces should  again  be  irrigated  and  dried,  the  strips  of  skin  placed  upon 
the  surface  so  as  to  cover  its  whole  extent,  and  a  piece  of  sterilized  rubber 
tissue  or  protective  and  a  sterilized  gauze  and  cotton  dressing  applied.  This 
dressing  should  not  be  removed  for  a  week  or  more,  and  subsequent  dress- 
ings should  be  made  in  the  same  manner.  If  at  the  end  of  a  few  days  the 
grafts  have  a  pink  tint,  it  is  a  good  sign,  but  if  they  are  white,  a  large  por- 
tion of  the  grafts  will  exfoliate,  although,  as  in  the  case  of  small  isolated 
grafts,  enough  epithelial  cells  may  remain  to  form  islands,  from  which  pro- 
liferation of  epithelium  may  occur.  Perfect  control  of  the  bleeding  is  an 
important  point,  for  if  this  is  not  acconiplished  the  blood  accumulates  under 
the  skin-grafts  and  separates  them  from  the  surface.  The  skin  from  the 
back  or  belly  of  a  frog,  or  tlie  hairless  skin  of  young  animals,  may  be  used 
for  grafting,  and  is  applied  with  the  same  precautions  and  in  the  same  way. 
"Where  skin-grafting  is  practised  upon  a  fresh  raw  surface  to  fill  a  gap  caused 
by  the  removal  of  a  tumor,  or  a  defect  resulting  from  a  plastic  operation,  the 
bleeding  should  be  controlled  and  the  grafts  applied  immediately.  The  raw 
surface  left  after  the  removal  of  the  grafts  should  be  covered  by  a  dry  aseptic 
dressing,  and  usually  heals  promptly. 

Transplantation  of  Isolated  Skin-Flaps.— Krause  recommends 
in  extensive  gi'anulatiug  surfaces  the  transplantation  of  one  or  more  isolated 
skin-flaps,  the  granulating  surface  being  scraped  or  curetted,  and  the  edges, 
if  unhealthy,  excised.  The  wound  is  irrigated  with  normal  salt  solution, 
and  if  bleeding  is  free  it  is  controlled  by  the  pressure  of  a  sterilized  gauze 
compress.  The  surface  from  which  the  flap  is  to  be  taken  being  shaved  and 
thoroughly  sterilized,  a  flap  at  least  one-third  larger  than  the  surface  to  be 
covered  is  dissected  tip,  including  the  epidermis  and  cutis.  The  flap  is 
placed  upon  the  raw  surface,  and  is  held  firmly  in  contact  with  it  by  a 
compress  of  sterilized  gauze,  and  a  copious  gauze  and  cotton  dressing  is 
next  apj)lied.  This  dressing  is  not  disturbed  for  four  or  five  days,  and, 
when  removed,  if  blebs  have  formed  between  the  epidermis  and  the  cutis 
they  should  be  opened,  and  a  similar  dressing  again  applied.  If  the  flap 
has  retained  its  vitality  at  the  end  of  a  week,  the  case  usually  progresses 
favorably. 

Transplantation  of  Mucous  Membrane.— Transplantation  of 
mucous  membrane  has  been  successfully  accomplished  in  a  few  cases,  but 
the  results  are  less  successful  than  those  following  skin-grafting,  from  the 
fact  that  it  is  i^ractically  impossible  to  maintain  asepsis.  Successful  trans- 
plantation of  mucous  membrane  has  been  accomplished  in  the  conjunctiva, 
urethra,  and  mouth.  The  grafts  are  taken  from  the  mucous  membrane 
of  the  mouth  or  from  the  mucous  membrane  of  animals.  The  surface  to 
which  the  graft  of  mucous  membrane  is  to  be  applied  is  carefully  freshened, 
and  the  graft  is  then  placed  upon  it  and  secured  by  sutures. 

Plastic  oj)erations  upon  bone,  muscles,  nerves,  and  tendons  are  described 
under  injuries  and  diseases  of  these  tissues. 


CHAPTER     XVIII. 


By  B.  Faequhab  Cuetis,  M.D. 

Definition. — Any  swelling  may  be  called  a  tumor,  but  tlie  term  is  gen- 
erally restricted  to  the  new  growths  or  neoplasms.  A  neoplasm  is  a  local- 
ized growth  of  tissue  out  of  place,  distinct  from  the  tissues  about  it,  and 
serving  no  purj^ose  in  the  economy  of  the  body,  although  its  structure  may 
resemble  that  of  normal  tissue.  It  is  generally  held  that,  with  a  few  doubtful 
exceptions,  a  true  neoplasm  never  disapjjears  spontaneously.  The  general 
changes  of  nutrition  in  the  body  do  not  affect  the  growth  of  a  neoplasm,  and 
a  lipoma  remains  of  the  same  size  whether  the  body  loses  or  gains  in  fat 
elsewhere,  while  a  cancer  actually  grows  at  the  expense  of  the  body. 

It  is  very  difficult  to  separate  the  ordinary  neoplasms  from  certain  con- 
genital malformations.  It  is  also  difficult,  often  impossible,  to  distinguish 
between  the  tumors  and  the  hypertrophies,  for  an  osteoma  is  merely  an 
abnormal  local  growth  of  bone,  and  an  adenoma  a  local  over-production  of 
glandular  tissue.  The  essential  distinctions  between  the  two  are  the  facts 
that  the  neoplasms  have  no  definite  limits  of  growth,  and  do  not  contribute 
in  any  way  to  the  performance  of  function  ;  the  osteoma  does  not  add  to  the 
strength  of  the  bone,  and  the  adenoma  does  not  produce  active  secretions. 

.  Benign  and  Malignant  Tumors.— K^eoplasms  may  be  divided  clin- 
ically into  the  benign  and  the  malignant.  Sarcoma  and  carcinoma  are 
malignant,  all  other  tumors  benign.  A  benign  tumor  has  no  tendency  to 
invade  the  surrounding  structures,  and  is  usually  limited  by  its  capsule, 
simply  pressing  the  adjacent  tissues  aside  as  it  grows.  The  existence  of  a 
capsule  is  indicated  clinically  by  the  free  motion  of  the  tumor  on  the  sur- 
rounding parts.  A  benign  tumor  grows  slowly,  is  fairly  well  supplied  with 
blood-vessels,  and  does  not  tend  to  ulcerate,  although  softening  and  breaking- 
down  sometimes  occur.  When  it  has  been  entirely  removed,  by  operation 
or  otherwise,  it  does  not  return,  and  it  does  not  form  secondary  tumors  in 
other  parts.  It  is,  therefore,  not  ijii  itself  dangeroiis  to  life,  but  it  may  become 
so,  on  account  of  its  situation,  by  interfering  with  the  performance  of  the 
functions  of  imj)ortant  organs.  Malignant  tumors  have  all  the  opposite 
characteristics :  they  grow  rapidly,  they  are  seldom  encapsulated,  and  they 
tend  to  spread  into  the  surroundiug  parts  by  direct  extension  of  the  cells 
which  convert  the  neighboring  tissues  into  tissue  identical  with  that  of  the 
neoplasm.  They  are  poorly  nourished  and  are  apt  to  slough  or  ulcerate, 
and  they  invade  the  blood-vessels  and  lym^ahatics  and  thus  form  secondary 
tumors.  On  account  of  these  reasons,  and  by  their  foul  discharges,  their 
interference  with  the  functions  of  various  organs,  and  a  jDecnliar  sort  of 
cachexia,  they  invariably  terminate  fatally.  But  there  are  some  inter- 
mediate varieties,  tumors  otherwise  benign  which  grow  rapidlj^  and  form 
266 


CLASSIFICATION  OF  TUMORS.  267 

secondary  tumors,  and  malignant  tumors  of  slow  growth  without  much  ten- 
dency to  dissemination.  Some  tumors  which  have  been  apparently  benign 
may  suddenly  begin  to  grow  rapidly  and  become  malignant.  These  cases  are 
explained  by  assuming  that  a  change  has  taken  place  in  the  tissues  of  the 
tumor,  and  that  they  have  taken  on  the  malignant  form  of  growth  and  lost 
their  innocent  character.  Malignant  tumors  are  commonly  called  cancer, 
but  some  would  restrict  that  name  to  malignant  epithelial  growths. 

Olassiflcation. — The  pathological  classification  is  based  on  the  structure 
of  the  tumors,  and  it  is  followed  in  the  nomenclature  of  new  growths,  the 
general  termination  oiiut  signifying  a  tumor,  and  being  preceded  by  a  prefix 
describing  the  tissue  of  which  it  is  composed.  Thus  we  have  osteoma,  a 
tumor  composed  of  bone  ;  fibroma,  a  tumor  of  fibrous  tissue  ;  and  angioma, 
a  tumor  of  newly  formed  vessels.  The  terms  sarcoma  and  carcinoma  are 
arbitrarily  formed  on  the  same  plan.  A  sarcoma  is  a  tumor  composed  of 
tissues  of  couuective-tissue  origin  resembling  those  normally  found  in  the 
foetus  but  not  in  the  adult.  A  carcinoma  is  a  tumor  formed  by  an  unnatural 
growth  of  epithelial  cells. 

Tumors  may  be  divided  into  two  main  classes,  according  to  their  origin 
from  the  connective  tissues  or  from  the  epithelium. 

There  is  a  fundamental  difference  between  the  tissues  of  the  mesoblastic 
layer  of  the  foetus,  from  which  arise  the  bones,  muscles,  connective  tissue, 
blood-vessels,  etc.,  and  the  epiblastic  and  hypoblastic  layers,  which  pro- 
duce the  epithelial  tissue, — skin,  mucous  membranes,  and  glaudxilar  struc- 
tures. As  no  cell  originates  spontaneously,  every  cell  must  be  descended 
from  a  previous  cell,  and  it  has  been  proved  that  every  cell  inherits  the 
characteristics  of  its  parent  cell;  in  other  words,  "like  begets  like."  On 
account  of  this  rule  a  cell  belonging  to  the  mesoblastic  layer,  whether  it  is 
in  the  bone,  muscle,  or  connective  tissue,  or  is  one  of  the  endothelial  cells 
lining  the  vessels  or  serous  cavities,  can  produce  only  a  connective-tissue 
cell,  never  an  epithelial  cell ;  and,  conversely,  a  cell  belonging  to  the  other 
two  layers  can  produce  only  epithelium.  This  rule  applies  to  the  origin  of 
tumors  as  well  as  to  the  growth  of  normal  tissues.  Epithelial  tumors  such 
as  adenoma  and  carcinoma  can  originate  only  from  tissues  or  organs  which 
contain  epithelial  cells.  Bony,  fatty,  and  other  tumors  composed  of  tissues 
of  mesoblastic  origin,  and  sarcoma  which  resembles  the  connective  tissues 
of  the  foetus  in  structure,  can  grow  only  from  tissues  of  like  origin. 

It  has  been  shown  that  there  is  a  definite  connection  between  the  struc- 
ture of  tumors  and  their  clinical  course.  It  may  be  said  in  a  general  way 
that  the  more  nearly  the  structure  of  the  tumor  approaches  some  normal 
adult  tissue  or  the  structure  of  a  normal  organ  the  more  benign  will  the 
growth  be ;  and  that,  on  the  other  hand,  the  farther  it  departs  from  these 
types  the  more  malignant  will  be  its  clinical  character. 

Etiology. — The  most  generally  accepted  theories  of  the  origin  of  tumors 
are  Cohnheim's,  known  as  the  theory  of  foetal  inclusion,  and  Volkmaun's 
theory  of  traumatic  origin,  or  a  combination  of  the  two. 

Foetal  Inclusion  Theory. — Foetal  tissues  are  remarkable  for  their 
power  of  growth  rather  than  for  their  functional  activity.  Cohnheim  im- 
agined that  small  fragments  of  embryonic  tissue  might  be  displaced  during 


268  ETIOLOGY  OF  TUMOES. 

foetal  development  and  mlglit  lie  dormant  in  their  unnatural  situation  until 
some  injury  or  unknown  influence  stimulated  them  to  grow.  He  supposed 
that  many  thoiisands  of  these  fragments  of  foetal  tissue,  consisting  of  single 
cells  or  grouj)s  of  cells,  exist  in  all  parts  of  the  body,  ready  to  develop 
into  tumors.  This  theory  would  make  all  tumors  similar  in  origin  to  the 
dermoids. 

Traumatic  Theory. — Volkmann's  theory  supj)Oses  that  the  normal 
cells  may  be  changed  by  some  traumatic  influence  and  begin  to  grow  in  an 
unnatural  way,  thus  producing  a  neoplasm.  The  tumors  of  the  connective- 
tissue  group  are  apt  to  follow  a  single  injury,  whereas  the  epithelial  tumors 
are  more  likely  to  follow  chronic  irritation  of  the  epithelium  by  mechanical, 
chemical,  or  other  agents.  In  the  first  case,  a  contusion  or  other  injury  of 
the  soft  parts  of  a  limb  occurs,  blood  is  extravasated,  and  changes  of  repair 
begin.  When  the  repair  has  been  finished,  all  these  changes  should  become 
retrogressive,  the  cells  should  return  to  their  normal  condition  of  slow 
growth  and  carry  on  their  functions.  But  sometimes  their  reaction  to  the 
injury  appears  excessive,  and  they  grow  out  of  proportion  to  the  necessity 
of  the  case,  and  more  new  tissue  is  formed  than  can  fully  organize,  so  that 
it  persists  in  the  foetal  character,  and  a  malignant  connective-tissue  growth 
— a  sarcoma — is  the  result. 

In  the  second  case,  continued  irritation  of  epithelial  cells  tends  to  make 
them  multiply,  and  instead  of  producing  their  normal  secretion  they  turn 
all  their  energies  towards  reproduction.  These  actively  growing  cells  have 
a  tendency  to  penetrate  the  connective-tissue  layer  or  basement  membrane 
on  which  they  should  normally  lie,  and  thus  malignant  epithelial  tumors 
originate.  The  appearance  of  a  tumor  as  the  immediate  result  of  a  blow  is 
not  very  common,  an  osteosarcoma  following  an  injury  to  a  bone  (more  fre- 
quently a  contusion  than  a  fracture)  being  probably  the  most  frequent  ex- 
ample, and  the  production  of  the  benign  tumors,  such  as  fibroma  or  lipoma, 
by  such  causes  is  very  rare.  Carcinoma  and  epithelioma,  however,  are  seen 
almost  daily  as  the  result  of  continuous  irritation.  Epithelioma  often  origi- 
nates in  the  lip  where  a  short  hot  pipe  is  held  in  smoking,  or  about  the 
edges  of  an  old  ulcer  of  the  leg.  Epithelial  growths  are  most  frequently 
found  in  situations  liable  to  irritation  and  injury,  the  majority  of  the  epi- 
theliomata  of  the  mucous  membranes  being  situated  on  the  lips,  the  tongue, 
the  larynx,  the  pylorus,  the  ileo-caecal  valve,  or  the  rectum.  The  testicle  is 
peculiarly  liable  to  malignant  disease  when  retained  in  the  inguinal  canal. 

Ribbert's  Theory. — A  theory  generally  known  as  Eibbert's  also  de- 
mands notice  as  bearing  upon  the  growth  of  tumors,  although  not  explaining 
their  origin.  As  the  tissues  grow  some  force  evidently  acts  to  maintain  a 
due  proportion  in  the  rate  and  manner  of  their  increase,  and  no  tissue  in 
health  outgrows  or  displaces  its  neighbors.  This  force  is  known  as  tissue 
tension.  When  a  tumor  has  formed  there  must  have  been  a  local  suspension 
of  this  force,  and  the  ''balance  of  power"  between  the  various  tissues  must 
have  been  disturbed. 

Traumatic  Epithelial  Cyst. — A  peculiar  form  of  tumor  directly  pro- 
duced by  injuries  is  the  traumatic  epithelial  cyst  (Garre,  Eeverdin).  It  is 
supposed  that  a  small  portion  of  the  external  epidermis  is  carried  down- 


ETIOLOGY  OF  TUMORS.  269 

ward  by  the  force  of  a  blow  by  some  pointed  object,  entirely  detached  from 
the  skin,  and  lodged  in  the  deei^er  parts.  This  fragment  of  epithelial  tissue 
tends  to  roll  up  at  once,  with  the  epithelial  cells  inside  and  the  corium  out- 
side, the  latter  forming  a  capsule  by  the  uniting  of  its  edges.  The  epithelial 
cells  then  grow  in  the  centre  and  distend  this  closed  capsule,  producing  the 
typical  cyst.  Usually  the  epithelial  cells  die  and  degenerate  in  the  centre, 
making  a  cheesy  mass,  the  tumor  resembling  a  sebaceous  cyst,  but  occasion- 
ally they  remain  viable,  and  a  solid  epithelial  growth  may  result,  as  has 
been  reported  in  one  case  on  the  forehead.  These  cysts  are  relatively  fre- 
quent on  the  palmar  surface  of  the  hand.  As  there  are  no  sebaceous  glands 
on  the  palms,  sebaceous  cysts  are  not  found  there,  and  dermoid  cysts  do  not 
occur  in  the  palm.  A  clear  history  of  antecedent  traumatism  may  also  be 
obtained  for  the  epithelial  cysts. 

Parasitic  Theory. — Recently  an  attempt  has  been  made  to  revive  the 
so-called  germ  theory,  referring  all  tumors  to  a  j)arasitic  origin.  The  ftara- 
site  now  favored,  however,  is  not  a  bacterium,  but  an  animal  parasite,  a  coc- 
cklium,  or  an  amoeba.  The  majority'  of  pathologists  believe  that  the  grounds 
on  which  this  theory  is  based  are  insufficient,  and  that  the  a^jpearances  in 
the  cancer-cells  which  are  supposed  to  be  parasites  or  their  products  are 
certain  alterations  of  the  cells  or  their  nuclei. 

Trophic  Influences. — It  has  long  been  known  that  certain  vasomotor 
or  other  reflex  influences  control  the  growth  of  tumors,  multiple  fatty 
tumors  of  the  skin  or  of  the  subcutaneous  connective  tissue  being  very 
common  in  certain  forms  of  central  nervous  disorders,  but  the  bearing  of 
the  latter  upon  the  etiology  of  tumors  is  not  yet  understood. 

Age. — Sarcoma  and  nearly  all  the  connective-tissue  group  are  common 
in  both  young  and  old,  bat  the  malignant  eiDithelial  tumors  are  unusual 
before  middle  life.  Thiersch  has  pointed  out  that  in  old  age  certain  changes 
take  place  in  the  tissues,  with  a  tendency  to  overgrowth  of  the  epithelium 
and  atrophy  of  the  connective  tissue,  especially  in  such  organs  as  the  lip  and 
the  tongue  (Woodhead),  the  epithelial  cells  also  tending  to  penetrate  the 
connective  tissue.  Thiersch  supposes  that  there  is  a  loss  of  balance  of  growth 
between  the  two  tissues,  and  that  their  relations  therefore  become  irregular  ; 
but  it  is  probable  that  the  changes  which  occur  in  old  age  are  only  jDredis- 
posing  causes,  and  that  some  irritation  is  needed  also  in  order  to  i3roduce 
the  growth.  Aside  from  the  necessarily  congenital  tumors  (dermoids)  and 
angioma,  neoplasms  are  rarely  seen  in  the  new-born.  Children  are  less 
likely  to  have  malignant  tumors  than  adults,  but  even  the  malignant  epithe- 
lial tumors  are  occasionally  found  in  very  early  life. 

Sex. — The  influence  of  sex  is  of  less  importance,  except  in  the  sexual 
organs  :  the  breast  in  the  male,  for  instance,  is  an  atrophied  organ,  and 
malignant  tumors  iu  it  are  rare,  whereas  in  the  female  it  is  one  of  the  parts 
most  commonly  affected.  There  are,  however,  some  curious  exceptions. 
Epithelioma  of  the  lip,  for  instance,  is  rare  iu  women.  When  it  does  occur 
iu  women  it  is  found  in  the  large  majority  of  cases  on  the  upper  lij),  whereas 
in  men,  iu  whom  epithelioma  of  the  lip  is  very  common,  the  lower  lip  is 
almost  invariably  the  one  attacked.  Carcinoma  of  the  tongue  is  also  said 
to  be  rare  in  women,  but  the  statistics  need  revision  upon  this  point. 


270  TERATOID  TUMORS. 

Race  and  Country. — Some  races  seem  to  be  more  predisposed  to  cer- 
tain tumors  than  others,  keloid  and  uterine  fibromyoma  being  very  common 
in  the  negroes  and  fibrolipoma  in  certain  East  Indian  races.  Attempts  have 
been  made  to  jjrove  that  cancer  is  indigenous  to  certain  districts  in  various 
countries,  but  without  much  success,  although  it  cannot  be  denied  that  the 
inhabitants  of  a  few  valleys  in  Prance  and  certain  districts  in  Bnglandj  and 
Germany  appear  to  be  peculiarly  liable  to  the  disease. 

Heredity. — The  older  authors  claimed  much  for  heredity  as  a  predis- 
posing cause  of  tumor  formation,  and  many  striking  family  histories  have 
been  reported  in  favor  of  this  view.  But  careful  investigation  has  shown 
that  a  family  tendency  to  the  production  of  tumors  can  be  found  in  only 
ten  to  fifteen  per  cent,  of  the  cases.     The  influence  of  heredity  is  slight. 

Contagion  of  Cancer, — There  is  a  theory  that  malignant  tumors  are 
contagious.  The  coincidence  of  epithelioma  of  the  penis  and  of  the  uterus 
in  man  and  wife  in  rare  cases  has  been  quoted  in  proof  of  this  theory,  but 
the  very  great  frecxuency  of  epithelioma  of  the  uterus  and  the  rarity  of  the 
same  disease  in  the  penis  argues  against  their  origin  by  direct  infection. 
There  are  many  cases  on  record  in  which  a  cancerous  ulcer  has  apparently 
infected  the  part  in  contact  with  it ;  for  example,  from  the  lower  to  the  upj)er 
lip,  from  the  gujn  to  the  cheek,  from  the  breast  to  the  skin  of  the  chest ;  but 
in  such  instances  we  are  dealing  with  an  inoculation  of  an  individual  already 
the  subject  of  the  disease.  This  theory  of  infection  and  the  fact  that  in  cer- 
tain districts  carcinoma  appears  to  be  more  frequent  than  in  others  are  the 
two  corner-stones  of  the  foundation  of  the  theory  of  the  parasitic  origin  of 
cancer,  for  the  disease  would  probably  be  contagious  if  it  were  parasitic. 

We  shall  describe  first  the  dermoid  and  other  tumors  of  congenital  origin, 
then  the  odontomata  of  similar  origin  but  of  a  later  stage  of  development. 
We  shall  postpone,  however,  consideration  of  "mixed"  tumors  and  renal 
tumors  of  adrenal  origin  until  later  because  of  their  more  complicated  char- 
acter. I^ext  we  shall  take  up  the  mesoblastic  tumors,  most  easily  explained 
by  Oohnheim's  "foetal"  theory,  then  the  epithelial  tumors,  and  finally  the 
mixed  tumors  and  the  cysts. 

TERATOID   TUMORS. 

Dermoid  Tumors. — Origin. — A  teratoma  is  a  tumor  formed  of  foetal 
tissue,  independent  of  the  body,  but  attached  to  or  included  in  it.  These 
tumors  are  supposed  to  owe  their  origin  to  causes  similar  to  those  concerned 
in  the  production  of  twins,  the  teratoma  rej)resenting  an  abnormal  or  incom- 
plete twin.  We  can  formulate  a  complete  series  from  twins  to  dermoid 
tumors,  the  connecting  links  being  the  joined  or  Siamese  twins  ;  individuals 
with  incomplete  twin  bodies  or  limbs  attached  to  them ;  individuals  with 
large  solid  tumors  of  foetal  structiu-es  growing  from  the  sacral  region  or 
pharynx  (the  true  teratomata)  ;  and,  finally,  individuals  with  dermoid  tumors 
and  cysts.  The  dermoid  tumors  are  good  illustrations  in  gross  of  Oohnheim's 
theory  of  the  origin  of  tumors  from  foetal  remains.  During  the  development 
of  the  foetus  various  parts  are  formed  by  iirojections  or  folds  growing  inward 
from  the  external  epithelial  covering,  and  normally  the  iDedicles  of  these 
infoldings  should  disappear  by  atrophy  of  the  epithelial  cells,  leaving  the 


DERMOID  TUMORS. 


271 


Fig.  205. 


mass  of  buried  epithelial  cells,  entirely  separated  from  the  suiierficial  layer, 
ready  to  form  the  special  organ.  The  groove  or  dimple  on  the  surface  where 
the  infolding  began  then  fills  up  level  with  the  surrounding  parts.  Occasion- 
ally this  atrophy  is  incomplete,  and  groups  of  epithelial  cells  may  persist  in 
the  connective  tissue  in  the  track  of  the  pedicle  between  the  organ  and  the 
epithelial  layer.  If  any  injury  or  irritation  causes  the  cells  so  included  to 
grow,  the  connective  tissue  about  them  forms  a  capsule,  and  solid  or  cystic 
tumors  result.  In  the  cysts  the  cells  die  in  the  centre  and  jyroduce  a  cheesy 
mass,  for  only  those  on  the  periphery  next  the  capsule  can  obtain  sufficient 
nourishment  to  live. 

Situation. — These  cysts  may  be  found  wherever  natural  clefts  occur  in 
the  fcetus,  but  they  are  most  common  about  the  face,  especially  at  the  exter- 
nal angle  of  the  orbit.  (Fig.  205.)  They 
are  rarely  found  in  the  median  line,  but 
are  occasionally  seen  about  the  anterior 
fontanelle  or  along  the  lambdoid  suture. 
In  the  latter  situation  they  represent  the 
infolding  of  the  surface  of  the  ovum  and 
fcetus  to  make  the  deep  fissures  dividing 
the  brain  into  the  different  lobes,  and 
hence  dermoid  cysts  are  also  found  in 
the  brain.  In  the  occipital  region  an 
entire  series  of  cases  of  these  cysts  has 
been  collected,  showing  their  mode  of 
development,  beginning  with  cysts  in 
the  occipital  lobe  of  the  brain,  some  of 
which  are  attached  to  the  occipital  bone 
by  a  pedicle.  Xext  there  are  dermoid 
cysts  between  the  dura  and  the  skull, 
and  others  in  the  bone.  Finally,  there 
are  dermoid  cysts  under  the  skin,  with 
pedicles  attached  to  the  bone,  making 
the  series  complete.     Dermoid  cysts  are 

also  found  elsewhere  on  the  head,  and  we  have  removed  one  which  lay  over 
the  masto-squamous  suture.  They  are  very  rare  on  the  skin  of  the  trunk,  but 
they  may  occur  in  the  median  line.  They  are  rare  on  the  external  genitals, 
but  frequently  originate  from  the  ovaries,  and  may  form  large  tumors.  Those 
which  have  been  reported  in  the  uj)per  part  of  the  abdominal  cavity,  without 
any  connection  by  a  pedicle  to  the  pelvis,  are  probably  instances  of  cysts 
which  originated  in  the  ovary  but  have  broken  their  pedicles  and  become 
transplanted  elsewhere.  For  a  description  of  the  ovarian  dermoids  we  refer 
to  the  section  on  the  ovary.  Very  rarely  dermoids  have  developed  in  con- 
nection with  the  folding  in  of  the  skin  at  the  umbilicus. 

Structure. — The  term  dermoid  in  connection  with  these  cysts  should  be 
understood  in  its  fullest  significance,  for  all  the  various  structures  produced 
by  the  skin  are  to  be  found  in  the  sac.  The  most  common  is  the  hair  which 
grows  on  the  inner  side  of  the  cyst  wall,  either  occurring  in  tufts  or  lining 
the  entire  cyst,  the  hair  being  long  or  short.     Sometimes  the  lining  skin  is 


Dermoid  c>  st  at  external  angle  of  orbit. 


272 


THYROID   DERMOIDS. 


affected  with  alopecia,  the  hair  being  found  loose  in  the  sac,  while  the  epi- 
thelial lining  is  perfectly  bald.  Hair,  teeth,  and  finger-nails  have  been 
found  in  these  structures,  and  bony  plates  are  not  infrequent  in  the  deeper 
layers,  owing  to  ossification  of  the  corium.  A  rudimentary  mamma  has  even 
been  observed,  which  is  not  surprising,  for  the  normal  mamma  may  be  con- 
sidered an  altered  sebaceous  gland.  The  various  tissues  or  organs  which  the 
dermoid  cysts  contain  may  be  attacked  by  hypertrophy  or  by  the  develop- 
ment of  neoplasms,  like  the  similar  external  tissues.  Thus  sarcoma,  paiiil- 
loma,  or  epithelioma  may  develop,  and  the  bony  deposits  represent  osteoma. 
While  hair  is  a  common  occurrence  in  all  dermoid  cysts,  the  more  compli- 
cated structures  just  mentioned  are  to  be  found  only  in  connection  with 
those  tumors  which  originate  from  the  pelvic  organs. 

There  is  usually  a  depression  in  the  bone  under  dermoid  cysts  situated 
over  the  skull,  caused  not  so  much  by  the  direct  mechanical  pressure  as  by 
the  accompanying  failure  of  development  of  the  bone  at  this  point.  In  some 
instances  there  is  a  complete  opening  in  the  bone,  the  pericranium  and  the 
dura  mater  being  in  contact,  which  may  be  an  awkward  complication  during 
an  operation.  Dermoid  cysts  of  the  head  are 
seldom  large,  although  they  may  attain  the  size 
of  a  hen's  egg,  they  have  very  little  tendency  to 
become  inflamed,  and  the  skin  over  them  is  gen- 
erally well  nourished  and  seldom  ulcerates. 

Thyroid.  Dermoids.— The  solid  dermoid 
tumors  are  called  thyroid  dermoids.  They  occur 
only  in  the  pharynx  or  in  the  neighborhood  of 
the  coccyx.  In  the  latter  situation  they  arise 
from  remains  of  the  depression  which  forms  the 
anus  and  the  anal  part  of  the  gut.  The  solid 
tumors  are  made  up  of  epithelial  cells  in  a  fibrous- 
tissue  stroma,  which  divides  them  into  lobes 
resembling  somewhat  the  structure  of  a  thyroid 
gland,  whence  their  name.  (Fig.  206.)  They 
sometimes  attain  such  a  size  in  the  coccygeal 
region  that  the  child  seems  an  appendage  of  the 
immense  tumor,  on  which  it  sits  as  on  a  cushion. 
In  other  cases  the  tumor  grows  within  the  pelvis. 
It  should  be  noted  that  not  all  dermoid  tumors 
iu  the  region  of  the  anus  are  of  the  solid  variety, 
dermoid  cysts  also  being  found  in  the  neighbor- 
hood of  the  coccygeal  dimple.  The  pharyngeal 
tumors  project  into  the  mouth  or  even  externally, 
and  are  very  rare.  The  removal  of  the  thyroid 
dermoids  from  the  region  of  the  rectum  is,  as  a  rule,  a  very  serious  operation, 
for  the  tumors  are  large  and  well  supplied  with  blood,  and  the  bowel  and 
bladder  are  often  adherent  and  exposed  to  injury. 

Branchial  Cysts. — In  the  development  of  the  face  and  neck  the  lower 
jaw,  larynx,  thyroid  gland,  and  tongue  are  formed  from  projections  which 
grow  forward  on  each  side  of  the  neck  from  the  main  mass  of  foetal  matter 


Congenital  sacral  thyroid  dermoid. 


BRANCHIAL  CYSTS. 


273. 


iu  the  neigliborliood  of  the  spinal  axis.  These  projections  are  separated  by- 
grooves  known  as  the  branchial  clefts,  but  the  clefts  are  not  comj)lete,  for 
both  the  ectoderm  and  the  entoderm  (skin  and  mncous  membrane)  are  con- 
tinuous from  one  projection  to  the  next,  the  mesoderm  (connective  tissue) 
being  wanting  at  the  so-called  cleft.  The  inner  and  outer  layers,  however, 
are  often  defective  at  the  bottom  of  the  grooves,  and  small  openings  may 
exist  in  the  clefts.  When  the  projections  from  both  sides  meet  in  the  median 
line  the  clefts  or  grooves  between  adjoining  projections  fill  up  to  the  level  of 
the  parts  on  each  side  of  them,  the  two  membranes  (entoderm  and  ectoderm) 
being  separated  by  a  growth  of  mesoderm  between  them.  Occasionally, 
however,  this  filling  up  is  incomplete,  and  a  deep  sinus  may  persist  between 
two  neighboring  projections,  passing  from  the  outer  surface  of  the  skin 
directly  to  the  inner  surface  of  the  x^haryux  and  the  adjacent  parts.  The 
outer  iiiirt  of  such  a  passage  is  lined  with  epithelium  corresponding  to  the 
skin,  and  the  inner  part  with  that  corresponding  to  the  mucous  membrane. 
There  may  be  a  thin  membranous  septum  between  them.  The  external 
auditory  meatus  and  the  Eustachian  tube  are  naturally  formed  in  this  manner, 
and  the  membrana  tymxjaui  represents  the  septum  between  the  two  parts. 

If  on  account  of  irregular  development  both  ends  of  one  of  these  abnormal 
sinuses  be  closed  by  the  parts  growing  over  them,  a  cavity  will  be  left  iu  the 
middle,  -which  is  lined  by  epithelium 

and  forms  a  cyst,  sometimes  attaining  Fig.  207. 

a  large  size.  (Fig.  207.)  The  char- 
acter of  the  epithelial  lining  will  de- 
pend upon  the  part  of  the  sinus  -which 
has  originated  the  cyst,  and  if  it  be 
near  the  skin  the  cyst  will  have  the 
characters  of  a  dermoid  cyst,  while  if 
it  be  near  the  mucous  membrane  the 
epithelium  will  be  mucous  epithelium 
and  will  form  a  typical  branchkd  cyst. 
The  wall  of  a  branchial  cyst  is  made 
up  of  connective  tissue  with  a  lining 
of  mucous  membrane  ei^ithelium, 
-which  is  usually  of  the  cylindrical 
variety,  but  may  be  ciliated  when  it 
originates  from  the  same  epithelium 

as  the  apex  of  the  pharynx.  The  contents  will  be  a  clear  or  milky  mucoid 
fluid,  secreted  by  the  mucous  lining.  If  the  cyst  is  exactly  in  the  centre 
of  the  cleft,  one  side  of  the  cyst  may  be  of  the  dermoid  and  the  other  of  the 
mucous  variety,  and  the  contents  show  a  mixture  of  the  two.  We  have 
removed  a  cyst  situated  over  the  upper  part  of  the  sternum  near  the  epi- 
sternal  notch  which  showed  a  very  abrupt  transition  from  one  epithelium 
to  the  other  at  a  certain  point  of  the  wall. 

The  important  parts  of  the  neck,  formed  by  the  branchial  projections, 
are  as  follows :  the  first  pair  form  the  inferior  maxilla  and  lower  lip  ;  the 
second  pair  form  the  styloid  process,  the  stylo-hyoid  ligaments,  and  the 
lesser  cornua  of  the  hyoid  bone ;  and  the  third  pair  form  the  rest  of  the 

18 


Congenital  c^^tll 


274  THYROGLOSSAL  TUMORS. 

hyoicl  bone.  The  anatomy  of  the  third  and  fourth  pair  is  not  thoroughly 
understood,  but  the  thyroid  gland  and  the  thymus  originate  from  these 
structures,  the  third  forming  the  two  lateral  lobes  of  the  thyroid  gland. 

Congenital  cysts,  which  are  iisually  of  the  branchial  type,  occasionally 
dermoids,  and  occasionally  solid  masses  of  thyroid  or  thymus  tissue,  may, 
therefore,  be  found  anywhere  in  the  clefts  between  these  foetal  processes,  but 
the  branchial  and  dermoid  cysts  aj)pear  to  be  very  rare  in  the  median  line, 
being  usually  situated  laterally  on  the  anterior  surface  of  the  neck.  Many 
of  the  cysts  in  the  median  line  of  the  thorax  are  to  be  considered  as  der- 
moid or  branchial  cysts  which  have  developed  in  the  neck  and  then  wan- 
dered downward  by  gravity,  as  is  not  uncommon  in  fluid  tumors,  so  that 
they  may  appear  in  front  of  the  sternum,  and  they  must  not  be  confused 
with  dermoid  cysts  originating  in  this  situation. 

Thyroglossal  Tumors.— The  central  lobe  of  the  thyroid  gland  is 
formed  by  a  special  turning  in  of  the  mucous  membrane  at  the  root  of  the 
tongue,  which  forms  a  jjrocess  of  epithelial  cells  running  forward  through 
the  body  of  the  hyoid  bone  to  the  centre  of  the  thyroid  gland.  This  process 
is  usually  spoken  of  as  a  canal,  but  for  nearly  the  whole  of  its  length  it  is  a 
solid  cord  of  epithelial  cells  without  any  lumen,  running  forward  and  down- 
ward from  the  root  of  the  tongue  at  the  foramen  csecum  anji  terminating  in 
the  pyramidal  lobe.  Tumors  frequently  develop  from  this  band  of  epithelial 
tissue,  and  are  known  as  tumors  of  the  thyroglossal  process  or  duct  (Boch- 
dalek).  In  the  course  of  development  the  hyoid  bone  becomes  solid  even 
where  the  epithelial  tissue  crosses  its  centre,  the  epithelium  disappearing  at 
this  point.     By  that  time,  however,  the  distal  part  of  the  process  towards 

the  thyroid  gland  should  be  entirely  ab- 
FiG.  208.  sorbed  or  converted  into  thyroid  tissue. 

In  some  cases  small  masses  of  epithelium 
remain  in  the  track  of  the  cord,  but  sepa- 
rated from  the  gland  on  one  side  and 
from  the  pharynx  on  the  other.  These 
may  grow  aud  form  solid  tumors  like  the 
thyroid  in  structure,  or  cysts  closely 
resembling  the  dermoid  cysts.  They  can 
be  recognized  by  their  situation  in  the 
course  of  the  former  cord,  although  occa- 
sionally they  may  lie  somewhat  to  one 
side,  as  diverticula  are  found  extending 
I  from  the  epithelial  mass  on  either  side. 

Thyroglossal  cyst.  Thcsc  tumors  sometlmes  reach  the  size 

of  a  goose-egg  (Fig.  '208),  and  may  cause 
a  little  difficulty  in  swallowing  and  some  deformity,  or  they  may  suppurate, 
and  when  incised  they  leave  a  permanent  sinus,  discharging  a  mucoid  iiuid. 
Solid  tumors  aud  cysts  may  also  develop  in  the  substance  of  the  hyoid  bone 
from  that  i^art  of  the  epithelial  cord  which  passes  through  it,  or  between  the 
hyoid  bone  and  the  tongue.  When  these  cysts  project  in  the  floor  of  the 
mouth,  coming  forward  between  the  tongue  and  the  lower  jaw,  they  are  very 
liable  to  be  mistaken  for  ranulse,  but  should  be  easily  recognized  by  theii- 


ODONTOMA.  275 

contents,  which  are  very  like  the  sebaceous  matter  of  the  dermoid  cysts. 
The  solid  tiiuiors  at  the  base  of  the  tongue  may  be  mistaken  for  sarcomata. 

Clinical  History. — All  of  these  cysts  grow  slowly,  usually  appearing 
in  infancy  or  at  ijuberty,  causing  no  symptoms  except  by  their  size,  and  not 
ulcerating,  although  they  may  become  infected  and  suiDpiirate.  The  diag- 
nosis is  made  by  finding  the  ordinary  signs  of  a  cyst  in  a  region  where  a 
congenital  cyst  would  be  likely  to  occur,  and  by  excluding  abscess,  aneurism, 
and  lymphangioma. 

Treatment. — A  dermoid  cyst  can  be  removed  only  by  operation,  and 
the  sac  must  be  completely  extirpated  or  it  will  reproduce  the  tumor.  The 
superficial  tumors  are  usually  small.  Their  removal  is  generally  undertaken 
for  cosmetic  purposes  only,  and  the  operation  is  simple,  involving  merely 
an  incision  of  the  skin,  turning  back  the  flaps,  and  shelling  out  the  tumor. 
In  the  case  of  dermoids  on  the  edge  of  the  orbit,  however,  a  prolongation 
of  the  sac  will  sometimes  be  found  running  down  well  into  the  orbit, 
although  it  will  seldom  be  found  attached  there,  and  can  generally  be 
shelled  out  by  blunt  dissection  without  injury  to  the  contents  of  that  cavity. 
Occasionally  the  intra-orbital  portion  is  connected  with  the  extra-orbital  by 
a  very  narrow  pedicle,  and  therefore  it  is  important  to  look  carefully  for 
such  a  process  in  attempting  the  removal  of  the  cyst,  as  the  part  within 
the  orbit  will  reproduce  the  tumor  if  overlooked.  The  treatment  of  the 
dermoids  originating  in  the  ovary  will  be  discussed  under  the  head  of  pelvic 
and  abdominal  tumors.  When  branchial  cysts  are  large  they  should  be 
removed  by  operation,  and  the  dissection  may  be  very  difficult,  on  account 
of  their  close  relations  to  the  vessels,  nerves,  and  deeper  parts  of  the  neck. 
In  some  cases  a  cure  has  been  obtained  by  aspiration  and  injection  of  iodine. 

The  tumors  originating  from  the  thyroglossal  tract  may  be  reached  exter- 
nally, or  through  the  floor  of  the  mouth  in  front  of  the  tongue,  but  the 
external  operation  should  be  preferred,  as  it  will  be  more  asej)tic.  Tumors 
situated  superficially  in  the  tongue  near  the  foramen  csecum  have  been 
removed  successfully  through  the  mouth.  Operation  is  to  be  urged  in  all 
these  thyroglossal  tumors,  as  they  tend  to  grow  and  will  interfere  with 
respiration  when  of  large  size. 

ODONTOMA. 

An  odontoma  is  a  tumor  develoiDing  from  some  part  of  the  tooth-germ. 
A  tooth-germ  may  be  displaced  and  may  grow  abnormally,  just  as  fragments 
of  displaced  epithelial  tissue  form  dermoid  cysts.  "We  therefore  consider 
the  odontomes  next  to  the  congenital  cysts,  although  they  originate  at  a 
later  i^eriod. 

Classification. — Sutton  classifies  the  odontomas  according  to  the  part 
of  the  tooth-germ  from  which  they  arise.  1.  From  the  enamel-organ 
come  certain  epithelial  cystic  tumors,  usually  multilocular,  which  may 
attain  a  very  large  size  and  involve  the  entire  jaw,  although  individual  cysts 
are  generally  small.  The  gross  appearances  of  these  tumors  resemble  those 
of  giant-celled  sarcomata  of  the  bone.  2.  Follicular  odontomata.  From 
the  tooth-follicle  originates  a  tumor  containing  as  a  centre  a  more  or  less 
irregularly   developed  tooth,  which  may  be  very  small.     (Fig.  209.)     A 


276 


ODONTOMA. 


Follicular  odontome  or  dentigerous  cyst.     (Agnew.) 


large  amoimt  of  fluid  may  surround  the  tootli  in  the  distended  follicle  and 
form  a  cj'st  of  considerable  size,  called  a  dentigerous  cyst.     If  the  sac  of 

this  cyst  thickens  and  the  fluid 
^''^  ^^^  disappears,    a    solid    tumor    is 

formed,  in  which  the  small  and 
malformed  tooth  may  be  over- 
looked. This  variety  is  known 
as  a  fibrous  odontome  ;  but  the 
sac  may  also  calcify  or  even  ossify. 
Sometimes  several  tooth- follicles 
are  concerned  in  this  process, 
and  a  large  number  of  irregular 
teeth  are  found,  to  the  number 
of  three  or  four  hundred  in  one 
tumor,  which  may  form  large 
irregularly  shaped  masses  of 
fibrous  material,  j)artly  calcified 
or  ossified,  and  containing  cystic 
cavities.  3.  Tumors  arising  from 
the  papillae  are  called  radicular 
tumors.  They  contain  only  cementum  and  dentine,  and  are  rare  tumors, 
found  attached  to  the  roots  of  the  teeth.  4.  Composite  odontomata. 
(Fig.  210.)  Sometimes  all  parts  of  the  tooth-germ  are  concerned  in  the 
tumor  formation,  making  masses  of  enamel,  dentine,  and  cementine,  or  it 
may  be  composed  mainly  of  one  sub- 
stance.    (Fig.  211.) 

Clinical  Appearance.— Odon- 
tomata are  generally  seen  soon  after 
puberty  or  in  early  adult  life.  They 
form  hard  tumors,  often  of  considerable 
size,  usually  about  the  lower  jaw,  more 
rarely  in  the  upper  jaw  or  the  antrum, 
covered  with  normal  mucous  mem- 
brane, generally  painless,  of  very  slow 
growth,  and  objectionable  only  be- 
cause of  the  deformity  which  they  occasion.  They  may  become  infected 
and  give  rise  to  symptoms  resembling  necrosis.  Their  existence  should  be 
thought  of  in  connection  with  any  tumor  about  the  alveolar  border,  or  in 
any  case  of  necrosis  which  j)resents  unusual  clinical  characteristics.  The 
diagnosis  can  generally  be  made  by  a  studj^  of  the  teeth,  observing  their 
irregular  formation,  or  the  failure  of  one  or  more  of  them  to  develop. 
Examination  with  the  X-ray  may  show  the  tooth  in  the  centre  of  the  tumor. 
A  doubtful  tumor,  supposed  to  be  a  sarcoma,  should  be  explored  by  incision 
before  sacrificing  the  jaw.  If  the  tumor  contains  one  of  these  badly  formed 
teeth  in  its  centre,  it  is  certain  to  be  an  odontome  and  not  malignant. 

Treatment. — Odontomes  should  be  removed  by  exposing  them,  re- 
moving the  solid  parts,  and  dissecting  out  every  part  of  the  lining  of  the 
sac,  chiselling  away  enough  bone  for  this  purpose. 


Fig.  210. 


Fig.  211. 


Composite  odontome 
of  \fisdom-tooth. 


Solid  enamel  odontome. 
(Agnew.) 


FIBROMA.  277 


A  fibroma  is  a  tumor  composed  of  any  of  the  different  types  of  fibrous 
tissue.  • 

Structure.— Some  fibromata  are  formed  of  a  bard,  dense,  ligamentous 
tissue,  with  fibres  closely  woven  in  different  directions,  but  often  arranged 
concentrically  around  the 
blood-vessels.     (Pig.  212.)  Fig.  212. 

Some    are   of    looser    and      ^^^^^^^^4^,^^' Wf^TM^^/fA 

somewhat  elastic  structure,         ^^ ,  ^^"- r- '  "{l\' !  >  ^\^i\ff  ^^      "       ' 

and  still  others  have  a  wide-        '  " 

meshed  areolar  tissue  often 

filled  with    serum,    which  ' 

gives  them  the  appearance  J 

of  cedematous  tissue.     Be-  i         ' 


t  'W 


\ 


sides  the  pure  fibromata,  '  \ 

fibrous  tissue  is  often  found  x 

as  a  part  of  other  tumors,  ^ 

associated  with  fat  in  fibro-  ^ 

lipomata,  or  with  muscular  \^ 

tissue  in  uterine  fibromyo-  ^ 

mata,  or  forming  the  stro-  \V^  \  \    ^\\^\^ 

ma   of  malignant   tumors.      ^-^t?x\%^X^\^x^"  ' 

The  boundary  line  between  ^ard  fibroma  of  the  thumb,  x  Suu.    ( Agnew. ) 

fibroma  and  fibrosarcoma 

is  sometimes  very  ill  defined,  sarcoma  being  distinguished  by  the  presence 
of  a  certain  quantity  of  actively  growing  cells  instead  of  the  quiescent  fibres, 
by  the  shorter  and  broader  nuclei,  and  by  the  incomplete  capsule.  Hard 
fibromata  are  usually  supplied  with  very  small  blood-vessels  and  are  well 
encapsulated,  and  they  grow  slowlj^  The  softer  variety  is  sometimes  very 
vascular  and  sometimes  deficient  in  blood  supply,  sloughing  readily  in  the 
latter  case.  The  lymphatic  spaces  in  the  soft  tumors  are  sometimes  so  much 
distended  by  serum  as  to  resemble  cedematous  tissue,  or  even  to  form  true 
cysts. 

Occurrence. — As  fibrous  tissue  is  found  throughout  the  bodj^,  fibromata 
occur  in  almost  any  situation.  The  hard  fibromata  may  dcA^elop  in  soft 
glandular  organs,  and  soft  fibromata  may  occur  in  connection  with  tendons, 
although  dense,  hard  fibromata  often  originate  from  the  ligamentous  struc- 
tures in  the  fingers  or  about  the  joints,  and  from  the  fibrous  sheaths  of  the 
nerves.  Fibroma  of  the  tendons  is  rare.  The  soft  variety  is  usually  found 
in  the  subcutaneous  connective  tissue,  and  also  grows  from  the  corium  of 
the  skin.  Fibromata  may  develop  in  the  periosteum,  and  growths  of  this 
character  are  most  frequently  found  attached  to  the  jaws,  the  lialate,  or  the 
base  of  the  skull.  lu  the  latter  situation  they  form  the  nasopharyngeal 
polyiji.  (See  chapter  on  the  I^Tose.)  A  peculiar  form  of  fibrous  tumor  known 
as  a  desmoid  grows  in  the  muscular  and  tendinous  parts  of  the  abdominal 
wall.  These  tumors  are  not  very  well  encapsulated,  and  resemble  sarcoma, 
having  a  tendency  to  return  after  removal. 


278 


FIBROMA  MOLLUSCUM. 


Clinical  Appearances. — A  fibroma  of  the  hard  variety  is  a  smooth  or 
nodular  jjainless  tumor,  freely  movable  under  the  skin  or  in  the  affected 
organ,  although  sometimes  adherent  at  its  point  of  origin,  and  varying  in 
size  from  a  pea  to  a  horse-chestnut.  The  soft  fibroma  is  jelly-like  or  semi- 
fluctuating,  often  pedunculated,  covered  by  normal  skin  or  mucous  mem- 
brane, painless,  and  may  attain  a  much  larger  size. 

History. — These  tumors  may  cause  ulceration  of  the  skin  by  pressure. 
If  pedunculated  they  may  slough  if  the  pedicle  is  twisted,  and  if  infected 
they  become  inflamed.  They  are  very  liable  to  cystic  degeneration.  Cal- 
cification and  ossification  also  occur.  They  do  not  return  if  thoroiighly 
removed,  and  with  extremely  rare  exceptions  they  do  not  form  metastatic 
tumors. 

Varieties. — A  keloid  is  a  fibrous  tumor  of  the  skin  which  develops 
fi-om  a  scar.     (Fig.  213.)     Keloids  do  not  originate  spontaneously,  for  those 

of    unknown    origin     probably 
Fig.  213.        -  grow  from  a  minute  scar,   such 

as  that  left  by  an  acne  pustule. 
The  distinction  between  Iceloids 
and  hypertropliied  scars  is  a  clin- 
ical one,  the  main  difference  be- 
tween them  being  that  an  hyper- 
trophied  scar  becomes  stationary 
after  a  time  and  may  grow  smaller 
and  flatter,  and  that  the  scar  is 
not  usually  so  bright  red  as  the 
keloid  is  apt  to  be.  The  keloid 
forms  a  densely  hard,  flat  tumor 
in  the  substance  of  the  skin, 
sometimes  with  a  straight  edge, 
but  more  fi'eqnently  with  claw- 
like projections  reaching  into 
the  surrounding  skin,  whence 
its  name.  It  may  be  white,  but 
is  usually  pinkish  in  hue.  It 
tends  to  spread  slowly  but  stead- 
ily on  all  sides.  Keloids  are 
occasionally  multiple,  and  form 
large  warty  tumors  in  some  cases 
instead  of  flat  patches.  Certain 
individuals  seem  to  have  a  pre- 
disposition to  keloid,  particularly  in  the  negro  race.  Keloids  appear  on  all 
parts  of  the  body,  but  most  freqiiently  upon  the  front  of  the  chest. 

Fibroma  Molluscum. — This  is  a  curious  tumor  of  the  skin,  consisting 
of  a  fibrous  tumor  starting  in  the  corium,  projecting  through  the  ei^ithelial 
layers,  and  forming  a  pedunculated  growth.  It  is  quite  soft,  and  when 
pressure  is  made  upon  it  in  the  early  stages,  when  it  does  not  jjroject  much 
beyond  the  level  of  the  surrounding  skin,  there  appears  to  be  a  gap  in  the  skin 
at  that  point,  through  which  the  soft  tissue  projects.    The  tumors  continue  to 


,  Mill  ) 


riBROaiA  OF  NERVES. 


279 


Central  fibro 
nerve-trunk.   (Agnew.) 


grow  until  they  reach  the  size  of  a  small  bean,  and  then  the  opening  in  the 

corium  through  which  they  have  appeared  to  come  grows  smaller,  cutting 

off  their  blood-supply,  and  the  interior  of  the  tumor  softens 

and  disappears,  leaving  only  a  bag  of  the  upper  layers  of 

the  skin  at  the  point  where  the  tumor  originated.    Finally, 

this  shrivels  up  and  disai^pears,  so  that  in  this  instance 

there  is  a  spontaneous  disappearance  of  a  tumor.    In  many 

cases,  however,  these  tumors  are  permanent  and  may  attain 

a  large  size. 

The  so-called  fibromata  of  the  uterus  are  composed 
rather  of  unstrij)ed  muscular  fibres  than  of  fibrous  tissue, 
and  will  be  considered  under  the  head  of  myoma.  The 
majority  of  fibromata  of  the  mamma  are  really  fibro- 
adenomata,  and  will  be  described  with  that  organ. 

Fibroma  of  the  Sheaths  of  Nerves. — This  is  rare, 
but  is  found  in  two  \arieties.  In  the  first  a  single  tumor 
forms  in  the  sheath  of  the  nerve,  involving  the  entire 
trunk  or  growing  upon  one  side  of  it.  Sometimes  the 
nerve-fibres  are  spread  over  the  oxitside  of  the  tumor  (Fig. 
214),  and  by  siDlitting  the  sheath  of  the  nerve  the  tumor  can  be  enucleated 
from  the  centre  of  the  fibres  without  injury.  In  other  cases  the  two  are  so 
intimately  connected  that  it  is  impossible  to 
separate  them,  and  a  part  of  the  nerve  must  be 
removed  with  the  tumor.  The  fibromata  of 
nerves  are  rather  small,  and  usually  not  of  much 
clinical  importance,  unless  they  excite  pain  by 
their  pressure  on  the  nerve.  Sometimes  they 
appeal'  as  small  nodules  in  the  skin,  and  their 
connection  with  the  nerve  can  be  determined 
only  by  the  pain  on  pressure,  or  by  the  ana- 
tomical proof  that  the  nerve  enters  them.  They 
may  be  multiple,  and  have  been  considered  by 
some  as  tumors  of  the  skin  only,  and  called 
•'painful  subcutaneous  tubercles." 

The  second  variety  of  fibroma  of  nerves  is 
the  curious  and  rather  rare  condition  known  as 
congenital  elephantiasis  of  the  nerves,  or 
plexiform    neuroma.      (Fig.    215.)      In   this 
disease  the  main  trunk  of  the  nerve  is  very  much 
enlarged  by  an  hypertrophy  of  the  subdivisions 
of  the  fibrous  sheath  (the  endoneurium),  while 
the  perineurium  remains  intact  and   prevents 
the  growth  from  extending  to  other  structures. 
The  true  nerve-fibres  do  not  undergo  any  en- 
largement or  increase  in  their  numbers  (although 
the  early  observers  claimed  that  this  was  the  case),  and  the  groAvth  is  entirely 
in  the  fibrous  structures,  so  .that  it  does  not  interfere  in  any  way  with  the 
transmission  of  impulses  through  the  nerve  or  with  its  function.    The  thick- 


Plexiform  fibroma  of  ner\  es 
(Agnew.) 


280 


FIBROMA  OF  NERVES. 


Fig.  21b 


ening  and  eulargenieut  extend  downward  along  the  nerve  even  to  its  fila- 
ments in  the  skin.  The  nerves  are  lengthened  as  well  as  thickened,  so  that 
they  resemble  the  tortuous  varicose  veins  often  seen  in  the  leg,  and  in  some 
places  they  form  tumors  of  considerable  size.  Tlie  involvement  of  the  ter- 
minal filaments  in  the  skin  gives  the 
latter  the  appearance  of  hypertrophy 
or  elephantiasis.  (Fig.  216.)  The  dis- 
ease is  essentially  a  new  growth  of  the 
nerve-sheath,  and  it  may  finally  in- 
volve all  the  cerebro-spinal  nerves,  al- 
though it  is  very  slow  in  its  extension, 
and  may  remain  limited  to  the  nerves 
of  one  limb  or  even  to  one  group. 
The  change  never  invades  the  central 
nervous  system,  but  is  arrested  at  the 
foramina  of  exit  of  the  nerves,  and  the 
optic  and  auditory  nerves  are  never 
affected.  Abbe  has  recorded  a  case  in 
which  the  cervical  sympathetic  nerve 
was  attacked.  The  disease  is  gener- 
ally supposed  to  be  of  congenital  ori- 
gin, although  it  is  seldom  recognized 
during  infancy.  It  produces  neither 
paralysis  nor  iiain,  and  extends  insidi- 
ously until  large  tvimors  may  be  pro- 
duced. The  latter  are  apt  to  become 
sarcomatous  in  structure  and  recur 
when  removed.  ^NTo  treatment  is  pos- 
sible in  this  disease,  although  some 
recent  writers  have  advocated  thor- 
ough extirpation  when  the  disease  is  limited  to  one  nerve  or  one  group  of 
nerves. 

Treatment. — The  removal  of  ordinary  fibromata  is  a  simj)le  operation, 
as  they  are  usually  well  encapsulated.  The  capsule,  however,  should  be 
removed,  as  the  growth  api^ears,  in  some  cases  at  least,  to  come  from  the 
capsule.  All  prolongations  of  the  tumor  in  one  direction  or  another  are  to 
be  removed  also,  or  the  tumor  may  be  reproduced.  The  treatment  of  Tteloid 
is  very  diflicult  and  unsatisfactory.  Small  keloids  may  be  excised  and  the 
wound  sutm-ed,  bxit  they  are  apt  to  return  even  when  perfect  aseptic  healing- 
of  the  wound  is  obtained.  Of  other  measures,  that  most  generally  in  use  is 
multiple  scarification  with  cross-hatching  lines.  With  a  very  sharp  knife 
fine  lines  are  carried  across  the  tumor,  cutting  completely  through  its  epi- 
thelial surface,  some  twelve  to  twenty  to  the  inch,  reaching  to  the  healthy 
tissue  at  the  edges  of  the  growth,  and  crossed  by  another  set  at  right  angles 
to  the  first.  If  the  knife  be  very  sharji  this  treatment  may  be  rapidly  exe- 
cuted, and  is  not  very  painful,  but  local  anaesthesia  can  easily  be  produced 
by  cocaine  injections  or  by  the  ethyl  chloride  or  other  cold  sprays.  Attempts 
to  cure  keloid  by  electrolysis  have  not  been  very  successful. 


Plexiform  fibroma  of  peroneal  nerve.     (Hiilke.) 


LIPOMA. 


281 


A  lipoma  is  a  tumor  formed  of  fatty  tissue,  and,  as  fat  is  of  almost  uni- 
versal distribution  in  the  bodj',  lipomata  are  to  be  found  everywhere.  The 
microscopic  structure  of  the  tumor  consists  of  a  loose  fibrous  stroma,  with 
particles  of  fat  included  in  it,  very  like  the  subcutaneous  tissue  (Fig.  217), 
but  in  some  cases  the  stroma  is  much  more  abundant  and  the  amount  of  fat 
much  less.  "When  the  two  are  equal  in  amount  the  tumor  should  be  called 
a  fibrolipoma.  The  fibrous  tissue  also  forms  a  capsule,  but  the  meshes  of  the 
stroma  often  x^ass  through  the 
capsule,  and  are  continuous  with 
the  stroma  of  the  normal  sub- 
cutaneous tissue,  extending  up 
into  the  corium.  The  capsule  is 
sometimes  wanting,  and  a  dif- 
fuse liiDomatous  growth  results 
without  any  definite  limit. 

Occurrence.  —  The    most 

common  situation  of  lipomata 
is  in  the  subcutaneous  tissue, 
but  they  are  also  found  deep 
down  among  the  muscles  of  the 
body  or  under  the  mucous  mem- 
brane of  the  intestines.  ]jipo- 
mata  are  even  found  where  fatty 
tissue  does  not  exist  normally 
(in  the  kidney  and  brain,  for 
example),  and  their  existence  in 

such  cases  can  be  explained  only  by  the  assumption  that  some  displacement 
of  the  fcetal  tissues  has  occurred.  Subcutaneous  lipomata  are  most  common 
on  the  neck,  the  back,  the  upijer  parts  of  the  extremities,  and  the  abdomen. 
They  are  not  usual  on  the  head,  and  are  rare  on  the  feet  and  hands,  only 
fifteen  or  twenty  cases  of  the  latter  being  on  record.  When  they  occur  in 
the  j)alm  of  the  hand  or  on  the  plantar  surface  of  the  foot  they  tend  to  grow 
deeply  between  the  bones  and  to  project  upon  the  opposite  side,  forcing 
the  bones  apart,  and  this  peculiarity  enables  one  to  make  the  diagnosis 
between  them  and  certain  forms  of  chronic  disease  of  the  tendon  sheaths, 
which  produce  tumors  of  about  the  same  size  and  consistency.  Lipoma 
also  occurs  within  the  tendon  sheaths  and  in  the  joints,  or  even  in  the  hursce, 
and  may  simulate  tuberculosis  of  these  parts.  Lipomata  are  quite  common 
in  the  layer  of  fat  which  lies  just  without  the  inguinal  and  femoral  rings 
and  in  the  omentum  and  mesentery.  Patty  tumors  also  occur  between 
the  mamma  and  the  chest.  A  curious  form  of  lipoma — the  so-called  paros- 
tecd  Ujmma—is  found  on  the  bone  under  the  periosteum,  and  is  suj^posed 
to  be  always  of  congenital  origin,  for  it  is  usual  to  iind  a  depression  in 
the  bone  due  to  its  pressure.  A  few  cases  of  this  kind  have  been  reported, 
some  of  them  on  the  long  bones  and  some  on  the  bones  of  the  skull  under 
the  pericranium  ;  but  the  diagnosis  of  the  former  is  not  likely  to  be  estab- 


Lipoma  from  the  thigh,  X  40.     (Agnew.) 


282 


LIPOMA. 


Lipoma  of  buttock,  "vvith  pedicle. 


]ished  before  operation,  and  tlie  latter  are  liable  to  be  mistaken  for  dermoid 

cysts. 

Clinical    Appearances. — A   subcutaneous   fatty   tumor   is    usually 

well  encapsulated  and  freely 
^''^-  -'^^-  movable,    although    slightly 

adherent  to  the  skin,  grow- 
ing slowly,  but  sometimes 
attaining  a  very  large  size. 
These  tumors  vary  in  density 
very  greatly,  according  to 
the  amount  of  fibrous  tissue 
stroma  and  the  state  of  ten- 
sion of  the  caj)sule,  and  a 
deceptive  wave,  like  the  fluc- 
tuation of  a  cyst,  may  some- 
times be  obtained.  When  the 
tumor  is  pinched  up  between 
the  fingei-s  the  skin  over  it 
dimples  from  the  attachment 

between  the  two  made  by  the  fibrous  bands  of  the  stroma.     If  the  lipoma 

lies  under  the  superficial  fascia,  however,  this  pulling  on  the  fibres  of  the 

skin  does  not  take  place.     On 

the  other  hand,  a  lipoma  may  Fig.  219. 

develop  in  the  corium  itself,  in 

which  case  the  epithelial  part  of 

the  skin  is  stretched  tightly  over 

it  and  cannot  be  made  to  dimijle, 

and  the  tumor  closely  resem- 
bles a  sebaceous  cyst,  the  resem- 
blance  being   increased   if   the 

contents  be  soft  and  the  capsule 

tolerably  tense,  so  that  a  feeling 

of  fluctuation  can  be  obtained. 

"S^Tiile  lipomata  are,  as  a  rule, 

i-ather    flat   tumors,    or,    at  the 

most,  globular,  they  may  become 

pedunculated    (Pig.    218),    and 

this,  in  our  exiDcrience,  is  most 

common   in   tumors  situated   in 

some  of  the  flexor  parts  of  the 

body,    such   as   the   axilla,    the 

folds  of  the  groin  or  the  but- 
tocks, and  the   popliteal  space. 

It  seems  probable  that  the  tumor 

is  forced  out  through  the  super- 
ficial fascia  and  made  to  distend 

the  movable  skin  in  these  localities  by  the  jiressure  of  the  parts  in  flexion. 

These  pedunculated  lipomata  sometimes  attain  a  large  size  and  have  a  very 


Multiple  lipomata  of  the  neck  and  back. 


MYXOMA. 


283 


Fig.  220. 


■^ 


long  ijedicle.  Pedunculated  liiiomata  are  very  liable  to  twisting  of  the 
pedicle  or  to  some  injury  which  forms  a  hasmatoma,  and  may  result  in 
sloughing.  MultiiJle  subcutaneous  lipomata  (Fig.  219)  are  sometimes  found 
scattered  all  over  the  body  in  great  numbers,  and  some  constitutional  nervous 
disease  is  so  often  associated  with  their  appearance  that  they  are  supposed 
to  be  due  to  some  unknown  troijhic  influence.  In  some  cases  severe  neu- 
ralgic pains  are  associated  with  them,  and  are  relieved  by  their  excision. 

History. — Lipoma  grows  very  slowly,  and  often  remains  stationary  for 
years.  Cysts  containing  oil  are  found  in  these  tumors  in  rare  cases,  and 
calcification  or  myxomatous  degeneration  of  the  stroma  is  occasionally  seen. 
They  are  liable  to  inflammation,  like  ordinary  fat,  and  they  frequently 
become  infected  with  tuberculosis  when  in  the  neighborhood  of  tuberculous 
joints,  like  the  fatty  tissue  which  lies  just  outside  the  capsule.  The  only 
effects  produced  by  these  tumors  are  those  due  to  their  bulk  or  the  deformity 
they  occasion. 

Treatment. — If  operation  is  considered  desirable,  the  tumor  should  be 
removed,  together  with  the  capsule.  In  some  cases  a  pedicle  can  be  traced 
from  the  superficial  tumor  down  through  the  deep  fascia  to  another  mass 
between  the  muscles.  In  one  case  a  deep-seated  thoracic  lipoma  had  a 
pedicle  which  passed  between  the  ribs  to  a  similar  tumor  in  the  chest.  These 
prolongations  should  be  carefully  fol- 
lowed out  and  removed,  or  the  tumor 
will  grow  again.  Eemoval  by  opera- 
tion is  the  only  possible  treatment. 

MYXOMA. 

Myxoma  is  a  tumor  formed  of  a 
tissue  like  the  so-called  Wharton's 
jelly  of  the  umbilical  cord,  which  is 
not  found  in  adult  life  except  in  the 
vitreous  humor  and  in  certain  degen- 
erations of  fat  or  bone.  Its  foundation 
consists  of  a  transparent  mucin-holding 
substance  in  which  ramify  stellate  or 
fusiform  cells  with  small  round  nuclei, 
the  branches  of  the  cells  often  com- 
municating and  forming  a  delicate 
reticulum.  (Fig.  220. )  Tumors  of  this 
kind  are  found  in  the  neighborhood 
of  the  umbilicus,  in  the  subcutaneous 
tissue,  the  brain,  and  other  parts  of 
the  body.  Myxoma  is  said  to  stand 
midway  between  the  benign  and  the  malignant  tumors.  Myxomatous  tissue 
is  often  found  as  a  partial  ingredient  of  the  sarcomata,  but  the  pure  myxoma 
is  considered  benign,  and  should  be  associated  with  the  lipomata,  for  the 
fatty  structures  of  adult  life  originate  from  myxomatous  tissue  in  the  foetus. 
These  tumors  are  of  little  clinical  significance,  on  account  of  their  rarity, 
but  should  be  removed  for  fear  of  sarcomatous  defeneration. 


Mj  voma  from  the  peritoneum 


284 


OSTEOMA. 


Fig   221 


\ 


An  osteoma  is  a  tumor  composed  of  bony  tissue.  Bony  tumors  attaclied 
to  the  external  surface  of  bones  are  known  as  exostoses  ;  the  term  enostosis 
has  sometimes  been  given  to  bony  tumors  projecting  into  the  skull,  grow- 
ing from  its  inner  layer,  but  it  should  be  reserved  for  bony  tumors  growing 
centrally  in  a  bone. 

Structure. — The  structure  is  simply  that  of  either  cancellous  or  com- 
pact bone,  without  auy  regular  arrangement,  except  that  in  globular  tumors 
the  fibres  are  placed  in  concentric  layers,  because  they  grow  from  an  ex- 
ternal layer  of  cartilage  ossifying  as  it  extends.  (Fig.  221.)  Exostoses  may 
be  met  with  on  the  face,  attached  especially  to  the  jaws  or  frontal  bones,  and 

similar  tumors  are  found  in  other 
parts  of  the  skeleton,  particularly 
in  the  flat  bones.  Those  on  the  skull 
are  sometimes  densely  hard,  and  no 
Haversian  canals  can  be  seen  iu 
them,  whence  they  are  called  ivory 
or  eburnated  exostoses.  Another 
form  of  osteoma  is  that  which  grows 
from  the  epiphyseal  ends  of  the  long 
■^  \  l)oues,  produced  by  the  ossification 

O  ^  cif  tumors  originally  cartilaginous. 

^'  ( )ssification  is  found  extending  from 

^  ^_  Ike  bone  down  into  the  attachments 

of  ligaments  and  muscles,  forming 
irregular  exostoses  more  or  less 
pointed  at  the  free  end,  where  they 
terminate  in  the  muscles  or  tendons. 
These  masses  are  not  tumors,  and 
should  not  be  called  osteomata. 

Occurrence.  —  The  various 
bones  differ  in  their  liability  to 
osteoma,  the  phalanges,  the  femur, 
the  tibia,  the  humerus,  the  vertebriB,  and  the  flat  bones,  such  as  the  scapula, 
being  liable  in  the  order  given,  but  there  is  no  bone  that  is  entirely  free 
from  it.  Osteoma  may  grow  from  the  phalanges  under  the  nails,  lifting  the 
latter.  Although  osteoma  usually  springs  from  bone,  or  at  least  from  peri- 
osteal tissue,  it  also  occurs  rarely  as  an  independent  neoplasm  in  such  organs 
as  the  breast,  the  testicle,  and  the  brain,  from  ossification  of  cartilaginous 
tumors.  Osteomata  are  multiple  in  one-tenth  of  the  cases,  and  this  variety 
seems  to  be  hereditary  in  some  families,  in  which,  ciu-iously  enough,  they 
often  affect  only  the  males,  the  female  side  escaping. 

Clinical  Appearance. — Osteomata  form  hard,  rounded  tumors,  often 
more  or  less  pedunculated,  frecxuently  lobulated  on  the  surface.  The  skin 
is  freely  movable  over  them,  and  a  bursa  is  often  developed  between  them 
and  the  surrounding  soft  parts.  They  vary  in  size,  the  pure  osteomata, 
and  especially  the  eburnated  variety,  seldom  being  large,  but  in  some  cases, 


/ 


iM^i 


Osteoma  of  femur,  ,^  200.     (Aguew  ) 


CHONDROMA.  285 

when  combined  with  cartilage,  they  may  i-each  the  size  of  a  man's  head. 
They  are  attached  to  the  bones,  and  are  free  from  pain  and  tenderness. 

History. — These  tumors  enlarge  very  slowly,  often  remain  stationary 
for  long  periods,  and  seldom  cause  any  symptoms  unless  they  grow  in  a 
closed  cavity,  like  the  antrum  of  Highmore,  when  they  may  cause  pain 
from  pressui'e  and  interfere  with  the  functions  of  the  neighboring  nerves. 
Osteoma  is  liable  to  inflammation  and  necrosis,  but  never  undergoes  malig- 
nant degeneration. 

Treatment. — The  only  treatment  for  osteomata  is  removal  by  operation, 
but  in  many  cases  they  may  be  left  untouched.  Operation  may  be  rendered 
necessary  by  the  large  size  of  the  tumor,  its  mechanical  interference  with 
the  motions  of  a  limb,  or  the  deformity  it  occasions.  It  is  also  necessary  to 
remove  osteomata  developing  in  the  sinuses  of  the  facial  bones  as  soon  as 
they  distend  the  latter.  The  ordinary  exostosis  is  easily  removed  with  the 
chisel,  but  the  base  should  be  thoroughly  gouged  out,  to  prevent  recurrence 
from  the  cartilaginous  matrix  often  found  beneath  it.  The  ivory  exostoses 
will  generally  require  the  use  of  a  saw,  on  account  of  their  great  hardness. 
To  remove  osteomata  from  any  of  the  sinuses  the  latter  must  be  opened,  and, 
if  the  tumor  springs  from  the  superior 

wall  of  the  frontal  sinus,  care  will  be  ^"^-  '^'^'^■ 

necessary  to  avoid  injury  to  the  brain, 
as  it  not  infrequently  extends  deeply  - 

into  the  cavity  of  the  skull.  ,  -  »   • " , 

7    «.,'-.  J       ;»•■ ,     .  •»' 

CHONDKOMA. 

A  chondroma  is  a  tumor  composed  ®,  -. 

of  cartilaginous  tissue.     All  the  vari-  ^ 

eties  of  cartilage  are  found   in  neo-  ,-      *. 

plasms,    the  hyaline    being   the   most      '■''  ,,\  f-      v 

common  and  fibrocartilage  and  reticu-  ,^    ~  „ 

lar  cartilage  rare.     Tumors  of  fibro-  * 

cartilage  are  usually  found  about  the 
ligaments  or  in  the  salivary  glands. 

We  must  distinguish  sharply  be- 
tween two  classes  of  chondromata, — 

those  which  spring  from  the  normal  •  -      '  'a        „  '^ 

cartilages  or  bones  and  those  which  '  i 

originate  elsewhere.    In  the  latter  case  ■* 

the  tumors  are  seldom  pure  chondro-         -i)  /^  "' 

mata  and  often  show  malignant  char-  ^ 

acteristics.    In  the  first  ease,  however,     „,     ,  ..,       »■  ,  «,         ,     ^      .  o„„ 

'  '       Chondroma  with  partial  hbrous  structure,  X  300. 

the  tumors  grow  slowly,  resemble  epi- 
physeal cartilage  in  their  structure,  and  are  usually  to  be  found  in  the 
neighborhood  of  the  epiphyses.  (Fig.  222.)  In  some  curious  cases  they 
appear  to  have  been  left  anchored  upon  the  shaft  at  the  point  where  thej^ 
first  appeared,  the  epiphysis  growing  beyond  them,  So  that  the  tumor  which 
first  api^eared  near  the  end  of  the  bone  is  found  later  near  the  middle  of 
the  shaft.     It  has  been  shown  that  some  small  fragments  of  cartilage  may, 


286 


CHONDROMA. 


be  left  behind  iu  the  ends  of  the  long  bones  as  the  epiphyses  advance,  and 
they  may  remain  without  ossification,  ready  to  form  tumors  later  in  life. 
This  fact  explains  the  frecxuent  association  of  rickets  with  multiple  chondro- 
mata,  for  irregular  ossification  is  often  observed  iu  that  disease.  Chondroma 
most  frequently  begins  in  youth,  when  the  bones  are  actively  growing. 

Occurrence. — About  two-thirds  of  the  chondromata   originate  from 
some  part  of  the  skeleton,  and  over  one-half  of  these  in  the  hand  (Fig.  223) 
and  foot  (Fig.  224).     They  are  also  common  iu  the 
jaws.     Chondromata  growing  from  the  costal  or  the 
nasal  cartilages  are  usually  small.     Chondroma  is 

Fig.  224. 


Fig.  223. 


Chondroma  of  hand. 


Chondroma  of  foot. 


also  observed  in  the  parotid,  the  breast,  the  testis,  the  ischio-rectal  space, 
and  the  subcutaneous  tissue,  but  it  is  seldom  pure,  being  usually  a  part 
of  the  mixed  tumors  in  the  salivary  glands  or  associated  with  sarcoma. 
The  occurrence  of  pure  chondromata  iu  these  regions  is  to  be  ascribed  to 
misplaced  foetal  remains,  those  in  the  parotid  being  derived  from  the  ear  or 
the  branchial  clefts.  Chondromata  are  frequently  multiple,  and  in  some 
rare  cases  they  are  present  iu  immense  numbers,  distorting  the  limbs  and 
the  jaws,  displacing  the  eyes,  and  producing  deformities  which  not  only 
render  the  patient  helpless,  but  may  terminate  his  life. 

Clinical  Appearance. — The  tumors  are  usually  small,  although  they 
may  attain  a  huge  size.  They  form  hard,  rounded,  smooth,  or  lobulated 
masses,  fixed  to  their  point  of  origin,  but  without  attachment  to  the  sur- 
rounding ]3arts.  They  grow  slowly  without  pain  or  other  symptoms  except 
such  as  may  be  caused  by  their  bulk  or  i^ressure,  and  they  often  become 
stationary.  If  they  grow  in  the  j)elvis  they  may  interfere  with  partiu'ition. 
Spontaneous  fracture  may  occur  iu  the  shaft  of  a  long  bone  which  has  be- 
come atrophied  by  the  pressure  of  a  chondroma.  When  inflamed,  necrosis 
and  sloughing  are  apt  to  follow.  Besides  being  liable  to  calcification  and 
ossification,  a  chondroma  may  undergo  gelatinous  softening  and  become 


MYOMA. 


287 


cystic.  It  also  becomes  sarcomatous  iu  some  eases.  After  an  injury  to  a 
bone,  for  instance,  a  chondroma  may  appear  and  develop)  with  some  rapidity, 
and  on  remo\'al  it  may  return,  and  finally  become  sarcomatous  in  structure 
and  form  secondary  tumors  in  the  lung  or  elsewhere.  Secondary  deposits 
in  the  lymph-nodes  and  in  the  lungs  are,  however,  rarely  seen  in  the  true 
chondromata  growing  from  bone.  Multiple  chondromata  are  less  apt  to  be- 
come malignant  than  single  ones.  Cartilaginous  tissue  often  forms  a  part  of 
other  tumors,  and  especially  of  the  so-called  mixed  tumors.  The  diagnosis 
between  chondroma  and  osteoma  will  often  be  impossible  in  the  epiphyseal 
tumors,  but  examination  with  a  needle  will  enable  one  to  recognize  the  former, 
as  the  needle  will  penetrate  it. 

Treatment. — The  majority  of  these  tumors  require  no  treatment,  but 
if  any  operation  is  attempted  they  should  be  thoroughly  eradicated.  The 
pedunculated  variety  is  easily  removed,  and  will  not  return  if  the  base  be 
thoroughly  gouged  out.  Those  with  broad  bases,  sometimes  encircling  a 
bone  or  originating  from  its  centre,  can  be  removed  only  by  amputation. 
Rapid  growth  and  softening  indicate  maligaant  change  and  the  necessity 
for  radical  operations.  The  chondromata  which  arise  independently  of 
the  normal  cartilages,  in  the  i>arotid,  for  instance,  grow  slowly,  but  are 
especially  liable  to  malignant  change,  and  shoidd  be  removed  unless  there  is 
great  danger  of  injury  to  the  facial  nerve.  If  they  show  any  tendency  to 
rapid  growth  a  very  complete 
extirpation  must  be  made  for  the 
same  reason,  not  merely  shelling 
the  tumor  out  of  its  capsule. 
Chondroma  of  the  upper  jaw  is 
especially  liable  to  recurrence 
and  final  malignant  changes,  and 
therefore  that  bone  should  be 
sacrificed  at  the  first  operation. 

MYOMA. 

A  myoma  is  a  tumor  com 
posed  of  muscular  tissue.  A 
tumor  formed  of  unstrij)ed  or  in- 
voluntary muscle  is  called  a 
leiomyoma,  and  one  of  striped 
muscle  a  rhabdomyoma.  The 
former  is  seldom  found  pure, 
being  almost  invariably  associ- 
ated with  fibrous  tissue,  the  mus 
cular  and  fibrous  cells  being  often 
so  much  alike  that  it  is  difficult 
to  distinguish  them.  (Fig.  225.)  It  is  far  more  common  than  rhabdo- 
myoma. The  latter  has  been  reported  as  occurring  in  a  pure  form  in  the 
testicle  in  infants  or  just  after  puberty. 

Leiomyomata  may  originate  from  the  muscular  coat  of  the  blood-vessels 
in  any  part  of  the  body,  but  tliey  are  especially  frequent  in  the  uterus, 


Leiom\omaof  uterus, 


■<  300      (Agne«  ) 


288  NEUEOMA.    ANGIOMA  OF  BLOOD-'S'ESSELS. 

arising  from  the  muscular  fibres,  and  also  develop  from  tlie  unstriped 
muscle  of  the  intestinal  tract  or  the  stomach.  Tumors  of  the  uterus  will 
be  j)articularly  considered  with  that  organ.  Myoma  of  the  stomach  or  i7ites- 
tines  usually  presents  a  tumor  of  considerable  size,  growing  slowly  under 
a  healthy  mucous  membrane,  tending  to  project  into  the  interior  of  the 
stomach  or  bowel,  and  occasionally  forming  polypoid  growths  with  a  thick 
pedicle.  Small  multij)le  tumors  of  smooth  muscle-fibre  occur  in  the  skin, 
especially  on  the  arms.  Myoma  seldom  attains  a  large  size  except  iu  the 
abdominal  organs.     It  can  be  removed  by  operation. 

NEUKOMA. 

Following  the  ordinary  classification,  we  place  here  neuroma,  but  the 
very  existence  of  a  true  neuroma  is  denied  by  many  excellent  authorities, 
the  so-called  neuroma  being  a  fibroma  arising  from  the  sheath  of  the  nerve 
or  causing  the  general  fibromatous  thickening  known  as  elephantiasis  of  the 
nerves,  or  plexiform  neuroma,  which  has  been  described  (page  279).  The 
term  neuroma  should  indicate  a  tumor  composed  of  nerve-tissue,  and  some  new 
production  of  nerve-fibres  should  be  present,  but  this  does  not  exist  in  the 
tumors  just  mentioned.  In  very  rare  oases  some  multiplication  of  the  nerve- 
cells  and  axis-cylinders  has  been  found,  but  these  are  pathological  curiosi- 
ties. According  to  the  majority  of  authorities,  the  nodular  swellings  at  the 
ends  of  the  divided  nerves  in  amputation  stumps  are  merely  fibrous  masses 
growing  from  the  sheaths,  and  do  not  contain  any  new-formed  fibres.  Some 
pathologists  reckon  glioma  as  neuroma,  for  it  originates  only  from  the  true 
nerve-cells  of  the  brain  and  optic  nerves,  although  the  large  round  cells  of 
the  tiimor  do  not  in  the  least  resemble  the  source  from  which  they  spring. 
Pure  glioma  is  such  a  rarity  that  we  shall  confine  our  notice  of  these  tumors 
to  the  description  of  giiosarcoma. 

ANGIOMA   OF   BLOOD-YESSELS. 

An  angioma  is  a  tumor  composed  of  a  mass  of  newly  formed  blood- 
vessels or  lymphatic  vessels.     By  the  term  angioma  is  generally  understood 
a  tumor  of  the  Mood-vessels  commonly  called  a  naevus,  a  tumor  of  lymphatic  ' 
A^essels  being  known  as  a  lymxihangioma. 

Structure. — Angiomata  which  arise  from  tlie  blood-vessels  may  contain 
dilated  capillaries  or  veins,  or  even  arteries,  for  cirsoid  aneurisms  are  tech- 
nically arterial  angiomata,  although  they  are  usually  considered  instances 
of  local  disease  of  the  arteries.  Cirsoid  aneurism  will  be  treated  of  in  the 
section  on  blood-vessels.  Angioma  may  be  strictly  encapsulated,  but  occa- 
sionallj'^  it  extends  without  any  distinct  boundary  into  the  skin,  muscles, 
and  subcutaneous  tissue  about  it.  It  may  involve  only  the  most  superficial 
layei's  of  the  skin,  producing  the  so-called  port-wine  mark,  but  more 
usually  the  deeper  layers  are  also  attacked,  and  the  ordinary  nsevus  is  pro- 
duced. In  the  port-wine  mark  only  the  smallest  capillaries  are  involved, 
without  other  changes  than  their  dilatation  and  remarkable  abundance.  To 
this  form  the  term  telangiectasis  is  most  properly  applied.  (Fig.  226.)  A 
cavernous  angioma  is  one  containing  dilated,  tortuous,  and  thickened 
veins,  as  well  as  caiiillaries,  and  resembles  cavernous  tissue  in  its  structure. 


ANGIOMA  OF  BLOOD-VESSELS. 


289 


Tic   22(1 


Subcutaneous  ingioma    a  normal  bkin    b  dilated  vessels 
of  the  tumor,  cut  across.    X  100.    (F.  C.  Wood,  M.D.) 


but  sometimes  the  septa  break  down  and  the  adjacent  veins  may  form  large 
cj'sts  full  of  blood.  When  an  angioma  is  encapsulated  the  blood  enters  it 
by  a  few  small  arteries,  and  leaves  it  by  similar  veins  of  normal  struc- 
ture, which  pass  through  the 
capsule  and  are  connected  with 
the  capillaries  and  veins  within 
the  tumor.  Even  when  the  tumor 
is  not  w'ell  limited,  the  transition 
from  the  normal  vessels  to  those 
of  the  tumor  is  quite  sharp. 

Angiomata  are  often  associ- 
ated with  a  large  amount  of  loose 
fibrous  tissue,  or,  still  more  fre- 
quentlj^,  with  fatty  tissue,  espe- 
cially in  the  substance  of  the 
cheek,  involviug  its  entire  thick- 
ness. The  diagnosis  of  these 
varieties  can  be  made  by  the  fact 
that  the  ordinary  angioma  is 
entirely  compressible,  the  newly  formed  tissue  in  the  vascular  walls  being 
too  thin  to  make  any  considerable  mass,  whereas  if  there  is  much  fibrous 
or  fatty  tissue  a  tumor  of  considerable  size  remains  even  after  compression. 
While  angiomata  occasionally  develop  later  in  life,  the  majority  of  them 
are  congenital.  In  individuals  past  middle  life  small  multiple  angiomata 
of  the  skin  are  not  uncommon,  although  they  are,  more  strictly  speaking, 
telangiectatic  spots  due  to  atrophy  of  the  skin. 

Occurrence. — Angiomata  are  most  frequent  in  the  skin.  They  are  seen 
in  the  mucous  membranes,  where  they  often  assume  the  form  of  a  papil- 
loma. They  occur  in  the  membranes  of 
the  brain,  esi^ecially  the  pia,  and  also  in 
the  glandular  organs,  such  as  the  liver 
and  kidneys,  being  generally  well  encap- 
sulated in  the  latter.  Three-quarters  of 
the  cutaneous  angiomata  are  found  upon 
the  head,  a  large  number  being  on  the 
face.  (Pig.  227.)  Those  in  the  neighbor- 
hood of  the  liiDS  are  sometimes  continu- 
ous with  similar  changes  on  the  mucous 
membrane  within  the  mouth. 

Clinical  Appearance.— Although 

^      these  tumors  are,  as  a  rule,  only  an  inch 
■%    or  so   in  diameter,  they  sometimes  in- 
volve an  entire  limb  or  half  of  the  trunk, 
/        and  in  these  extensive  cases  all  the  tis- 
sues of  the  i^art,  even  the  bones,  are  apt 
to  be  affected.     (Pig.  228.)     Sometimes 
the  tumors  are  pedunculated,  and  this  is  perhaps  more  common  in  the 
neighborhood  of  the  nose  and  ear  and  in  the  mucous  membrane  than  in 

19 


Fig.  227. 


Angioma  of  the  cheek  and  of  the  chest. 


290 


TREATMENT  OF  ANGIOMA. 


Other  situations.    Even  when  the  angioma  extends  deeply,  it  usually  involves 
the  skin  also,  but  in  some  cases  the  tumor  is  entirely  below  the  fascia,  and 
the  skin  over  it  is  healthy.     The  diagnosis  is  then  often  impossible,  unless 
the  venons  blood  of  the  tumor  shows  a  blue  tint  through  the  overlying  skin. 
History. — Angiomata  are  generally  observed  at  birth  or  soon  after. 
They  may  remain  stationary  for  years,  or  may  spread  slowly  or  rapidly. 
Earely  they  disappear  spontaneously.     If  injured,  they  bleed  profusely  and 
are  liable  to  infection,  and  the  intensity  of  the  infection  may  cause  a  slough 
of  all  the  vascular  tissue  and  result  in  a  cure 
Fig.  228.  by  cicatrization,  but  the  sloughing  of  such  vas- 

cular tissues  is  not  without  danger  to  the 
patient,  as  it  may  give  rise  to  pyemia.  While 
in  general  these  tumors  have  a  benign  history, 
the  possibility  of  extensive  growth,  hemor- 
rhage, or  infection,  or  the  deformity  they  y>vo- 
dnce,  makes  prompt  treatment  advisable.  We 
have  seen  one  case  end  in  death  in  a  few  months 
from  rapid  growth  of  an  originally  small  an- 
gioma in  which  operation  was  not  j)ermitted. 
The  diminished  frequency  of  cirsoid  aneurism 
is  ascribed  by  some  to  the  more  energetic  treat- 
ment of  angioma  now  adopted. 

Treatment.  —  The  various  methods  of 
treatment  of  angioma  may  be  divided  into  three 
classes :  first,  entire  removal  by  excision  or 
destruction  by  the  cautery ;  secondly,  the  pro- 
duction of  thrombosis  in  the  tumor  by  liga- 
tion of  the  vessels  at  a  distance,  or  by  injection 
of  stj'ptic  fluids  into  the  tumor,  or  by  its  trans- 
fixion with  threads  impregnated  with  sty^jtic 
fluids  ;  or,  finally,  the  production  of  cicatrization  by  the  induction  of  sujd- 
puration,  by  multiple  scarification,  by  the  actual  cautery,  or  by  electrolysis. 
The  choice  of  the  method  of  treatment  will  vary  with  the  particular  tumor 
to  be  treated,  and  with  its  situation.  When  the  tumor  is  small  or  peduncu- 
lated, excision  is  probably  the  best  method  of  treatment,  for  the  edges  of  the 
wound  can  then  be  brought  together  without  tension  and  only  a  slight  scar 
is  the  result.  The  operation  is  not  difficult  if  the  incision  is  made  through 
the  healthy  skin  beyond  the  dilated  vessels,  and  the  hemorrhage  will  be 
no  greater  than  in  any  ordinary  wound.  Excision  is  especially  suited  for 
angiomata  of  the  scalp,  for  the  blood-sujaply  can  be  controlled  in  such  cases 
by  pressure  with  the  assistant's  hands  around  the  tumor  while  the  surgeon 
makes  his  incisions.  Even  upon  the  face  excision  is  the  best  method  of 
treatment,  when  the  tumor  is  not  extensive  and  narrow  linear  scars  can  be 
produced  which  correspond  more  or  less  with  the  natural  wrinkles  or  folds 
in  the  skin.  Destruction  of  the  tiimors  by  the  cautery  or  caustics,  such 
as  nitric  acid,  should  be  reserved  for  very  small  tumors,  on  account  of  the 
slow  healing  and  unsightly  scars,  but  this  is  the  method  preferred  for  small 
tumors  by  some  surgeons.     In  the  method  of  treatment  by  thrombosis  we 


Angioma  of  hand  and  fingers. 


TREATMENT  OF  ANGIOMA.  291 

may  act  ou  the  old  suggestion  to  pass  ligatures  through  the  base  of  the 
tumor  iu  the  healthy  tissue  with  the  idea  of  constrictiug  the  blood-supply  of 
the  part,  as  explained  on  page  168.  If  the  operation  is  done  aseptically 
there  is  no  very  serious  objection  to  the  method,  except  the  danger  of  causing 
extensive  sloughing  of  the  skin,  and  this  may  be  avoided  by  not  tying  the 
ligature  tightly,  as  a  very  slight  pressure  is  sufficient  to  control  the  blood- 
supply  and  to  allow  the  vessels  to  be  filled  with  clot.  A  very  old  method  of 
treatment  consists  in  the  injection  of  styptic  substances,  such  as  the  sesqui- 
chloride  of  iron,  but  this  method  is  dangerous,  because  it  forms  clots  in  the 
vessels,  and  occasionally  small  clots  may  be  washed  away  by  the  blood- 
current  and  occasion  embolism.  Far  safer  and  very  efficient  is  Esmarch's 
method  of  treating  the  tumor  by  styptic  substances,  which  consists  in  pass- 
ing sterilized  stout  silk  threads  wet  with  the  iron  solution  back  and  forth 
through  the  substance  of  the  tumor,  interlacing  the  threads  in  all  directions. 
A  large  number  of  sutures  should  be  i^assed  at  intervals  of  an  eighth  of  an 
inch  or  a  quarter  of  an  inch,  left  in  place  for  some  days,  and  then  with- 
drawn. Before  any  such  operation  is  done,  the  parts  should  be  rendered 
thoroughly  aseptic,  and  suppuration  along  the  course  of  the  threads  should 
be  avoided  by  sterilizing  the  threads,  instruments,  and  hands.  If  suppura- 
tion should  set  in,  it  may  assist  the  cure,  but  there  is  danger  of  pyaemia, 
and  an  unsightly  scar  results,  while  if  asepsis  is  preserved,  the  scar  con- 
sists simply  of  punctate  spots  of  cicatricial  tissue.  Iu  the  third  class  of 
methods  also  we  endeavor  to  produce  scar-tissue,  and  this  may  be  done  by 
exciting  suppuration.  Vaccination,  for  instance,  has  been  practised  directly 
on  the  angioma,  and  cures  have  thus  been  obtained,  but  the  objection  to 
inducing  suppuration  is  that  the  infection  is  likely  to  travel  beyond  the  part 
intended  and  to  do  more  damage  than  the  surgeon  wishes.  Another  method 
of  producing  scar-tissue  is  multiple  scarification  by  a  sharp  knife,  a  method 
which  is  suitable  for  superficial  angiomata,  the  resulting  hemorrhage  coming 
from  such  small  vessels  that  it  is  readily  controlled  by  pressure.  The  cure 
is  produced  by  the  scars  following  the  nniltiple  incisions,  the  vessels  being 
divided  and  obliterated  at  many  j)oints.  The  treatment  by  the  punctate 
cautery,  a  red-hot  needle  being  thrust  repeatedly  into  the  tumor,  is  based 
on  a  similar  theory.  An  ordinary  needle  heated  in  the  flame  of  a  spirit- 
lamp  may  be  employed,  or,  iu  the  case  of  large  angiomata,  situated  where 
a  scar  is  not  objectionable,  the  fine  point  of  the  Paquelin  thermo- cautery 
will  answer.  Finally,  we  may  describe  the  treatment  by  electrolysis. 
The  negative  or  positive  pole  is  to  be  used  according  to  the  effect  desired. 
If  an  attempt  is  to  be  made  to  cure  the  tumor  by  thrombosis  only,  the  posi- 
tive pole  should  be  attached  to  the  needle  which  makes  the  punctui-es,  clots 
forming  in  the  track  of  the  needle,  and  the  vessels  being  obliterated.  If  the 
negative  pole  be  used,  the  tissue  around  the  needle  is  actually  destroyed  by 
the  current  and  cicatricial  tissue  produced,  as  in  the  method  with  the  punc- 
tate cavitery.  In  either  case  the  other  pole  is  attached  to  a  large  sponge 
electrode  applied  on  the  neighboring  skin.  The  positive  pole  produces  the 
smoother  scar,  but  the  method  is  tedious  and  unreliable.  The  negative  pole 
also  requires  frequent  sittings,  even  if  a  considerable  number  of  punctures 
are  made  at  each  sitting.    The  treatment  is  somewhat  painful,  but  we  prefer 


292 


LYMPHANGIOMA. 


Fig.  229. 


not  to  give  an  aniiesthetic,  as  so  many  applications  must  he  made.    It  is  best 
suited  for  tlie  port-wine  mark. 

The  choice  of  the  method  of  treatment  depends  upon  the  size  and  situ- 
ation of  the  tumor.  When  it  is  small  or  has  a  narrow  base  it  may  be 
excised  ;  and  even  large  tumors  may  be  so  treated  when  a  scar  is  not  objec- 
tionable. Superficial  tumors  may  be  cauterized  with  acid  or  treated  by 
punctate  cautery  or  electrolysis,  the  latter  being  preferable  when  they  are 
extensive.  When  the  soft  parts  are  extensively  diseased  and  the  tumor 
forms  a  considerable  mass,  Esmarch's  method  is  the  best  plan  of  treatment. 

LYMPHAlSraiOMA. 

Lymphatic  vessels  produce  the  same  varieties  of  tumors  as  the  blood- 
vessels, and  we  may  distinguish  a  lymphatic  telangiectasis  or  capillary  form, 

a  cavernous  form,  aud  a  cystic  lym- 
phangioma. 

Structure. — The  gross  structure 
of  the  capillarj-  and  the  cavernous  lym- 
phangioma exactly  resembles  that  of 
the  corresj)onding  tumors  of  the  blood- 
vessels, except  that  the  vessels  have 
thinner  walls  and  cystic  changes  are 
more  frequent.  (Fig.  229.)  The  cysts 
of  lymjihaugioma  are  produced  by  ex- 
treme dilatation  of  vessels  in  the  tumor, 
with  absorption  of  the  walls  between 
the  adjacent  distended  A^essels,  the 
result  being  the  formation  of  large 
irregular  cavities  connected  at  many  points  with  the  lymphatic  system  of 
the  tumor.  These  cavities  have  a  tendency  to  increase  constantly  at  the 
expense  of  the  surrounding  parts.  In  some 
cases  the  lymphangioma  will  be  found  full  Fig.  230. 

of  small  cavities  constructed  in  this  way ; 
in  other  cases  the  entire  tumor  may  be  con- 
verted into  one  large  cyst,  especially  in  the 
neck.  Like  the  blood  augiomata,  the  lymph- 
angiomata  are  usually  congenital  in  origin, 
and  may  extend  slowly  or  rapidly.  They 
are  most  frequently  seen  iu  the  lips  and  the 
tongue,  where  they  give  rise  to  the  deformi- 
ties known  as  macrocheilia  and  macroglossia. 

Lymphatic  cysts  of  the  neck  (Fig.  230) 
have  been  given  the  name  of  hygroma  colli 
cysticum,  or  hydrocele  of  the  neck,  but  the 
term  cystic  lymphangioma  is  preferable.  In 
many  of  the  branchial  cysts  there  is  an  accu- 
mulation of  round  cells  in  the  walls  with  a  structure  resembling  that  of  a 
lymphatic  gland  or  a  lymphangioma,  aud,  while  it  is  possible  that  some 
supposed  branchial  cysts  are  really  of  lymphatic  origin,  the  mere  presence 


Lymphangioma,  X  XOO.     (F.  C.  Wood,  M.D.) 


Lymphatic  cyst  of  neck.    (Agnew.) 


ENDOTHELIOMA.  293 

of  this  lymi^hatic  tissue  proves  uothing  against  the  branchial  origin  of  the 
cyst.     The  diagnosis  between  the  two  forms  of  cyst  may  be  very  difficult. 

Treatment. — These  cysts  have  been  treated  successfully  by  aspii-ation 
and  the  injection  of  iodine,  but  failures  are  common  with  this  method. 
Extiri^ation,  on  the  other  hand,  is  generally  very  difficult,  because  these 
tumors  originate  in  the  neighborhood  of  the  great  vessels  and  nerves,  and 
a  preliminary  attempt  to  cm-e  the  cyst  by  injection  creates  adhesions  and 
adds  to  the  difficulties.  The  ordinary  lymphangiomata  may  be  treated  on 
the  same  lines  as  the  tiimors  of  the  blood-vessels,  but  free  excision  is  the 
best  method  of  dealing  with  them. 

ENDOTHELIOMA. 

An  endothelioma  is  a  tumor  composed  of  endothelial  cells  in  a  stroma 
of  connective  tissue.  In  pathological  structure  and  in  clinical  significance 
it  stands  midway  between  the  connective-tissue  grouj)  and  the  epithelial 
tumors. 

Structure. — The  tumors  originate  in  the  endothelial  cells  which  line  the 
blood-vessels,  the  lymphatic  vessels,  and  the  lymphatic  spaces  in  the  connec- 
tive tissue,  and  which  cover  the  serous  and  synovial  membranes,  so  that  they 
are  very  widely  distributed  and  of  varying  structure  according  to  the  tissue 
from  which  they  have  sprung.  Formed  from  the  endothelium,  they  belong- 
to  the  group  of  connective-tissue  tumors,  but  the  rapidly  proliferating  cells 
of  which  they  are  composed  bear  so  close  a  resemblance  to  the  cells  of  epi- 
thelial growths  that  the  diagnosis  is  exceedingly  difficult,  and  in  some  cases 
impossible.  The  tumor  called  cylindroma  was  supposed  to  be  the  product 
of  epithelial  cells  growing  in  convoluted  tubes,  but  is  undoubtedly  an  endo- 
thelioma, the  tubes  representing  the  vessels  in  which  the  cells  have  grown. 
The  characteristic  cells  in  these  tumors  are  large,  with  a  large  nucleus,  irreg- 
ular in  shape,  flattened,  or  almost  cylindrical,  or  globular.  They  are  con- 
tained in  a  stroma  of  connective  tissue,  which  may  be  scanty  or  may  form 
spaces  containing  the  cells.  These  spaces  often  form  convoluted  tubes,  in 
which  one  may  trace  the  winding  of  the  vessels  as  in  an  angioma,  and  in 
other  cases  they  form  cavities  closely  resembling  the  acini  of  an  acinous 
gland.  The  boundary  line  between  angiosarcoma  and  endothelioma  is  dif- 
ficult to  define,  and  it  is  probable  that  the  latter  often  changes  to  sarcoma. 

Varieties. — The  important  varieties  of  endothelioma  are  those  of  the 
skin,  the  serous  membranes,  the  breast,  alnd  the  ovary. 

Endothelioma  of  the  skin  has  the  tubular  structure  which  has  already 
been  mentioned,  and  forms  small,  flat  nodules  in  the  corium  or  limited  to  the 
papillary  layer,  with  little  tendency  to  ulceration.  Tlie  tumors  are  generally 
small  and  multiple.  Endothelioma  growing  from  the  serous  membranes 
may  show  itself  merely  as  a  flat  mass  formed  by  hyjaertroiihy  of  the  endo- 
thelial layer,  or  many  layers  of  these  cells  may  form  a  thick  wart-like 
protuberance  upon  the  surface  of  the  serous  membrane.  In  other  cases 
tumors  of  the  cylindroma  variety  are  found,  making  hard  nodules  which 
may  attain  a  considerable  size,  although  they  are  seldom  more  than  half  an 
inch  in  diameter.  Such  tumors  occur  in  the  peritoneal  cavity  and  in  the 
arachnoid. 


294  SARCOMA. 

Endothelioma  of  the  breast  may  closely  resemble  carcinoma.  The 
tumors  are  usually  superficial,  grow  very  slowly,  witb  few  symptoms,  and 
seldom  attain  a  large  size.  The  lymphatic  glands  are  not  involved,  the 
skin  is  generally  not  adherent  over  the  tnmor,  and  there  is  little  tendency  to 
ulceration.  The  diagnosis  from  carcinoma  can  be  made  by  the  exceedingly 
slow  growth  of  endothelioma,  its  encapsulation,  and  the  freedom  of  the 
axillary  glands.  In  some  cases,  however,  these  tumors  have  a  course  like 
that  of  sarcoma. 

Endothelioma  of  the  ovary  is  a  small  tumor,  usually  of  the  cylindroma 
type,  and  is  rare.  It  has  none  of  the  characteristics  of  sarcoma  in  this 
region,  and  is  usually  discovered  accidentally  in  an  "enlarged"  ovary. 

Clinical  History. — The  clinical  history  of  endothelioma  can  be  deduced 
from  the  above,  the  tumors  growing  slowly,  with  little  tendency  to  ulcera- 
tion or  invasion  of  surrounding  parts.  But  they  represent  a  type  of  those 
suspicious  tumors  which  are  liable  to  become  malignant,  especially  under 
the  stimulation  of  injury  or  irritation. 

Treatment. — A  doubtful  tumor  of  this  character  should  most  certainly 
be  extirpated,  but  the  operations  need  not  be  so  extensive  as  those  for  malig- 
nant disease.  In  the  serous  cavities  of  the  [»eritoneum  and  brain  the  tumors 
are  usually  very  small,  and  not  likely  to  produce  symptoms  serious  enough 
to  demand  operative  interference,  although  in  the  brain  they  may  give  rise 
to  serious  pressure  symptoms. 

SAECOMA. 

We  have  considered  the  tumors  which  spring  from  the  mesoblast  and 
resemble  in  structure  the  various  tissues  which  descend  from  that  layer,  but 
there  is  a  group  of  tumors  of  similar  origin  which  do  not  resemble  any  tis- 
sues found  in  the  adult  body,  except  the  gramilation-tissue  found  in  the 
repair  of  wounds  and  in  inflammation.  The  last- mentioned  tumors  are  of 
various  structure,  but  they  all  resemble  the  different  forms  of  fcetal  connec- 
tive tissues,  tissues  therefore  which  are  normal  in  the  fcetus,  but  abnormal  in 
adult  life.  A  sarcoma  may  be  defined  as  a  tumor  comi^osed  of  embryonic 
tissues  of  mesoblastic  origin.  It  is  always  malignant,  although  its  malig- 
nancy varies  gi-eatly  in  degree.  The  embryonic  tissue  is  often  found  asso- 
ciated with  fully  developed  tissues,  and  the  malignancy  of  any  tumor  in 
which  both  tissues  occur  corresponds  to  the  proportion  between  the  two, 
for  when  the  tumor  contains  much  fully  developed  adult  tissue  it  is  less 
malignant. 

Structure. — Sarcomata  are  formed  of  cells  of  varying  shapes,  always 
embedded  in  an  intercellular  substance,  although  in  many  cases  the  latter  is 
very  delicate  and  can  be  seen  only  by  removing  the  cells  from  its  meshes. 
The  tumors  are  vascular,  and  the  capillaries  have  very  thin  walls.  (Fig. 
231.)  The  walls  of  the  vessels  may  be  formed  of  endothelial  cells  lying 
directly  upon  the  cells  of  the  tumor,  or  they  may  be  entirely  absent,  and 
the  blood  may  flow  in  channels  between  the  cells  of  the  tumor.  The  tumor 
is  often  partly  encapsulated,  but  the  abnormal  cells  usually  infiltrate  the 
capsule  somewhat.  (Fig.  2.31.)  The  cells  of  these  tumors  are  round  or 
spindle-shaped,  or  giant-cells.     The  round  cells  may  be  small  or  large, 


STRUCTURE  OF  SARCOMA.  295 

most  frequently  the  former.  In  either  case  the  nucleus  is  very  large  and 
nearly  fills  the  cell  body.  The  small  round-cell  tumors  (Fig.  231)  resemble 
granulation-tissue  very  closely,  and  often  cannot  be  distinguished  from  it 
except  by  the  fact  that  granulation  tends  to  the  i^roduction  of  normal  adult 
coimective  tissue,  while  the  growth  of  sarcoma  remains  embryonic.  The 
spindle-cells  are  usually  small  (Fig. 
232),  but  they  may  attain  a  very  large 


Fig  232 


Fig.  231. 


^ 


J^f«  ^^-J^^&^^^  ,^       „  .    -  .  '  > 


^-O 


^, 


Small  round  cell  sarcoma     a   small  round  cells  Small  spindle-cell  sarcoma ;  a,  blood-vessel :  h, 

and  thin-walled  vessels   6  capsule  of  tumor  infiltrated       transverse  section  of  spindle-cells.    (F.C.Wood, 
with  cells  from  the  tumor.    (F.  C.  Wood,  M.D.)  M.D.) 

size,  and  the  intercellular  substance  may  be  very  scanty.     (Fig.  233.)    The 

giant-cells  are  multinuclear  cells  of  large  size,  similar  to  those  seen  in 

actively  growing  bone.     (Fig.  234. )     These  cells  are  most  frequently  found 

in  sarcomata  with  a  tendency 

to  produce  bone  (Fig.  236),  but  ^'^  233 

their  function  seems  to  be  the  ^  ,^    — 

absorj^tioh  of  the  newly  formed  -  -^  j-i^^^^"^''" 

bone.     In  some  tumors  any  or  ^  -"  c^ 

all  of  these  various  cells  will     c    -'''  _^  ^  „- 

be    found    combined,    and    the  -^  ^ 

name  of  mixed-cell  sarcoma  ^        —  _ 

has  been  apj)lied  to  them.     All  '^  _^  P* 

these  varieties  of  sarcomatous  -  c^  ^  -^ 

tissue  are  often  found  associated        ...    v  c  ^   -^  -(^■' 

with  tissues  of  a  higher  type,  "^    -' 

_£•!  ,.  .-1  1  Large  spindle  cell  si  1  it^c^te     X  300 

fibrous  tissue,   cartilage,  bone,  ^    ^        (r  c  « oud  m  d  ) 

fat,  and  myxoma  being  very  fre- 
quently combined  with  them  :  hence  the  names  fibrosarcoma,  osteosarcoma, 
myxosarcoma,  angiosarcoma,  etc.    (Figs.  235  and  236.)    Cystic  degeneration 
may  occur. 

Gliosarcoma. — Gliosarcoma  is  a  variety  of  round-cell  sarcoma  with 
large  cells,  containing  a  large  nucleus,  springing  fi'om  the  neuroglia  of 
the  nerve-centres,  and  found  ouly  in  the  brain  and  in  the  eye.  They  are 
encaijsulated  at  first,  and  do  not  generally  grow  raj)idly  or  tend  to 
metastasis.  Their  chief  claim  to  malignancy  is  their  situation,  where 
even  a  benign  tumor  is  dangerous.  They  may  attain  a  considerable  size, 
although  usually  not  larger  than  a  walnut.     When  removed  they  are  aiJt 


296 


VARIETIES   OF  SAECOMA. 


to  return,   for  the  diagnosis  is  seldom  made  until  the  tumors  are  well 
grown  and  invasion  of  the  surrounding  tissues  has  begun.     For  their 

treatment  we  refer  to  the  section 


Fig.  234. 


on  tumors  of  the  brain. 

Fig.  235. 


c    f^ 


:«^' 


l>  p 


^          ;  ,, 

fl      O       ,■ 

..  ^    -  ^ 

0 


Giantcell  sarcoma,  X  300     (F  C  Wood,  M  D  ) 


Fig.  236. 


Myxochondrosarcoma  of  parotid. 
(F.  C.  Wood,  M.D.) 


^1 


^ 


% 
<^') 


^'    0 


o 


r^ 


ra/ 


Osteosarcoma  of  humerus :  a,  lami  ILl  of  bone  ,  \i  spindle-cell  of  tlic  sarcoma ;  c,  giant-eell  acting  as  an 
osteoclast  and  causing  absorption  of  bone.    (F.  C.  Wood,  M.D.) 

Alveolar  Sarcoma. — Alveolar  sarcoma  is  a  form  in  which  the  inter- 
cellular substance  is  increased  in  some  of  its  strands  and  so  arranged  as  to 


VARIETIES  OF  SABCOMA.  297 

form  alveoli  containing  groups  of  cells  and  resembling  carcinoma.  The 
cells  are  roviud  or  spindle-shaped,  most  frequently  the  former.  An  inter- 
cellular substance  can  generally  be  demonstrated,  although  it  may  be  very 
scanty,  and  serves  to  distingiiish  these  neoplasms  from  the  epithelial  tumors. 
It  seems  probable  that  the  round-cell  alveolar  sarcomata  are  of  endothelial 
origin,  the  walls  of  the  vessels  or  lymph  spaces  forming  the  alveoli  and  the 
cells  originating  from  their  endothelial  lining. 

Melanotic  Sarcoma. — Deposits  of  pigment  are  found  in  round-cell 
and  spindle-cell  sarcoma,  and  occur  both  in  the  cells  and  stroma.  The 
presence  of  pigment  generally  indicates  a  more  malignant  type  of  tumor, 
although  over  ten  per  cent,  of  the  cases  have  remained  well  after  operation, 
so  that  the  prognosis  is  not  hopeless.  Melanotic  tumors  do  not  otherwise 
differ  from  the  other  sarcomata.  They  occur  at  all  ages,  and  in  both  sexes, 
but  more  frequently  in  men.  They  develop  where  pigment  occurs  normally, 
in  the  choroid  coat  of  the  eye,  and  in  the  skin,  frequently  originating  from 
a  congenital  mole.  The  lymphatic  glands  are  affected  in  at  least  one-fifth  of 
the  cases,  and  sometimes  the  primary  tumor  develops  in  a  lymph-node. 
Without  operation  the  disease  runs  its  course  in  less  than  eighteen  months, 
but  occasionally  the  tumors  appear  to  have  a  very  slow  growth.  Secondary 
deposits  in  the  deeper  organs  are  the  rule,  and  in  advanced  cases  the  urine 
may  be  discolored  by  elimination  of  the  pigment  by  the  kidneys,  showing 
that  the  coloring-matter  finds  its  way  into  the  circulation,  probably  by  means 
of  the  cells,  which  enter  it  and  disintegrate  in  the  blood. 

Metastasis. — The  metastasis  of  sarcoma  takes  place  by  the  growth  pene- 
trating the  blood-vessels,  infection  of  the  lymphatic  system  being  infrequent, 
although  it  is  more  common  than  usually  supposed,  as  the  glands  have  been 
found  to  be  involved  in  about  one-sixth  of  the  cases  of  sarcoma  of  the  breast. 
"When  the  wall  of  a  vein  is  attacked  by  the  growth,  a  bud  of  sarcomatous 
tissue  forms  on  its  inner  surface,  and  small  iiarticles  or  single  cells  may  be 
swept  away  by  the  blood-current  to  other  parts  of  the  body,  giving  rise  to 
secondary  tumors  wherever  they  are  arrested,  the  dissemination  resembling 
that  of  pytemia.  (Figs.  237  and  238.)  An  embolus  from  such  a  tumor  must 
pass  the  minute  capillaries  of  the  lungs  before  again  entering  the  general 
circulation  so  as  to  cause  secondary  tumors  elsewhere,  and  this  accounts  for 
the  frequency  with  which  secondary  tumors  occur  in  the  lung.  It  is  not 
easy  to  explain  how  they  ever  escape,  and  yet  the  lungs  are  often  found 
to  be  healthy  even  when  secondary  tumors  are  present  elsewhere.  In  addi- 
tion to  true  metastasis  by  the  blood-vessels  and  the  lymph- vessels,  a  sort  of 
tiansplantation  may  occur  in  a  sarcoma  growing  from  one  of  the  serous  sur- 
faces of  the  body,  as,  for  instance,  the  i^eritoneum,  which  may  give  rise  to 
growth  elsewhere  in  that  cavity  by  fragments  or  cells,  which  are  detached 
from  its  surface  and  implanted  in  other  j)arts  of  the  serous  lining. 

Occurrence. — Sarcoma  is  found  in  all  the  organs  and  tissues  of  the 
body,  the  bones,  skin,  testicles,  ovary,  breast,  and  uterus  being  most  fre- 
quently involved.  Multiple  sarcoma  is  found  in  the  skin  in  the  form  of 
numerous  small  growths  scattered  over  the  body,  and  its  course  is  rather  a 
slow  one,  although  it  progresses  to  a  fatal  termination,  the  tumors  finally 
ulcerating,  and  internal  secondary  deposits  taking  place.     Sarcoma  of  the 


298 


CLINICAL   HISTORY   OF  SARCOMA. 


skin,  however,  also  occurs  in  single  tumors,  which  often  arise  from  a  wart  or 
congenital  mole,  and  these  may  be  very  malignant,  not  merely  making  large 
tumors  locally,  but  spreading  very  rapidly  to  other  parts  and  forming  meta- 
static deposits. 

Clinical  Appearance  and  History.— The  clinical  history  of  sarco- 
mata is  not  easy  to  sketch,  on  account  of  the  variations  in  the  different  tyj)es. 
Sarcoma  is  found  at  all  ages,  but  is  more  frequent  from  puberty  to  the  thii-- 
tieth  year  of  life.  In  general  it  may  be  said  that  sarcoma  grows  very  rapidly, 
and  remains  partially  encapsulated  from  the  surrounding  tissue.      It  is 

Fig.  237.  Fig.  238. 


Sarcoma  of  tibia,  secondary  involvement  of 
inguinal  glands. 


Metastatic  sarcoma  of  grom  secondary  to  sarcoma 
of  neck.    (Dr.  E.  Abbe.) 


very  vascular,  and  its  growth  is  apt  to  be  painful,  but  ulceration  does  not, 
as  a  rule,  set  in  until  late,  although  if  the  tumor  be  very  prominent  the  skin 
over  the  surface  may  slough  in  conseqiience  of  injury  or  because  its  blood- 
supply  is  interfered  with.  The  sloughing  is  unlike  the  ulceration  occurring 
in  carcinoma,  in  which  the  skin  actually  becomes  involved  in  the  epithelial 
growth  and  then  breaks  down.  When  an  oijening  has  thus  been  made  in 
the  overlying  tissues  the  capsule  yields,  and  the  tumor  is  apt  to  project 
through  it  in  a  mass  of  cauliflower  shape.  In  sarcoma  of  the  internal  organs 
a  rise  of  temperature  in  irregular  curves  resembling  pyaemia  or  tubercu- 
losis or  even  typhoid  fever  often  takes  place  ;  and  a  local  rise  of  tempera- 
ture is  not  uncommon  in  sarcoma,  a  difference  of  as  much  as  one  degree 
having  been  detected  by  the  surface  thermometer.  Leucocytosis  is  often 
found  in  the  later  stages.  Other  symptoms  xjroduced  by  the  tumors  will  be 
described  in  connection  with  the  different  organs  in  which  they  occur. 


SARCOMA  OF  BONE.  299 

The  course  of  a  sarcoma  depends  largely  upon  its  structure  :  thus,  the 
round-cell  sarcomata  (especially  if  the  cells  are  small)  are  more  malignant 

Fig.  240. 
Fig.  239.  ^^ 


,I»^^ 


Sarcoma  of  scapula. 


Osteosarcoma  of  scapulii 


than  the  spindle-cell  tumors,  and  both  of  these  are  more  malignant  than  the 
giant-cell  variety.  The  presence  of  fibrous  tissue  or  of  true  bone  in  a  sar- 
coma also  renders  the  prognosis  better.  The  p^^  241 
duration  of  sarcoma  seems  to  be  a  very  varia- 
ble one.  Some  tumors  run  a  course  of  great 
rapidity,  the  growths  spreading  through  the 
tissues  almost  as  rapidly  as  a  purulent  infil- 
tration, and  secondary  tumors  appearing  at 
once  in  distant  organs.  Others  resemble  a 
fibroma,  growing  very  slowly,  being  encapsu- 
lated, giving  absolutely  no  symptoms,  and 
sometimes  remaining  stationary  in  size  and 
without  dissemination  elsewhere  for  years, 
until  a  blow  or  some  unknown  cause  brings 
out  their  malignant  character.  It  is  as  yet 
uncertain  whether  these  latter  tumors  are  sar- 
comatous from  the  first  or  whether  they  are 
benign  tumors  in  which  a  sarcomatous  change 
takes  place. 

Sarcoma  of  Bone. — Sarcoma  occurs  in 
both  the  flat  (Figs.  239  and  240)  and  the  long 
bones,  and  may  develop  centrally  or  in  the 
periosteum.  It  may  be  round-cell,  spindle- 
cell,  giant-cell,  or  mixed-cell  sarcoma,  and  is 
sometimes  associated  with  abundant  production  of  cartilage  or  bone.  The 
giant-cell  is  the  most  common  of  the  central  tumors  (Fig.  241),  especiallj^  in 


Skiagraph   of   central  giant-cell  sar- 
coma of  radius. 


300 


SARCOMA   OF  BONE. 


Fig.  2-13. 


the  upper  i^art  of  the  tibia,  where  it  usually  presents  the  peculiar  symptoms 
of  i:)ulsation  and  egg-shell  crackling.  The  latter  symptom  is  due  to  the  thin 
superficial  layers  of  bone  (Fig.  242),  which  crack  under  firm  i)ressure  with 
the  finger.  The  pulsation  is  expansile,  like  that  of  aneurism,  and  is  due 
to  the  abundant  blood-supply.  Central  giant-cell  sarcomata  of  the  shaft  of 
the  long  bones  do  uot  usually  give  these  symptoms.  Bound-cell  sarcomata 
growing  centrally  in  the  shafts  present  pulsation, 
and  are  very  malignant.  (Gross.)  The  round-cell 
periosteal  sarcomata  usually  attack  the  shafts  of  the 
long  bones,  and  are  also  very  malignant,  but  do  not 
pulsate  or  give  egg-shell  crackling.  The  spindle-cell 
tumors  of  central  origin  generally  occur  near  the 
knee  and  grow  slowly ;  when  of  periosteal  origin 
they  also  appear  at  the  epiphyses,  but  are  more 

Fig.  242. 


Skiagraph  ol  central  sarcoma  of  head  of  tihia,  shoiving  thin  bony 
capsule. 


Osteosarcoma  of  femur. 


maligna;ut.  Central  tumors  of  the  bones  are  usually  symmetrical  (Fig.  243), 
while  the  periosteal  tumors  always  grow  from  one  side  of  the  bone.  The 
shape  of  the  limb  in  sarcoma  of  the  soft  parts  is  generally  altered  more  on 
one  side  than  on  the  other.  (Figs.  244  and  245. )  Sarcoma  of  the  bone  usually 
causes  great  pain,  especially  if  it  be  central,  and  cachexia  with  marked  blood- 
changes  may  develop  early.  Fracture  of  the  bone  is  common  in  the  central 
variety.  The  soft  parts  are  generally  not  invaded  until  late,  except  in 
round-cell  sarcoma.  Metastasis  and  lymxshatic  involvement  occur  in  all 
forms,  some  other  bone  being  frequently  involved.     Eecurrence  or  death 


DIAGNOSIS   OF  SARCOMA. 


301 


from  metastasis  is  common  in  all  cases,  except  those  of  giant-cell  sarcoma, 
even  after  high  amputation.  The  j)resence  of  much  cartilage  or  bone  in  the 
tumor  indicates  a  somewhat  better  i)roguosis  than  otherwise. 

Diagnosis. — The  diagnosis  of  a  sarcoma  is  to  be  made  when  a  well- 
encapsulated  tumor  originates  from  some  iiart  of  the  body  which  does  not 
contain  epithelial  cells,  and  grows  rapidly,  especially  if  it  directly  follows  a 
severe  injury.     If  the  tumor  is  subcutaneous,  the  skin  will  not  be  involved 

or  even  adherent  until  late 

Fig.  2-15. 


Fig.  244, 


in  the  disease.  If  it  origi- 
nates in  the  skin,  it  may 
be  learned  that  a  wart  or 
mole  existed  previously  in 
that  situation.  The  diag- 
nosis may  be  made  certain 
by  excluding  benign  tu- 
mors, inflammatory  swell- 
ings, and  epithelial  tu- 
mors. The  first  can  usually 
be  done  by  the  short  dura- 
tion and  rajpid  growth  of 
sarcoma,  and  occasionally 
by  its  less  distinct  encap- 
sulation. The  diagnosis 
from  inflammatory  swell- 
ings is  not  always  easy, 
because  the  rapidly  grow- 
ing sarcomata  are  some- 
times marked  by  local  heat 
and  acute,  throbbing  pain, 
but  there  is  a  lack  of  infil- 
tration in  the  neighborhood  of  the  ordinary  sarcoma,  and  its  growth  is 
rarely  so  rapid  as  that  of  inflammation.  Leucocytosis  is  present  in  both. 
The  principal  difficulty  will  be  found  in  the  chronic  inflammations,  such 
as  syphilis,  actinomycosis,  and  tubercle.  The  recognition  of  epithelial 
growths  will  dej)end  largely  upon  the  fact  that  such  tumors  must  take  their 
origin  from  epithelial  tissue,  hence  primary  epithelial  tumors  cannot  occur 
in  the  bones  or  the  Ij'^mphatic  glands,  nor  are  they  so  frequent  in  the  subcu- 
taneous tissue  as  sarcomata.  A  sarcoma  generally  presents  more  or  less 
rounded  surfaces  of  varying  consistency,  hard  in  one  part  and  soft  in  another, 
and  the  tumor  is  usually  partly  encapsulated,  and  often  movable  at  first, 
whereas  the  epithelial  growths  are  generally  of  stony  hardness,  and  liable  to 
become  adherent  to  the  skin  or  mucous  membrane  even  before  the  latter  are 
actually  involved.  Enlargement  of  the  glands  in  the  early  stages  indicates 
that  the  growth  is  epithelial,  although  this  rule  is  not  invariable,  nor  is  the 
age  of  the  patient  altogether  to  be  relied  upon,  for  sarcoma,  may  appear 
late  in  life,  although  it  is  much  less  common  than  the  epithelial  tumors  at 
that  ijeriod.  In  many  cases  the  excision  of  a  fragment  by  the  knife  or  by 
Warren's  punch  (a  cauula  with  a  cutting  edge,  to  be  thrust  into  the  growth 


Myxosarcoma  of  thigh. 


Sarcoma  of  muscles  of  left  thigh 
(shaven),  femur  not  involved. 


302  ADENOMA. 

to  be  examined)  for  microscopic  examination  will  be  the  only  means  of 
determining  the  real  nature  of  these  growths.  Positive  evidence  of  malig- 
nant disease  may  be  thus  obtained,  but  if  the  result  of  the  examination  is 
negative  it  should  be  accepted  with  reserve,  because  the  examination  of 
small  portions  is  not  always  satisfactory,  for  the  tumor  may  vary  in  structure 
in  different  parts. 

Treatment. — Thorough  extirpation  is  the  only  eifective  treatment  for 
sarcoma,  and  the  neighboring  glands  of  the  region  should  also  be  removed, 
even  if  no  visible  sign  of  disease  is  present.  In  the  case  of  sarcoma  of  one 
of  the  extremities,  amputation  is  often  necessary,  in  order  to  remove  the 
tumor  or  because  its  complete  removal  would  leave  a  useless  limb.  If 
attempts  are  made  to  extirpate  the  tumor  and  save  the  limb,  the  surgeon  is 
apt  to  err  on  the  side  of  conservatism.  When  the  long  bones  are  involved, 
the  entire  bone  should  be  removed  at  the  joint  above,  whether  the  tumor  be 
periosteal  or  central.  It  is  true  that  the  giant-cell  sarcomata  of  bone  seem 
to  be  rather  less  malignant,  and  a  cure  has  been  obtained  in  some  cases  by 
partial  removal  of  the  bone.  The  many  failures  observed  in  the  treatment 
of  malignant  tumors  bj'  the  most  thorough  operations,  however,  indicate 
that  prudence  should  compel  us  to  do  too  much  rather  than  too  little  until  our 
means  of  controlling  the  disease  imj)rove.  Eesection  of  the  shaft  of  a  bone, 
therefore,  cannot  be  recommended,  nor  amputation  through  the  middle  of  a 
long  bone,  even  when  the  distal  extremity  only  is  involved.  Large  doses  of 
arsenic  have  been  used  in  the  treatment  of  lymphosarcoma,  and  hypoder- 
mic injections  of  that  substance  into  the  glands  have  been  made,  but  cures 
have  very  rarely  been  obtained. 

Erysipelas-Inoculation. — A  considerable  number  of  cases  are  on  record 
in  which  sarcoma  or  carcinoma  has  disapj)eared  after  attacks  of  erysipelas, 
and  the  effect  of  erysipelas  in  xJi'oducing  this  result  cannot  be  denied. 
Attempts  have  been  made  to  utilize  this  effect  by  inoculating  patients  with 
erysipelas,  but  the  results  were  uncertain  and  the  risk  was  considerable, 
the  eiysipelas  being  very  difficult  to  control  and  often  ending  fatally.  On 
the  supposition  that  the  effects  of  ei'ysipelas  upon  malignant  tumors  were 
due  to  the  toxines  of  the  streptococcus  which  caused  the  inflammation, 
attempts  have  been  made  to  produce  similar  effects  by  injecting  a  sterilized 
pure  culture  into  the  tumor.  The  result  of  these  injections  is  a  severe  chill 
and  a  rise  of  temperature,  but  no  inflammation  is  set  up  if  the  injections  are 
sterile.  In  a  few  cases  fibrous  sarcomata  have  beeu  observed  to  disappear 
after  these  injections,  but  the  method  of  treatment  has  proved  very  unre- 
liable. In  cases  suitable  for  operation  the  method  should  not  be  thought 
of,  as  operation  gives  far  better  results. 

X-Ray. — Eecent  experience  raises  a  hope  that  it  may  become  possible 
to  influence  the  growth  of  deep  sarcomata  by  passing  through  them  the 
Eontgen  ray,  but  the  results  are  as  yet  uncertain. 

ADENOMA. 

An  adenoma  is  a  tumor  consisting  of  epithelial  cells  and  a  fibrous  stroma 
simulating  the  structure  of  the  gland  in  which  it  occurs,  and  it  may  be 
tubular  or  acinous.     Some  authorities  call  tumors  of  the  lymphatic  glands 


STRUCTURE   OF  ADENOMA.  303 

lymphadenomata,  just  as  the  term  adenitis  is  applied  to  their  iuflammation, 
but  this  nomenclature  should  be  altered,  as  the  lymphatic  glands  are  mere 
aggregations  of  lymphatic  tissue  and  not  true  exci-etiug  or  secreting  glands, 
and  we  shall  limit  the  term  adenoma  to  epithelial  tumors.  In  sim^jle  hyper- 
trophy of  a  gland  there  is  an  increase  in  the  amount  of  the  glandular  tissues, 
but  they  retain  their  functional  powers,  while  in  adenoma  the  cells  are  with- 
out function  and  there  are  no  ducts.  An  adenoma  is  usually  encapsulated 
and  distinct  from  the  gland-tissue,  but  sometimes  the  entire  gland  may  be 
involved  in  adenomatous  degeneration,  and  in  such  cases  it  is  not  easy  to 
distinguish  the  neoplasm  from  simple  hypertro]3hy.  With  the  exception  of 
the  ovarian  or  thyroid  cysts,  the  tumors  are  not  of  large  size. 

Occurrence. — Adenoma  is  common  in  the  glands  of  the  mucous  mem- 
branes, and  is  also  found  in  those  of  the  skin.  It  frequently  occurs  in  the 
thyroid,  the  ovaries,  the  mamma,  the  testicles,  and  the  rectum,  and  less 
commonly  in  the  kidney  and  the  liver. 

Structure. — The  structure  of  adenoma  is  seldom  exactly  like  that  of  the 
gland  from  which  it  springs,  adenoma  of  the  kidney  being  a  simple  tubular 
glandular  structure,  quite  different  from  the  con^'Oluted  tubules  of  the  kidney, 
and  adenoma  of  the  intestine  being  far  more  com]3licated  than  the  Lieber- 
kiihn's  glands  from  which  it  originates.  In  the  breast  the  structure  looks 
like  normal  mammary  tissue,  except  that  there  are  no  ducts  (Fig.  246) ;  but 
pure  adenoma  of  the  breast  is  rai-e,  the  tumors  generally  being  largely  com- 
posed of  fibrous  tissue.  In  some  cases  the  intes-  „  ^ .  „ 
tinal  adenomata  are  polypoid  in.  shape  aird  are 
quite  benign,  but  in  others  the  newly  formed  ^ 
tubular  tissue  tends  to  invade  the  neighboring 
mucous  membrane  (Fig.  247),  and,  although  the 
cells  do  not  penetrate  the  basement  membrane 
upon  which  they  rest,  the  tumor  is  analogous  to 
carcinoma  in  its  active  growth  and  its  tendency 
to  recurrence  and  even  to  metastasis.  In  the 
kidney  and  liver  the  adenomata  form  well  encaj)- 
sulated  tumors,  seldom  attaining  a  large  size.  Adenoma  ot  breast  (f  c. 
In  many  of  these  epithelial  tumors  it  is  im^jos-  wood,  m.d.) 
sible  to  draw  a  sharp  line  between  the  benign  and  the  malignant.  Adenoma 
of  the  thyroid  gland  (which  is  described  in  the  section  upon  the  thyroid) 
not  infrequently  causes  metastases  in  spite  of  its  innocent  structure,  the 
secondary  tumors  being  formed  most  commonly  in  the  bones  and  having  the 
histological  appearance  of  the  normal  thyroid.  The  ovarian  adenoma  also 
sometimes  resembles  a  malignant  tumor,  for  its  proliferating  or  papilloma- 
tous form  is  capable  of  infecting  other  parts  of  the  peritoneal  surfaces  and 
causing  the  growth  of  similar  tumors  there. 

Adenoma  is  very  liable  to  cystic  changes,  as  is  natural  in  a  glandular 
structure  without  excretory  ducts  to  carry  off  its  secretions  and  degenerating 
epithelium.  The  sebaceous  cysts  are  reckoned  by  some  pathologists  among 
the  adenomata.  Hemorrhages  frequently  occur  in  these  tumors,  and  myx- 
omatous degeneration  of  the  stroma  may  be  found.  A  change  to  carcinoma 
easily  takes  place  and  is  not  uncommon. 


304 


PAPILLOMA. 


Clinical  Appearance. — The  tumors  vary  so  much  that  we  refer  to  the 
descriptions  in  the  sections  on  the  various  organs  in  which  adenoma  occurs. 


Fig  247 


Adenoma  of  rectum,  X  150  :  a,  normal  rectal  mucous  membrane ;  b,  beginning  growth  of  follicles  of  tbe 
mucous  coat ;  c,  irregular  growth  forming  adenomatous  tissue  and  penetrating  the  submucosa  e ;  d,  muscular 
coat;  €,  submucosa  ;  II.,  a  part  of  the  gland  marked  b,  ><  4-50. 

Treatment. — The  treatment  of  adenoma  is  removal  by  operation,  on 
account  of  its  great  liabilitj^  to  malignant  degeneration. 


PAPILLOMA. 

structure". — While  adenoma  is  a  benign  epithelial  tumor  in  which  the 
epithelial  cells  are  enclosed  in  a  fibrous  stroma,  papilloma  is  a  similar  growth 
in  which  the  stroma  forms  an  inside  skeleton,  covered  by  the  eiDithelial  cells 
like  the  ordinary  papillie.  The  paijillse  grow  in  various  shapes,  sometimes 
rather  broad  and  flat,  sometimes  in  large  masses  with  a  narrow  pedicle  like 
a  cauliflower  (Fig.  248),  sometimes  with  long  fimbriated  extremities  growing 
from  a  common  broad  base,  the  last-named  form  being  called  dendritic,  from 
its  resemblance  to  a  tree.  Every  papilla  in  the  growth  contains  a  looj)  of  a 
small  blood-vessel,  a  formation  which  explains  the  frequencj'^  of  dangerous 
hemorrhage,  especially  in  the  papillomata  of  a  very  soft  mucous  membrane 
like  the  intestine  or  the  bladder.  (Fig.  249.)  The  growths  diifer  in  the 
thickness  of  the  layers  of  epithelium  over  the  papillte,  the  thickened  epithe- 
lial coat  sometimes  forming  the  princixaal  mass  of  the  tumor,  while  in  other 
cases  it  is  very  thin  and  the  mass  is  formed  bj^  the  large  fibrous  bodies  of 
the  papillfe. 

Occurrence. — Papillomata  are  found  in  regions  where  i^apillse  nor- 
mally occur,  such  as  the  skin  and  mucous  membranes  of  the  body.  They 
are  common  on  the  skin  in  the  form  of  the  ordinary  wart,  in  the  larynx,  in 
the  bladder,  and  in  the  rectum.    The  frequent  association  of  papillomata 


PAPILLOMA.  305 

about  the  genital  tract  with  a  venereal  disease  which  causes  an  irritating- 
discharge  shows  very  clearly  the  influence  of  chronic  irritation  in  producing 
these  growths.  Their  common  occurrence  in  the  larynx  of  singers  is  another 
proof  of  the  same  effect. 

Fig   248 


I)    0 


Papilloma  of  glans  penis  lo\v  power      (F  C  ^^ood  M  I>  ) 

Clinical  Appearance. — The  growths  may  be  single,  but  more  fre- 
quently they  are  multiple,  and  sometimes  they  occur  in  very  large  numbers. 
On  the  skin  they  may  cover  the  entire  hand  or  the  genitals,  and  they  may 
completely  fill  a  cavity,  as  in  the  larjmx.     Multii^le  papillomata  are  also  the 


\  ? 


^    ' 


i   ; '"-' 


^ 


,-  r 


I.,  Papilloma  of  uniui\  1  I    Uri  11  i    I         111    t  1    1  i   I  h  niigmfied    n  n-utral  blood-vessel- 

(P  C  A\ood  M  D  ) 

rule  in  the  rectum.     In  the  bladder  they  occasionally  attain  a  large  size,  but 
their  bases  are  usually  small.     They  may  be  warty  or  polypoid  in  shape. 

History. — On  the  skin  their  presence  has  no  clinical  significance,  but 
on  the  genitals  they  retain  the  offensive  secretions.     In  the  larynx  they  may 

20 


306  CARCINOMA. 

completely  obstruct  tlie  opening,  and  even  minute  iDapillomata  upon  the 
edges  of  tlie  vocal  cords  may  interfere  with  their  movements  and  cause 
hoarseness  and  loss  of  voice.  In  the  rectum  they  are  serious  mainly  from 
the  discharges  which  they  excite.  Papilloma  of  the  bladder  is  one  of  the 
most  dangerous  of  these  growths,  often  filling  the  entire  bladder,  and  some- 
times sending  processes  down  the  urethra  even  to  the  meatus,  and  the  severe 
and  frequent  hemorrhages  which  take  place  from  its  surfaces  occasionally 
result  fatally.  Papilloma  is  essentially  a  disease  of  youth,  although  it  may 
develop  at  any  age.  The  multii^le  form  in  the  larynx  is  seldom  found 
except  in  children.  Papillomata  may  slough  if  their  nutrition  is  cut  oif  by 
traction  or  twisting  of  the  pedicle.  In  other  cases  they  disappear  sponta- 
neously through  causes  which  are  not  understood,  and  it  is  not  uncommon 
to  see  a  crop  of  warts  develop  and  persist  for  some  months  upon  the  hands 
of  children  and  then  suddenly  disappear.  Like  all  epithelial  growths,  the 
papillomata  are  liable  to  malignant  degeneration  as  the  result  of  con- 
tinued or  increased  irritation.  The  change  most  naturallj^  results  in  the 
formation  of  an  epithelioma,  the  epithelial  cells  beginning  to  burrow  into 
the  basement  membrane,  and  the  process  of  corniflcation  which  belongs 
solely  to  the  suiDcrficial  cells  affecting  the  entire  thickness  of  the  epithelial 
layer.  The  clinical  signs  of  this  dangerous  change  are  induration  of  the  base 
of  the  tumor  and  a  tendency  to  ulceration  and  hemorrhage.  Papilloma  is 
also  liable  to  sarcomatous  degeneration  owing  to  changes  taking  place  in  the 
fibrous  parts  of  its  structure,  and  this  is  especially  true  of  those  j^apillomata 
in  which  the  fibrous  tissue  approaches  a  myxomatous  character. 

Treatment. — Warts  may  be  cauterized  with  strong  acetic  or  nitric  acid. 
Frequent  applications  of  mild  caustics,  such  as  nitrate  of  silver,  are  very 
dangerous,  because  the  constant  irritation  may  result  in  malignant  degen- 
eration. In  papilloma  of  the  genitals  bismuth,  or  boric  acid,  or  some  astrin- 
gent powder,  such  as  calomel,  dermatol,  or  aristol,  may  be  applied,  after 
proper  attention  to  cleanliness.  The  arrest  of  any  genital  discharge  which 
may  be  present  will  often  effect  a  cui'e.  Ligation  of  the  pedicle  has  been 
recommended  in  order  to  remove  these  tumors,  but  it  should  not  be  employed, 
because  there  is  danger  of  infection  from  the  mass  as  it  sloughs  away.  It  is 
far  better  to  excise  the  tumor  and  ligate  any  bleeding  vessel  which  may  be 
found.  The  treatment  of  papilloma  of  the  larynx,  bladder,  and  rectum  is 
described  in  the  chapters  on  those  organs. 

CARCINOMA. 

Carcinoma  is  a  tumor  formed  of  epithelial  cells  contained  in  irregular 
alveoli  formed  by  a  fibrous  stroma,  and  characterized  by  a  tendency  to 
l^enetrate  the  basement  membrane  upon  which  they  grow  and  to  invade  the 
surrounding  tissue.  These  tumors  vary  in  the  arrangement  of  the  stroma 
and  cells,  and  their  structure  and  the  character  of  their  epithelium  corre- 
spond to  those  of  the  part  from  which  they  originate. 

Pathology. — By  studying  the  edges  of  old  ulcers  of  the  legs,  and  the 
glands  of  the  lips  in  the  aged,  or  seborrhoeic  patches  on  the  face,  all  the 
changes  from  normal  epithelium  through  the  stages  of  irritation  to  that  of 
malignant  degeneration  can  be  distinctlv  traced. 


METASTASIS   OF   CARCINOMA.  307 

One  of  the  earliest  changes  in  the  epithelial  cells  tending  to  produce 
these  growths  appears  to  be  a  premature  cornification.  The  young  cells  are 
irregular  in  shape  and  have  a  marked  tendency  to  rapid  reproduction,  as  is 
indicated  by  the  usual  signs  of  karyokinesis.  But  the  most  significant 
change  is  the  tendency  of  the  newly  formed  cells  to  penetrate  the  basement 
membrane  and  to  extend  into  the  corium  of  the  skin  or  into  the  submucous 
layers  in  solid  masses.  When  this  stage  is  reached  the  transformation  is 
complete  and  the  cancer  has  begun.  Clinically  these  changes  show  them- 
selves by  a  hardening  and  thickening  of  the  tissues,  by  a  tendency  to  ulcer- 
ation or  the  formation  of  dry  scabs  on  the  surface,  and  by  the  extension  of 
the  infiltration  beyond  the  original  mass,  and  it  is  by  these  signs  that  the 
diagnosis  must  be  made.  The  induration  is  quite  different  from  that  of 
ordinary  inflammation,  being  more  marked,  having  no  trace  of  oedema,  and 
its  outlines  being  very  sharply  limited. 

Carcinoma  extends  by  a  growth  of  the  epithelial  cells  into  the  surround- 
ing tissue  on  all  sides,  there  being  usually  no  trace  of  encapsulation,  but  the 
method  of  this  extension  is  not  yet  understood.  The  epithelial  cells  multi- 
ply by  karyokinesis,  like  normal  cells.  There  is  a  zone  of  small  round-cell 
infiltration,  which  usually  spreads  beyond  the  most  advanced  line  of  epithe- 
lial cells,  and  a  similar  round-cell  infiltration  is  seen  in  the  stroma  of  the 
tumor,  especially  when  it  is  growing  rapidly.  These  small  round  cells  are 
probably  of  connective-tissue  origin,  and  indicate  an  inflammatory  reaction 
of  the  tissues  against  the  epithelial  invasion.  The  growth  of  the  epithelial 
cells  in  the  alveoli  of  the  tumor  is  out  of  j)roportion  to  their  blood-supply, 
and  the  central  cells  of  each  mass  are  so  far  removed  from  the  vessels  in  the 
stroma  that  they  are  insufficiently  nourished  and  are  liable  to  break  down  and 
produce  softening  or  ulceration.  This  degeneration  may  be  fatty,  colloid, 
or  myxomatous,  and  may  involve  the  stroma  as  well  as  the  epithelial  cells. 
Cysts  may  be  formed  in  the  tumor  by  this  degeneration.  If  the  tumor  grows 
in  the  secretory  glands  it  may  exert  pressure  upon  the  ducts  and  cause 
retention  cysts.  Cystic  carcinoma  is  especially  in  danger  of  inflammatory 
changes;  but  all  carcinomata,  on  account  of  their  poor  blood-supply  and 
insufficient  nutrition,  are  liable  to  inflammation,  and  to  very  rapid  and 
extensive  destruction  in  consequence. 

Metastasis. — These  epithelial  tumors  have  a  strong  tendency  to  spread 
in  the  lymphatic  spaces  and  lymphatic  vessels.  They  may  extend  along  a 
lymphatic  vessel  to  the  nearest  lymph-node,  making  a  continuous  growth 
of  malignant  tissue.  Or  a  cell  of  the  tumor  may  be  carried  on  like  an 
embolus  and  pass  directly  through  the  lymphatic  vessels  without  contami- 
nating them,  as  water  might  pass  through  a  pipe,  and  attack  the  next  lym- 
phatic gland.  When  the  gland  is  infected  with  the  disease  the  epithelial 
cells  grow  freely  in  it,  penetrate  its  capsule,  and  attack  the  surrounding 
cellular  tissue,  and  they  also  spread  onward  through  the  lymiAatic  vessels 
to  the  next  lymph-node  above.  This  is  the  most  common  method  of  exten- 
sion of  malignant  epithelial  growths  ;  but  they  also  invade  the  blood-vessels, 
like  sarcoma.  In  such  cases  the  wall  of  a  vessel,  usually  a  large  vein,  is 
attacked  by  the  tumor,  and  the  epithelial  cells  grow  into  the  lumen  of  the 
vessel,  producing  a  projection  at  that  point,  from  which  isolated  cells  or 


308  METASTASIS   OF  CARCINOMA. 

clusters  of  cells  may  be  detached  by  the  blood-current  and  carried  into  the 
circulation,  and  thus  graft  the  tumor-tissue  in  different  organs. 

The  vessel  involved  is  usually  one  of  the  veins  of  the  general  circulation, 
and  the  blood  must  pass  through  the  right  side  of  the  heart  and  be  filtered 
through  the  lungs  :  hence  tiimors  of  the  lungs  are  very  frequent,  the  infect- 
ing cells  being  caught  in  the  capillaries.  Not  infrequently,  however,  the 
embolus  passes  the  capillaries  of  the  lung  and  goes  onward  to  more  distant 
organs,  passing  through  the  heart  a  second  time.  It  is  most  frequently 
arrested  in  the  liver,  in  the  bones,  and  in  the  brain,  but  no  part  of  the  body 
is  entirely  exempt  from  secoudai-y  tumors.  The  liver,  however,  is  doubly 
exposed  if  the  tumor  be  situated  in  the  region  of  the  portal  circulation,  for 
an  embolus  may  also  be  detached  from  the  tumor  in  those  vessels  and  be 
arrested  in  the  j)ortal  capillaries  of  the  liver.  It  is  not  yet  understood  why 
the  infection  passes  through  the  lung  in  some  cases  without  involving  it. 

Fig.  250. 


'7/ 


L 


I.  Epithelioma  of  the  hand :  a,  slough  covering  ulcerating  area ;  6,  epithelial  pearl,  more  liighly  magnifled 
in  II. ;  c,  round-cell  infiltration  of  subcutaneous  tissue ;  d,  normal  skin,    x  100.    (F.  C.  Wood,  M.D.) 

while  in  others  it  is  arrested  at  this  point.  In  order  to  traverse  the  capil- 
laries of  the  lung  the  masses  which  convey  the  infection  must  be  very 
minute,  as  an  ordinary  epithelial  cell  would  be  arrested  in  them  unless  it 
had  the  power  of  amoeboid  movement.  It  is  possible  that  the  conditions 
for  the  growth  of  these  cells  in  the  lung  capillaries  are  not  so  favorable  as 
elsewhere,  for  the  proportions  of  oxygen  and  carbonic  dioxide,  not  to  mention 
the  more  complicated  compounds  of  the  blood,  are  very  different  in  the 
pulmonary  circulation.     A  purely  mechanical  explanation  has  been  given 


EPITHELIOMA. 


309 


by  some,  who  assume  that  the  foramen  ovale  has  remained  oiieu,  and  that  in 
this  way  the  cells  have  i^assed  directly  from  the  right  side  of  the  heart  to 
the  left  without  traversing  the  i^ulmouary  circulation  ;  but,  even  granting 
that  this  condition  is  j)i'esent  in  a  larger  proportion  of  cases  than  is  usually 
supposed,  it  seems  improbable  that  the  few  cells  circulating  in  the  blood 
would  often  pass  through  this  small  opening. 

Varieties. — The  principal  varieties  of  carcinoma  are  epithelioma,  tubu- 
lar carcinoma,  and  acinous  carcinoma. 

Epithelioma. — Epithelioma  is  a  tamor  formed  of  flat  ("pavement," 
"  squamous")  epithelial  cells  growing  in  globular  or  cylindrical  masses,  the 
cells  at  the  centre  of  each  mass  being  closely  compressed  and  degenerated, 
forming  the  so-called  "epithelial  pearls"  in  the  fully  developed  tumor. 
(Fig.  250.)  A  section  through  tliese  pearls  shows  concentric  zones  of  cells 
like  the  layers  of  an  onion,  the  degenerated  central  cells  being  converted 
into  a  cheesy  mass.  Two-fifths  of  all  the  malignant  epithelial  growths  are 
of  this  structure.  Epithelioma  occurs  wherever  flat  ej)ithelium  is  found, 
on  the  skin,  the  lips,  the  tongue,  and  in  the  oesophagus,  larynx,  vagina, 
cervix  uteri,  and  urethra.  E'earlj^  three-quarters  of  the  tumors  occur  on  the 
face  and  lips.  Epithelioma  may  also  develop  in  the  deep  tissues  of  the  neck 
from  small  dermoid  cysts  or  foetal  remains,  and  on  the  internal  surface  of 
ovarian  dermoid  cysts.  Epithelioma  which  develops  from  congenital  moles, 
warts,  or  nievi  of  the  skin  is  very  malignant,  but  when  it  originates  from 
warts  which  have  appeared  later  in  life  or  from  such  conditions  as  chronic 
ulcers,  lupus,  and  scars,  it  is  the  least  malignant  of  these 
tumors.  (Fig.  251.)  Melanotic  epithelioma  is  quite  rare, 
even  rarer  than  pigmented  sarcoma,  and  it  is  usually  rather 
more  malignant.  Epithelioma  of  the  tongue  grows  rajiidly, 
and  has  a  strong  tendency  to  sfiread  beyond  the  organ,  but 
in  all  other  situations  epithelioma  grows  slowly,  invades  the 
lymjihatic  glands  late,  and  seldom  produces  metastases,  the 
duration  of  life,  even  without  operation,  often  being  several 
years.  In  one  particular  variety  of  epithelioma  known  as 
rodent  ulcer,  or  Jacob's  ulcer,  the  disease  jprogresses  very 
slowly,  lasting  for  ten,  fifteen,  or  twenty  years,  sometimes 
growing  at  one  edge,  while  arrested  and  apparently  healing 
at  another.  It  is  often  difficult  to  prove  the  epithelioma- 
tous  nature  of  this  disease,  althoiigh  epithelial  pearls  can 
generally  be  found  by  a  thorough  search,  and  the  character- 
istic penetration  of  the  basement  membrane  by  the  cells  is 
usually  well  marked. 

Tubular  Carcinoma. — Carcinoma  growing  from  those 
mucous  membranes  which  have  not  pavement  epithelium 
contains  cylindrical  cells  arranged  like  the  tubular  glands. 
Tubular  carcinoma  occurs  in  the  stomach  and  intestines, 
being  most  frequent  at  points  of  narrowing  like  the  pylorus  and  the  ileo- 
cecal valve,  and  also  in  the  sigmoid  flexure  and  the  rectum.     Three-fourths 
of  the  cases  of  cancer  of  the  bowel  occur  in  the  rectum,  and  only  about  two 
per  cent,  of  them  in  the  small  intestine.     Tubular  carcinoma  is  common  in 


Fig.  251. 


Epitlielioma  of 
foot. 


310  ACINOUS  CARCINOMA. 

the  uterus,  beginning  in  the  mucous  membrane.  Cancer  of  the  kidney  is 
always  tubular,  but  this  form  is  rare  in  the  testicle,  where  the  disease  is 
usually  encephaloid  of  the  acinous  type.  Tubular  carcinoma  is  also  found 
in  the  skin,  originating  from  the  sebaceous  and  sweat  glands,  and  it  is  even 
seen  in  some  of  the  acinous  glands,  such  as  the  parotid  and  the  mamma, 
arising  from  the  small  primary  branches  of  the  excretory  ducts  which  are 
lined  with  columnar  epithelium. 

Tubular  carcinoma  may  grow  rapidly  and  form  large  tumors,  but  in 
the  intestine  it  makes  small  tumors  and  tends  to  produce  strictures,  owing 
to  the  contraction  of  the  fibrous  tissue  of  the  stroma  of  the  neoplasm, 
analogous  to  the  shrinkage  found  in  the  atroi^hic  form  of  scirrhus  of  the 
breast.  "Where  this  takes  place  the  mucous  membrane  will  be  found  thick- 
ened and  the  caliber  of  the  intestine  is  very  much  narrowed.  Viewed 
externally  the  bowel  often  shows  no  tumor,  and  may  look  constricted,  as  if 
a  string  had  been  tied  about  it  at  that  point,  the  hard  nodules  being  evident 
only  when  the  gut  is  pressed  between  the  fingers.  The  contracting  form  of 
tubular  carcinoma  is  rather  slow  in  its  growth,  affects  the  glands  late,  and 
is  not  very  apt  to  form  metastases  ;  the  softer  and  rapidly  growing  variety 
has  a  much  more  malignant  character.  These  tumors  run  a  course  of  about 
two  years  fi'om  the  time  when  the  first  symptoms  are  discovered,  unless  life 

Tig  252 


6 
Soft  carcinoma  of  breast,  x  150 :  a,  broken-down  centre  of  a  mass  of  epithelial  cells ;  6,  small  round-cell 
infiltration  of  stroma.    (F.  C.  Wood,  M.D.) 

be  prolonged  by  surgical  treatment.  Metastases  from  cancer  of  the  stomach 
and  intestine  occur  most  frequently  in  the  liver,  and  next  in  the  lungs,  but 
they  have  also  been  fouud  in  the  brain  and  in  the  bones. 

Acinous  Carcinoma.— The  acinous  glands  give  rise  to  carcinomatous 
growths  with  cuboidal  or  many-sided  eijithelium  lying  in  a  stroma  which 


COLLOID  CARCINOMA. 


311 


more  or  less  closely  imitates  the  gland  from  which  they  spring.  This  vari- 
ety occurs  in  the  breast  (Fig.  252),  in  the  thyroid  and  salivary  glands,  and 
in  the  pancreas,  the  ovary,  the  testicle,  and  the  prostate. 

The  proportion  of  the  epithelial  cells  to  the  fibrous  tissue  is  very 
variable.  In  some  cases  the  tumors  are  very  soft,  with  a  scarcely  visible 
stroma  (Figs.  252  and  253),  while  in  others  the  latter  forms  the  important 
part  of  the  tumor,  and  only  isolated  groups  of  epithelial  cells  are  found. 
The  first  variety  is  encephaloid  cancer,  which  grows  rapidly,  makes  large 
tumors,  ulcerates,  infects  the  lymphatics  and  forms  metastases  early,  and 
has  a  short  clinical  course.  If  the  fibrous  tissue  is  well  develoi^ed,  we  have 
the  scirrhus  (Fig.  254),  which,  although  equally  malignant,  is  less  raj)id  in 
its  progress.  When  the  fibrous  stroma  is  very  abundant  and  the  number 
of  cells  is  very  small,  the  so-called  atrophic  scirrhus  is  produced.  In 
atrophic  scirrhus  the  fibrous  tissue  of  the  tumor  seems  to  undergo  constant 
contraction,  lilce  that  seen  in  scars, 
and,  although  the  growth  extends 
by  the  spread  of  the  epithelial  cells 
into   the   surrounding    i)arts,    the 

Fig.  253. 


Cells  of  soft  carcinoma,  highly  magnified :  d,  Scirrhus  of  breast,  X  400.     (F.  C.  Wood,  M.D.) 

stroma ;  e,  cell  In  active  mitosis.    (F.  C.  Wood, 
M.D.) 

contracting  stroma  apparently  interferes  with  the  nutrition  of  the  cells,  so 
that  their  number  is  greatly  diminished  in  the  older  portions.  This  contrac- 
tion actually  reduces  the  size  of  the  organ  in  which  it  develops,  the  latter 
shrinking  away,  so  that  when  the  tumor  is  in  the  breast  the  latter  may- 
become  as  small  as  an  English  walnut,  the  final  result  being  a  fibrous  mass 
containing  a  few  epithelial  cells  scattered  through  it,  all  trace  of  the  gland- 
tissue  being  lost.  This  variety  of  tumor  grows  very  slowly,  running  a  course 
of  from  six  to  ten  years,  with  very  little  tendency  to  ulceration  or  hemor- 
rhage, involving  the  glands  very  late  or  sometimes  not  at  all,  and  forming 
no  metastases.  The  most  common  of  these  varieties  of  acinous  carcinoma  is 
the  scirrhus. 

Colloid  Carcinoma. — Colloid  carcinoma  is  a  rare  variety,  in  which 
the  cells  or  stroma  or  both  have  undergone  extensive  colloid  transformation. 
The  cells  are  of  the  cuboidal  type,  the  stroma  is  tolerably  abundant,  the 
tumors  are  hard,  not  very  lai'ge,  and  are  prone  to  cystic  degeneration. 
These  tumors  are  most  frequently  found  in  the  breast,  their  coiu'se  being  slow 
but  distinctly  malignant. 


312  COLLOID  CARCINOMA. 

Symptoms. — The  most  evident  symptom  of  carcinoma  is  generally  the 
appearance  of  a  tumor,  although  it  may  be  very  small,  or  not  detected  ou 
account  of  its  concealed  situation.  Pain  is  present  in  a  certain  number  of 
cases,  but  only,  as  a  rule,  when  the  nerves  are  directly  pressed  upon  or  when 
the  tumor  has  attained  a  very  considerable  size  or  is  growing  so  rapidly  that 
the  parts  about  it  are  subject  to  great  pressure.  In  a  very  large  number  of 
cases  of  cancer  there  is  no  pain,  and  this  fact  must  be  emphasized,  because 
too  much  reliance  has  been  placed  on  the  existence  of  pain  in  making  the 
diagnosis.  When  the  tumor  has  reached  a  certain  size  ulceration  usually 
sets  in,  and  severe  hemorrhages  may  follow.  A  hemorrhage  which  occurs 
directly  from  the  tumor  is  exceedingly  difficult  to  control  imless  it  yields  to 
Ijressure,  as  uo  ligature  will  hold  in  the  soft  and  friable  tissue.  The  nearest 
lymjihatic  glands  will  usually  be  enlarged,  but  the  time  of  the  beginning 
and  the  extent  of  this  enlargement  vary  greatly  in  the  different  varieties  of 
tumors  and  also  in  individual  cases  of  the  same  tumor.  The  extension  of 
the  tumor  into  the  surrounding  parts  is  shown  by  the  adhesion  of  the  skin 
over  its  surface  or  by  the  fixation  of  the  tumor  to  the  deeper  parts,  due 
to  the  direct  connection  between  the  stroma  and  the  fibrous  tissue  about  it. 

In  the  later  stages  of  malignant  disease  a  condition  of  cachexia  or 
exhaustion  develops,  a  large  part  of  which  is  caused  by  the  actual  pain  of 
the  tumor  and  the  mental  anxiety  excited  by  its  presence,  or  by  its  inter- 
ference with  the  functions  of  some  of  the  important  organs.  Secondary 
tumors  in  the  lungs  or  liver,  and  occasionally  the  primary  growth,  interfere 
with  the  nutrition  of  the  patient  sufficiently  to  account  for  the  anaemia  which 
is  so  marked.  A  yellowish  tinge  of  the  skin  is  frequently  observed,  and 
]nay  be  due  to  the  presence  of  a  secondary  tumor  in  the  liver.  It  was  once 
supposed  that  the  natural  chemical  products  of  these  tumors  produced  a  sort 
of  toxaemia,  but  this  view  is  now  held  by  few,  although  it  has  recently  been 
found  that  the  haemoglobin  of  the  blood  is  actually  diminished  in  quantity, 
even  when  the  tumor  is  small  and  the  patient  is  not  aware  of  its  existence. 
When  the  tumor  has  been  removed  and  two.  or  three  years  have  passed 
without  recurrence,  Mikulicz  claims  that  the  proportion  of  haemoglobin  in 
the  blood  still  remains  below  the  normal.  In  the  cachectic  state  the  number 
of  leucocytes  in  the  blood  is  increased. 

Prognosis. — Death  is  the  inevitable  termination  of  carcinoma,  and  this 
may  be  expected  after  one,  two,  or  three  years,  unless  life  be  prolonged  by 
operation.  The  ultimate  results  of  these  operations  vary  with  the  region 
involved,  being  best  in  epithelioma  of  the  skin  and  of  the  lips,  of  which 
one  can  hope  to  cure  forty  or  fifty  per  cent.  In  cancer  of  the  breast  equally 
good  results  are  claimed.  In  the  rectum  as  high  as  twenty-five  per  cent, 
of  cures  can  be  obtained.  Operations  upon  the  uterus  also  give  very  good 
results,  from  twenty-five  to  fifty  per  cent,  of  cures  being  claimed  by  some 
authorities.  The  results  are  especially  bad  in  the  internal  organs,  as  in  the 
stomach  or  intestines,  because  of  the  difficulty  of  making  an  early  diagnosis  ; 
and  also  in  the  tongue,  because  of  the  unusually  rapid  diffusion  of  the  growth. 
The  results  of  treatment  depend  upon  the  duration  of  the  tumor  at  the  time 
of  bj)eration.  In  order  to  obtain  a  cure  the  operation  must  be  done,  if 
possible,  in  the  first  stage  of  the  disease,  before  the  lymphatics  have  been 


TREATMENT  OF  CARCINOMA.  313 

involved.  In  the  breast,  cures  may  be  expected  in  the  majority  of  cases 
when  the  glands  are  not  seriously  involved,  but  after  the  latter  are  diseased 
only  a  small  proportion  can  be  cured.  In  fact,  it  is  desirable  to  make  the 
diagnosis  of  impending  malignant  disease  and  to  treat  it  before  it  fully 
develops.  This  may  be  done  in  the  case  of  epithelioma  of  the  skin  by 
removing  warts  which  show  signs  of  irritation,  and  treating  patches  of  sebor- 
rhoea  which  are  beginning  to  ulcerate,  or  chronic  ulcers  of  the  leg  which 
show  induration  of  their  edges.  The  breast  should  also  be  removed  after  the 
menopause  when  it  is  the  seat  of  chronic  mastitis  and  similar  conditions. 
Comparatively  small  oj)erations  under  these  circumstances  will  result  in  the 
permanent  cure  or  prevention  of  malignant  disease. 

Treatment. — The  treatment  of  carcinoma  consists  in  radical  removal 
not  only  of  the  original  tumor,  but  of  all  the  involved  lymphatic  glands  and, 
if  possible,  the  intervening  parts  through  which  the  lymphatic  vessels  run. 
The  reason  is  evident  from  the  description  already  given  of  the  mode  of 
extension  of  the  growth,  and  the  rule  holds  in  spite  of  the  rare  instances  in 
which  enlarged  glands  have  been  left  when  the  tumor  was  removed  and 
have  been  observed  to  disappear  afterwards  ;  or  the  cases  in  which  no  recur- 
rence has  taken  place,  although  when  the  tumor  and  the  glands  were  removed 
the  tissue  between  them  (containing  lymphatic  vessels  exposed  to  the  disease) 
was  left  untouched.  The  enlargement  of  the  glands  noted  in  the  iirst- 
mentioned  cases  was  undoubtedly  inflammatory  and  not  true  malignant 
infection,  and  the  success  in  the  second  class  of  cases  is  to  be  ascribed  to 
the  fact  that  the  lymphatic  vessel  had  escaped  contamination  although  the 
glands  had  been  involved.  The  boundaries  of  the  growth  of  carcinoma  are 
not  easy  to  determine  witJi  the  naked  eye,  therefore  abundant  allowance 
should  be  made  by  removing  with  the  tumor  a  wide  zone  of  the  healthy 
tissue  in  its  neighborhood.  The  amount  of  healthy  tissue  to  be  removed 
will  depend  upon  the  size  of  the  tumor  and  its  situation,  while  a  knowl- 
edge of  the  anatomy  of  the  lymphatics  and  blood-vessels  will  indicate  the 
direction  in  which  the  greater  amount  of  tissue  must  be  removed.  In 
general  it  may  be  said  that  infected  or  adherent  skin  must  be  avoided  by  at 
least  two  inches  in  the  removal  of  large  tumors,  and  half  that  distance  in 
the  removal  of  small  ones.  We  may  rely  upon  a  margin  of  only  one-quarter 
of  an  inch  in  minute  epitheliomata  of  the  face,  where  scarring  is  of  impor- 
tance, but  in  larger  tumors  or  in  other  situations  not  less  than  one  inch 
will  answer.  The  fibrous  layers,  of  aponeuroses  sometimes  form  a  natural 
barrier  to  the  neoplasm ;  thus,  in  the  breast,  the  fascia  over  the  pectoral 
muscle  will  prevent  extension  inward  for  a  time.  In  the  limbs  when  there 
is  extensive  involvement  of  the  soft  parts  and  the  glands  are  clearly  infected, 
amputation  should  be  done,  if  possible,  above  the  mass  of  involved  glands, 
as  it  is  not  safe  to  leave  the  intermediate  tissue. 

While,  as  a  rule,  it  is  unwise  to  attempt  any  operation  on  tumors  which 
cannot  be  completely  removed,  there  are  cases  in  which  life  can  be  prolonged 
or  comfort  secured  by  such  palliative  operations.  It  is  claimed  by  many 
surgeons  of  experience  that  incomplete  operations  ujjon  malignant  tumors 
hasten  their  growth,  but  the  evidence  upon  which  this  is  founded  is  not 
entirely  satisfactory,  and  there  is  room  for  the  individual  judgment  of  the 


314  MIXED  TUMORS. 

surgeon  as  to  when  he  should  operate  upon  cases  of  this  description.  A 
large  ulcerating  tumor  of  the  breast,  for  instance,  may  be  removed  when 
there  is  no  hope  of  a  cure,  in  order  to  rid  the  patient  of  the  discomfort  of 
the  tumor.  Metastatic  growths  should  never  be  operated  upon,  except  for 
the  same  reason,  for  other  secondary  growths  will  probably  be  found,  and 
there  is  no  hope  for  a  radical  cure.  This  rule,  however,  should  not  be  held 
to  exclude  operations  for  a  tumor  of  the  remaining  breast  after  the  other 
has  been  removed,  because  the  tumor  in  the  second  breast  is  rarely  meta- 
static, and  it  is  to  be  considered  as  a  primary  tumor  of  another  organ. 

MIXED  TUMOES. 

Certain  tumors  are  formed  of  a  great  variety  of  tissues,  but  chiefly  of 
the  connective-tissue  group,  growing  together  without  definite  arrangement. 
They  contain  fibrous,  fatty,  and  myxomatous  tissues,  strijsed  muscle,  carti- 
lage, newly  formed  blood-vessels,  and  masses  of  endothelial  and  epithelial 
cells.  It  is  probable  that  all  the  reported  rhabdomyomata  were  mixed 
tumors  which  were  not  thoroughly  examined.  They  are  of  early  foetal 
origin,  for  there  can  be  no  doubt  that  they  grow  from  embryonic  cells 
separated  from  their  proper  position  in  the  fcetus  at  such  an  early  period 
that  the  cells  are  not  completely  differentiated,  and  are  able  to  produce  any 
variety  of  the  mesoblastic  tissues.  Wilms  supposes  that  the  cells  of  these 
tumors  originate  from  the  mesenchyme,  the  tissue  lying  between  the  dif- 
ferent layers  of  the  embryo.  But  it  is  possible  for  epithelial  cells  also  to 
be  included,  originating  from  the  embryonic  kidney  or  the  Wolffian  body 
when  the  mixed  tumor  is  in  the  kidney  or  the  pelvic  organs.  When  mixed 
tumors  occur  in  the  kidney,  however,  Wilms  agrees  with  those  who  ascribe 
their  origin  to  the  peculiar  genital  power  of  the  sperm  cells  (as  in  dermoid 
tumors  of  the  testicle  or  ovary),  by  which  power  they  are  enabled  to  produce 
all  of  the  tissues,  both  connective  and  epithelial,  without  regard  to  the 
layer  from  which  they  spring.  In  other  places  than  the  kidney  and  genito- 
urinary organs,  epithelial  cells  occur  very  rarely  in  the  mixed  tumors,  the 
cells  often  mistaken  for  epithelial  cells  being  endothelial  cells.  The  mixed 
tumors  are  encapsulated  and  simply  displace  without  infiltrating  the  tissues, 
of  the  organ  in  which  they  grow. 

Mixed  tumors  are  most  frequently  found  in  the  salivary  glands,  especially 
the  parotid,  in  the  lips,  mouth,  and  jaws  ;  in  the  kidney,  the  testicle,  the 
vagina,  and  other  pelvic  organs.  They  make  their  appearance  in  infancy 
or  about  puberty.  They  present  every  grade  of  variety  from  innocent 
tumors  which  grow  slowly  for  a  lifetime,  to  rapidly  growing  sarcomata 
which  cause  death  in  a  few  months.  The  parotid  tumors  are  the  most 
innocent  of  the  group,  and  those  of  the  kidney  and  vagina  the  most  malig- 
nant. The  latter  are  cauliflower  growths.  The  renal  tumors  grow  within 
the  capsule  of  the  kidney,  displacing  and  flatteniug  out  the  latter  on  one 
side,  or  evenly  over  the  tumor  if  the  neoplasm  is  growing  towards  the  pelvis. 
Metastasis  is  not  common,  even  in  the  true  sarcomata.  But  the  slowly 
growing  parotid  tumors  not  infrequently  suddenly  or  slowly  become  malig- 
nant, so  that  unless  there  are  serious  objections  to  operative  interference, 
thorough  removal  is  to  be  advised.     An  operation  must  be  insisted  upon  as 


CYSTS.  315 

soon  as  evidences  of  malignancy  appear.     We  refer  to  the  sections  on  the 
various  organs  mentioned  for  the  clinical  history  and  detailed  treatment  of 

these  tumors. 

CYSTS. 

A  cyst  is  a  tumor  containing  fluid  surrounded  by  a  capsule,  either 
organized  or  accidental. 

Pathology. — Cysts  are  variously  produced.  If  the  duct  of  a  gland  or 
hollow  organ  be  occluded  by  the  growth  of  a  tumor,  by  cicatricial  contrac- 
tion, or  by  swelling  due  to  inflammation,  the  organ  may  become  distended 
and  form  a  cyst.  These  are  called  retention  cysts,  and  include  hydro- 
nephrosis, hydrops  of  the  gall-bladder,  sebaceous  cysts,  mucous  cysts,  and 
lacteal  cysts.  Solid  tumors  may  break  down  and  soften  in  the  centre,  their 
contents  becoming  fluid,  and  the  remaining  j)art  of  the  tumor  being  flat- 
tened out  by  the  pressure  of  this  fluid  until  it  forms  a  thin  layer,  and  thus  a 
cyst  may  be  produced.  Finally,  a  true  neoplasm  of  a  cystic  nature  may  de- 
velop, like  the  cysts  produced  in  the  ovaries,  where  the  cells  lining  the  fol- 
licles take  on  an  active  growth  and  the  capsule  enlarges,  keeping  pace  with 
the  increase  of  the  contents.  Cysts  of  this  nature  are  usually  congenital,  and 
are  really  analogous  to  the  retention  cysts,  because  they  represent  glandu- 
lar structures  in  which  the  outlet  for  the  natural  escape  of  the  secretion  has 
been  cut  off.  Cysts  are  also  formed  from  old  hemorrhages,  the  clot  being- 
absorbed  in  part  and  its  place  being  takeu  by  serum  which  exudes  from  the 
sides  of  the  cavity.  Cysts  may  also  be  produced  by  dilatation  of  serous 
cavities  such  as  the  bnrste.     Congenital  cysts  have  already  been  described. 

Sebaceous  Cysts. — Sebaceous  cysts  are  found  anywhere  in  the  skin 
where  the  sebaceous  glands  exist,  and  seem  to  be  caused  by  an  obstruction 
of  the  duct,  although  very  frequently  the  latter  is  free  enough  to  allow  the 
escape  of  the  contents  if  considerable  pressure  be  put  upon  them.  The  cause 
of  this  obstruction  may  be  inspissated  secretion  or  a  cicatricial  contraction 
about  the  canal.  Sebaceous  cysts  are  most  common  upon  the  scalp  and  upon 
the  back,  particularly  at  the  nape  of  the  neck.  They  vary  in  size  from  a  pin's 
head  to  a  man's  fist,  although  they  are  seldom  larger  than  an  egg.  They  form 
tense  or  soft  fluctuating  tumors,  covered  by  normal  skin,  which  is  usually 
somewhat  adherent,  particularly  in  the  centre,  where  the  original  duct  is 
found.  These  cysts  are  very  liable  to  inflammation,  and  form  abscesses, 
which  may  leave  a  sinus.  If  the  sinus  closes,  the  cyst  is  liable  to  form  again. 
The  contents  of  these  cysts  are  the  ordinary  sebaceous  matter  secreted  by  the 
gland.  The  wall  of  the  cyst  is  formed  of  the  fibrous  capsule  of  the  distended 
gland  and  is  lined  with  flat  epithelium,  the  normal  cuboidal  epithelium  of 
the  sebaceous  gland  being  flattened  by  pressure. 

Treatment. — The  treatment  of  these  cysts  is  excision,  and  the  entire 
capsule  must  be  removed,  or  the  epithelial  cells  which  line  it  will  reproduce 
the  tumor.  When  the  cyst  is  not  yet  adherent  to  the  surrounding  parts  its 
removal  is  easy,  a  simple  incision  being  made  in  the  skin  and  the  sac  being- 
extirpated  unopened,  but  if  there  are  adhesions  the  removal  may  be  more  dif- 
ficult. In  such  a  case  it  is  well  to  make  two  short  incisions  at  the  edge  of  the 
sac  on  opposite  sides,  so  as  to  introduce  a  blunt  instrument  and  work  up 
towards  the  apex  of  the  sac,  where  the  adhesions  are  usually  strongest.    It  will 


316  CYSTS. 

often  be  possible  to  enucleate  the  sac  under  the  skin,  and  then  the  skin  can 
be  completely  divided  over  the  apex  of  the  sac  and  the  latter  lifted  out.  If 
the  sac  ruptures  it  is  best  to  cut  entirely  through  the  tumor,  dividing  the 
sac  into  two  halves.  The  contents  are  wiped  out,  and  the  divided  edge  of 
the  sac  at  the  bottom  is  seized  with  a  strong  pair  of  forceps  and  each  half 
twisted  out  of  the  wound.  This  method  has  the  disadvantage  of  bringing 
the  contents  of  the  sac  in  contact  with  the  wound,  and,  although  they  are 
not  actually  septic  unless  inflammation  has  set  in,  they  are  apt  to  prevent 
primary  union. 

Mucous  Cysts. — Cysts  similar  in  structure  to  the  sebaceous  cysts  are 
fovmd  on  the  mucous  membranes,  the  only  difference  being  in  their  contents 
and  in  the  mucous  character  of  the  epithelium  which  lines  them.  They 
usually  have  thin  walls,  and  a  single  application  of  a  strong  caustic  suiiices, 
as  a  rule,  to  obliterate  the  epithelial  lining  and  effect  a  cure,  although  they 
may  also  be  dissected  out.  They  are  most  frequently  found  on  the  inner 
surface  of  the  lips.  They  sometimes  become  inflamed  and  burst,  and  a 
spontaneous  cure  may  result,  but  a  recurrence  is  likely  to  follow. 

Betention  cysts  formed  by  the  gall-bladdei;  kidney  (hydronephrosis),  or  by 
obstruction  of  the  ducts  of  the  mammary  gland,  will  be  described  with  those 
organs.  Ovarian  cysts,  congenital  cysts  of  the  Mdney,  and  cysts  of  the  thyroid 
gland  will  also  be  found  in  the  proper  sections.  Congenital  cysts,  dermoid, 
branchial,  and  others  are  described  on  page  270,  et  seq.  Cystic  degeneration  is 
very  common  in  many  tumors,  but  does  not  alter  their  course  or  character, 
except  that  their  growth  is  apt  to  be  rather  more  rapid  under  these  circum- 
stances. We  have  already  described  this  change  in  fibroma,  lipoma,  lym- 
phangioma, sarcoma,  adenoma,  and  carcinoma.  The  character  of  the  solid 
part  of  these  tumors  determines  their  nature  and  history. 


CHAPTEEXIX.      - 

SURGERY  OF  THE  LYMPHATIC   SYSTEM. 
By  B.  Parquhae  Cuhtis,  M.D. 

Injuries.^ — Wouuds  of  the  lymi^hatics  may  result  in  extravasation  of 
lympli  or  the  formation  of  fistiilfe.  Injury  of  the  main  thoracic  duct  causes 
deatli  by  loss  of  the  chyle,  or  by  rupture  of  the  receptaculum  chyll  if  the  duct 
becomes  occluded,  unless  there  is  unusually  free  anastomosis  by  other 
branches.  Partial  division  of  the  duct  in  the  neck  may  be  treated  like 
wounds  of  veins  by  suture  or  lateral  ligature. 

Obstruction  of  the  Lymphatics. — Obstruction  of  the  lymphatics  is 
seen  more  frequently  as  the  result  of  inflammation  than  of  injury,  manifest- 
ing itself  by  dilatation  of  the  larger  vessels  and  hypertrophy  of  the  skin 
and  subcutaneous  tissues,  producing  the  condition  known  as  elephantiasis, 
(Pig.  255.)  The  skin  is  rough,  and  the  papillae  and  folds  are  thickened, 
with  a  tendency  to  the  production  of  warty 
outgrowths.    The  subcutaneous  tissue  is  thick-  Fin.  25(i. 

ened,  resembling  oedema,  but  not  ijitting  upon 
pressure.  In  rare  instances  the  bones  are 
also  hypertrophied.    The  most  frequent  situa- 


Elephantiasis  of  the  leg  fiom  chrome  ulcer 
and  inflammation. 


Elephantiasis  Aratium  of  the  genitals  and 
lower  extremities.    (Harte.) 


tion  of  this  lj^mj)hatic  overgrowth  is  on  the  lower  extremities  and  the 
genitals,  although  it  has  been  observed  on  the  upper  extremities.  The 
hypertrophy  may  reach  such  an  extent  as  to  make  the  limb  several  times  its 
normal  diameter,  while  the  huge  folds  of  the  skin  add  to  the  deformity. 

317 


318  LYMPHANGITIS. 

This  condition  is  sometimes  produced  by  the  presence  of  parasitic  filaria 
in  the  blood,  which  enter  and  occlude  the  lymph-vessels,  and  is  then  known 
as  true  elephantiasis,  or  elephantiasis  Arabum.  (Fig.  2.56.)  In  many 
cases  this  hypertrophy  is  present  at  birth  or  develops  immediately  after, 
implying  a  congenital  occlusion  or  insufficiency  of  the  lymph-channels. 
The  dilated  lymphatic  vessels  are  rarely  large  enough  to  be  of  importance 
externallj^,  for  the  so-called  lymph-sacs  of  the  neck  develop  from  lymphangi- 
omatous  tumors  and  are  cysts  rather  than  dilated  vessels.  Internally,  how- 
ever, cysts  of  large  size  may  form  in  the  mesentery  from  dilatation  of  the 
chyle -vessels,  giving  the  usual  symptoms  of  abdominal  cysts  and  necessitating 
operation. 

Lymphatic  Pistulse. — When  a  large  lymphatic  vessel  is  divided  it 
sometimes  fails  to  heal,  and  a  tistula  is  produced,  which  discharges  lymph 
uj)on  the  surface  of  the  skin.  The  most  common  situation  of  lymphatic 
fistulfe  is  in  the  groin.  They  are  of  little  clinical  significance  ax^art  from 
the  annoyance  caused  by  the  constant  moisture  of  the  parts.  A  fistula  caused 
by  injury  of  the  thoracic  duct  or  its  branches  in  the  neck  may  result  in 
death  by  starvation  from  loss  of  the  chyle.  In  some  cases  there  is  sufficient 
anastomosis  to  carry  the  chyle  into  the  veins,  and  the  tistnla  may  be  suc- 
cessfully treated  by  exjjosing  the  injured  duct  by  dissection  and  ligating  the 
vessel  or  packing  the  wound  with  gauze  until  cicatrization  closes  the  vessel. 

Lymphangitis.— Inflammation  of  the  lymphatics,  or  lymphangitis,  may 
occur  in  the  acute  or  the  chronic  form,  with  or  without  a  perilymphangitis. 
When  the  superficial  vessels  are  affected,  a  jjink  line,  associated  with  local- 
ized tenderness,  marks  their  course  uijon  the  skin,  as  is  frequentlj'  seen  when 
infection  extends  up  the  arm  from  the  hand.  A  deep  lymphangitis  may  give 
no  signs  externally.  In  the  chronic  form  the  vessel  is  felt  as  an  insensitive 
cord,  in  which  the  beads  produced  by  its  valves  can  sometimes  be  distin- 
guished, rolling  under  the  finger  beneath  the  skin.  This  condition  is  found 
in  the  penis  in  primary  syphilis.  The  inflammation  may  end  in  resolution, 
or  result  in  numerous  points  of  suppuration.  The  treatment  consists  in 
wet  dressings  or  xjoultices  in  the  acute  stage,  and  counterirritation  with 
iodine  or  the  thermo-cautery  in  the  chronic.  The  part  must  be  ]3laced  at 
rest,  any  limb  which  may  be  affected  being  secured  on  a  splint. 

Lymph-Nodes. — The  lymph-nodes,  known  also  as  glands  or  ganglia, 
act  as  filters,  arresting  solid  particles,  bacteria,  and  even  the  chemical 
imi)iarities"of  the  lymph,  and  purifying  the  latter  as  it  passes  through  them. 
They  are,  therefore,  often  involved  in  case  of  infection,  although  they  seem 
to  possess  great  resisting  powers  and  prevent  the  spread  of  the  infection  to 
parts  beyond,  or  at  lea;st  hinder  its  advance  until  they  are  themselves  over- 
whelmed by  the  poison.  When  their  resisting  power  is  overcome,  in  siip- 
purative  inflammations  they  form  abscesses,  in  the  chronic  granulation- 
inflammations  they  become  infiltrated  with  tuberculous  or  syphilitic  tissue, 
and  in  neoplasms  they  develop  the  characteristic  tissue  of  the  tumor  con- 
cerned. Early  removal  of  the  infected  glands  will  often  prevent  septictemia 
when  there  is  a  septic  inflammation  of  a  limb  ;  and  whenever  a  malignant 
neoplasm  is  extirpated,  the  nearest  glands  should  also  be  removed,  because 
they  are  generally  involved. 


LYMPH-NODES.  319 

Inflammation. — Inflammatory  enlargement  of  the  glands,  or  lymph- 
adenitis, whatever  its  cause,  is  shown  by  the  growth  of  those  glands  which 
were  previously  evident  and  the  appearance  of  some  formerly  too  small  to 
be  detected.  A  considerable  number  of  glands  are  apt  to  be  affected,  begin- 
ning in  the  region  nearest  to  the  primary  source  of  infection.  At  first  they 
are  freely  movable  under  the  skin  and  on  the  deeper  parts,  but  if  suppura- 
tion occur  the  inflammation  may  spread  to  the  neighboring  cellular  tissue, 
and  they  then  become  fixed  and  the  overlying  skin  becomes  adherent  and 
reddened.  Pain  will  usually  appear  at  this  time,  if  not  already  present. 
The  inflammation  may  terminate  in  resolution,  in  which  case  the  giaud  may 
return  to  its  original  size  or  may  remain  permanently  enlarged  by  the  new 
tissue  formed  as  the  result  of  the  infection. 

Abscess. — In  abscesses  arising  from  the  lymph-glands  it  is  important 
to  distinguish  between  the  acute  and  the  chronic,  and  especially  to  determine 
the  form  of  infection.  The  acute  supijuration  caused  by  some  virulent  septic 
infection  may  be  of  the  most  threatening  nature,  especially  if  the  glands  lie 
deep  under  some  strong  fascia,  as  in  that  form  of  cellulitis  of  the  neck 
known  as  Ludwig's  angina;  and,  on  the  other  hand,  the  abscess  which 
forms  from  a  tuberculous  gland  has  all  the  mildness  of  a  cold  abscess.  It  is 
also  important  to  distinguish  between  a  simple  adenitis  and  one  complicated 
by  a  periadenitis,  the  pus  being  contained  in  the  capsule  of  the  gland  as  if 
in  a  sac  in  the  first  case,  whereas  there  may  be  a  diffuse  infiltration  of  the 
surrounding  cellular  tissue  in  the  second.  Cold  abscesses  are  not  without 
danger,  for  the  vessels  with  which  they  come  in  contact  may  be  attacked, 
especially  at  their  forks  or  where  they  are  exposed  to  pressure  in  the  flexures 
of  the  joints.  The  wall  of  the  vessel  may  be  simply  dissolved  by  a  pro- 
cess known  as  arrosion,  or  a  fibrous  degeneration  may  be  set  up  in  the  mus- 
cular coat.  Glandular  abscesses  show  this  tendency  most  frequently  in 
persons  exhausted  by  disease,  especially  in  the  convalescence  from  scarlet 
fever,  which  appears  to  have  a  very  injurious  effect  on  the  glands.  The 
Ijossibility  of  such  changes  in  the  vessels  makes  it  necessary  to  exercise 
great  care  in  opening  these  abscesses,  for  the  sudden  removal  of  external 
pressui-e  may  be  followed  by  the  bursting  of  a  weakened  wall  in  a  large 
vein,  or  even  in  an  artery,  with  a  fatal  hemorrhage.  When  this  accident 
occurs  it  is  very  difficult  to  secure  the  injured  vessel,  owing  to  its  depth  and 
to  the  diseased  nature  of  its  wall,  and  it  may  be  necessary  to  ligate  it  at  a 
distance.  The  glandular  abscesses  may  undergo  absorption,  or  the  pus  may 
be  converted  into  a  stringy,  almost  clear,  fluid,  forming  a  sort  of  cyst ;  but 
these  terminations  are  rare.  More  common  is  the  calcification  of  glands 
which  contain  minute  foci  of  pus  or  degenerated  tissue.  The  manner  in 
which  glandular  abscesses  discharge,  if  left  to  themselves,  is  characteristic. 
The  pus  is  very  slow  in  reaching  the  surface,  fluctuation  being  evident  long 
before  the  skin  sloughs.  A  very  small  opening  forms  in  the  centre,  and  the 
discharge  persists  for  a  long  time.  The  opening  is  usually  surrounded  by 
bluish  undermined  skin,  and  unhealthy  granulations  may  protrude  from  it. 
If  there  is  periadenitis  the  remains  of  the  gland  may  be  found  in  the  cavity 
of  the  abscess,  not  much  altered  in  appearance. 

The  diagnosis  between  simple  or  inflammatory  hypertrophy  of  a  gland 


320 


LYMPHATIC  TUMORS. 


aud  sarcoma  attacking  a  gland  is  generally  possible,  even  if  no  marked  signs 
of  inflammation  are  present,  for  in  hypertrophy  there  are  usually  several 
glands  enlarged,  and  a  peripheral  lesion  can  in  most  cases  be  found  to  account 
for  the  infection.  Hypertrophy  is  distinguished  from  malignant  Ij^mphoma 
by  the  fact  that  in  the  latter  several  or  all  of  the  groups  of  lymphatic  glands 
are  involved,  while  in  the  former  only  a  single  region  may  be  aiiected. 

Treatment. — The  resolution  of  inflamed  glands  may  be  favored  by  cold 
wet  dressings,  the  ice-bag,  or  counterirritation  with  iodine  or  the  thermo- 
cautery. Suppuration  demands  incision,  and  the  complete  removal  of  all 
remaining  gland-tissue  by  the  curette  or  the  knife,  in  order  to  prevent  the 
formation  of  troublesome  sinuses.  When  the  infection  is  tuberculous  the 
glands  may  be  excised,  or  when  they  have  formed  abscesses  they  may  be 
incised  and  scraped,  or  aspirated  and  injected  with  iodoform,  as  described 
on  page  66.  Syphilitic  enlargements  will  usually  disappear  under  constitu- 
tional treatment,  although  here  also  extirpation  may  be  necessary  for  very 
large  and  indurated  masses.  "We  have  already  mentioned  the  necessity  for 
the  removal  of  glands  in  septic  inflammation  and  in  malignant  disease. 

The  so-called  scrofulous  diathesis  undoubtedly  predisposes  to  hypertro- 
phy of  the  lymph-nodes,  even  when  no  characteristic  tuberculous  change 
can  be  found  there  or  elsewhere  in  the  body,  and  in  such  iudividuals  the 
glands  should  be  removed  as  soon  as  they  enlarge,  unless  great  numbers  of 
them  are  hypertrophied.  It  is  generally  wise  to  remove  hypertrophied 
glands  as  soon  as  it  is  evident  that  they  will  not  resolve,  for  if  tuberculous 

they  are  a  constant  menace  of  consti- 
Fio.  257.  ■  tutional  infection,  and  are  also  much 

more  diificult  to  cure  after  suppura- 
tion has  taken  place.  When  chronic 
sinuses  have  formed  as  the  result  of 
adenitis,  thorough  lemoval  of  the 
broken-down  gland  by  curetting  or 
excision  is  usually  necessary  to  a  cure. 
Tumors. — While  the  other  tu- 
mors of  the  lymphatic  nodes  are  else- 
where described,  it  will  be  well  to 
consider  in  this  place  the  peculiar 
disease  known  as  malignant  lymphoma. 
or  Hodgkin's  disease.  (Fig.  257.) 
Multiple  enlargement  of  the  glands 
is  found  in  leukaemia,  but  in  Hodg- 
kin's disease  the  blood  appears  to  be 
normal,  and  the  latter  for  that  reason 
has  been  called  pseudoleukaemia.  In 
malignant  lymphoma  one  group  of 
glands  enlarges  without  apparent 
cause,  usually  in  the  neck  or  in  the 
axilla,  and  the  process  then  spreads  to  other  groups,  including  the  internal 
glands,  especially  those  of  the  mediastinum.  The  patient  becomes  cachectic, 
feverish,  suffers  from  diarrha?,a,  and  gradually  fails ;  and  at  autopsy  it  is 


Malignant  lymphoma,  or  Hodgkii 


STATUS  LYMPHATICUS.  321 

found  that  there  has  been  a  metastasis  to  the  lungs,  liver,  and  other  organs. 
The  tumors  may  be  formed  of  soft  tissue  like  the  ordinary  hyxjerplastic 
lymph-gland,  or  of  a  dense,  hard,  fibrous  tissue  with  spindle-cells,  as  if  the 
connective-tissue  stroma  of  the  glands  had  increased  and  caused  the  dis- 
appearance of  the  softer  parts.  Nothing  is  known  of  the  etiology  of  this 
disease,  nor  can  anything  be  done  in  the  way  of  treatment. 

Status  Lymphaticus. — There  is  a  condition  marked  by  persistence 
of  the  thymus  gland,  hyperplasia  of  the  lymphatic  glands,  especially  of  the 
pharyngeal  (tonsils),  bronchial,  and  mesenteric  glands,  moderate  enlarge- 
ment of  the  spleen  and  thyroid  glands,  a  foetal  condition  of  the  bone-marrow, 
and  poor  development  of  the  heart  and  blood-vessels.  In  some  cases  the 
blood  shows  a  marked  lymphocytosis.  This  disease  is  known  as  status  lym- 
phaticus. It  is  important  to  the  surgeon,  as  many  sudden  deaths,  chiefly 
during  chloroform  anaesthesia  for  operations  upon  adenoids  or  the  thyroid 
gland,  have  occurred  in  persons  so  affected.  While  most  frequent  in  the 
young,  it  is  found  also  in  later  life.  The  thymus  may  be  very  large,  but  the 
deaths  are  uot  caused  Ijy  the  mechanical  effects  of  its  presence,  for  the  fi^tal 
symptoms  are  those  of  shock. 


CHAPTEE   XX. 

SURGERY    OF    THE    BLOOD-VESSELS. 
By  Henry  E.  Wharton,  M.D. 

injueies  op  arteries. 

Arteries  may  suffer  from  contusion,  or  from  lacerated,  punctured,  and 
incised  wounds. 

Contusion  of  Arteries. — This  form  of  injury  is  probably  much  more 
common  in  subcutaneous  injuries  than  is  generally  supposed,  as  in  the  case 
of  extensive  contusions  many  arteries  are  necessarily  involved,  but  it  is 
only  when  an  artery  of  considerable  size  is  injured  that  distinctive  symptoms 
arise  by  which  the  nature  of  the  injury  can  be  recognized.  A  severe  local- 
ized contusion  of  an  artery  may  result  in  partial  oi"  complete  laceration  of 
the  inner  and  middle  coats,  the  external  coat  remaining  uninjured  ;  in  con- 
sequence, a  thrombus  forms  in  the  vessel,  and  subsequent  obliteration  of 
the  vessel  at  the  laoint  of  injury  may  occur,  or  the  force  of  the  blood-current 
may  distend  the  external  coat,  giving  rise  to  an  aneurism  or  to  rupture  of 
the  external  coat,  producing  a  diffused  aneurism.  Complete  rupture  of  all 
the  coats  may  follow  contusion  of  an  artery,  which  in  the  smaller  vessels  is 
followed  by  retraction  and  curling  up  of  the  divided  ends,  so  that  little 
blood  escapes,  and  healing  with  obliteration  of  the  vessel  occurs.  In  larger 
vessels  complete  rupture  is  followed  by  the  rapid  escape  of  blood,  with  the 
constitutional  symptoms  of  concealed  hemorrhage,  and  a  tumor  rapidly 
forms  at  the  seat  of  injury,  in  which  slight  pulsation  may  be  discovered. 
The  later  results  of  contusion  of  arteries  depend  upon  the  loss  of  blood- 
supply  to  the  parts  supplied  by  the  injured  vessels,  and  maj^  be  shown  by 
loss  of  color,  by  coldness  of  the  parts,  and  later  by  ulceration  or  gangrene  ;  if 
sloughing  of  the  skin  over  the  tumor  takes  place,  hemorrhage  occurs. 

Symptoms. — If  after  contusion  of  an  artery  jaulsation  immediately  or 
slowly  disaiDpears  from  the  vessel  below  the  seat  of  injury,  it  is  probable 
that  a  thrombus  has  formed,  and  if  sloughing  of  the  vessel  at  the  seat  of 
injury  does  not  occur  and  the  collateral  circulation  is  established,  the  vitality 
of  the  parts  supplied  by  the  vessel  is  retained.  We  have  seen  cases  of  con- 
tusion of  the  brachial  artery  at  the  elbow  and  of  the  femoral  artery  in 
Scarpa's  triangle  followed  by  obliteration  of  these  vessels,  where  the  vitality 
of  the  parts  below  was  maintained.  In  many  cases  so  fortunate  a  result 
does  not  occur  ;  gangrene  may  occur  in  the  parts  supplied  by  the  vessel,  or 
sloughing  of  the  vessel  at  the  seat  of  injury  may  cause  a  diffused  aneurism. 

Treatment. — In  contusion  of  an  artery  followed  by  obliteration  of  the 
vessel,  the  early  treatment  consists  in  putting  the  part  at  rest,  and  the  appli- 
cation of  warmth  to  the  parts  supplied  by  the  occluded  vessel,  to  encourage 
and  maintain  their  vitality ;  if  this  is  secured,  the  patient  should  be  kept 
322 


LACERATION   OF  ARTERIES.  323 

quiet  for  a  few  weeks,  to  allow  the  collateral  circulation  to  be  perfectly 
establislied  and  to  i^ermit  of  the  satisfactory  organization  of  the  blood-clot 
at  the  seat  of  injury.  Contusion  of  an  artery,  followed  by  the  appearance 
of  a  tumor  at  the  seat  of  injury,  with  or  without  pulsation,  and  with  impair- 
ment of  the  circulation  in  the  parts  supplied  by  the  vessel  and  obstruction 
of  the  return  venous  circulation,  should  be  promj)tly  treated  by  the  ex^iosure 
of  the  injured  artery  by  incision  and  turning  out  of  the  blood-clots  which 
largely  produce  obstruction  to  the  return  circulation,  and  the  application 
of  two  ligatures  to  the  injured  artery  at  parts  where  the  vitality  of  its  coats 
is  unimpaired.  If  the  vessel  has  not  been  completely  divided,  its  division 
should  be  completed,  to  permit  of  retraction  of  its  ends..  Esmarch's  elastic 
bandage  will  be  found  very  useful  in  these  cases  in  controlling  the  bleeding, 
and  thus  assist  in  locating  the  point  of  ruptui'e  of  the  artery. 

Laceration  of  Arteries. — Laceration  of  arteries,  even  of  consider- 
able size,  is  usually  accompanied  by  little  primary  hemorrhage,  owing  to 
the  fact  that  the  inner  and  middle  coats  tear  and  curl  up  within  the  artery, 
and  the  outer  coat  is  stretched  beyond  the  limit  of  its  elasticity  and  breaks, 
leaving  a  frayed  edge,  which  falls  over  the  end  of  the  artery  ;  a  blood-clot 
soon  forms  upon  the  roughened  edges  of  the  inner  and  middle  coats,  which 
arrests  the  bleeding  ;  the  i^roximal  end  of  the  vessel  can  often  be  seen  pul- 
sating in  the  wound  almost  down  to  its  extremity,  and  yet  no  blood  escapes. 
Laceration  of  arteries  results  from  the  same  causes  that  produce  laceration 
of  muscles,  nerves,  and  fasciae,  and  is  most  commonly  seen  in  machinery  and 
railroad  accidents  and  in  cases  of  avulsion  of  the  limbs.  Primary  hemor- 
rhage in  laceration  of  arteries,  as  previously  stated,  is  often  insignificant, 
but  if  the  damage  to  the  vessel  has  been  great  enough  to  interfere  with  its 
vitality,  or  if  the  wound  becomes  septic,  sloughing  is  apt  to  take  jilace  and 
secondary  hemorrhage  is  very  likely  to  occur. 

Treatment. — In  an  aseptic  wound  repair  of  a  lacerated  artery  may  take 
place,  and  with  this  i^ossibility  in  view  some  surgeons  recommend  that  a 
case  presenting  such  a  condition  should  be  carefully  watched,  and  that  no 
active  treatment  be  employed  unless  bleeding  occurs.  Although  healing  in 
aseptic  wounds  may  take  place  without  the  occurrence  of  secondary  hemor- 
rhage, we  think  the  treatment  above  mentioned  is  not  to  be  recommended, 
as  it  entails  an  element  of  risk  to  the  patient  which  we  do  not  consider  justi- 
fiable. We  consider  it  a  safer  method  of  treatment  in  the  case  of  laceration 
of  the  larger  arteries  to  secure  both  the  proximal  and  distal  ends  of  the 
vessel  in  the  wound  by  ligatures  applied  to  a  part  of  the  vessel  at  which 
there  is  no  question  as  to  its  vitality ;  the  contused  and  lacerated  ijortiou 
should  be  cut  away  between  the  ligatures. 

Punctured  Wounds  of  Arteries.— These  are  always  serious  inju- 
ries, although  at  the  time  of  their  occurrence  they  may  appear  trivial. 
These  injuries  are  jDroduced  by  stabs  with  sharj)  narrow  knives,  by  splinters 
of  metal,  glass,  wood,  or  bone,  and  by  nails,  needles,  or  any  sharp-pointed 
instrument.  Hemorrhage  in  punctured  wounds  of  arteries  is  apt  to  be  con- 
tinuous, as  the  clot  does  not  extend  into  the  artery  but  is  deposited  outside 
of  it,  and,  as  the  wound  is  a  small  one,  the  blood  cannot  escape,  and  infil- 
trates the  tissues,  causes  pressure  upon  the  veins,  and  interferes  with  the 


324  GUNSHOT  WOUNDS   OF  ARTERIES. 

return  venous  circulation,  or  a  diffused  aneurism  results.  If  the  wound 
has  been  infected  by  the  vulnerating  instrument  or  becomes  septic  later, 
septic  arteritis  d.eve]ops  and  secondary  hemorrhage  is  apt  to  take  place. 

Treatment. — In  vievr  of  the  above-named  complications  which  may 
follow  punctured  wounds  of  arteries,  the  treatment  which  is  most  judicious 
consists  in  exposing  the  artery  freely  by  an  incision  at  the  site  of  the  wound, 
with  due  care  as  regards  asepsis,  and  in  applying  ligatures  to  the  vessel  on 
each  side  of  the  puncture,  and  subsequently  dividing  the  artery  comf)letely 
at  the  site  of  the  puncture,  or  in  suturing  the  wound  of  the  artery.  If  the 
accompanying  vein  has  also  been  punctured  and  bleeds,  it  should  be  secured 
by  two  ligatures  or  by  the  use  of  a  lateral  ligature  or  sutures. 

Incised  "Wounds  of  Arteries.— These  are  among  the  most  frequent 
wounds  of  arteries,  and  may  be  produced  by  accidental  division  by  sharp 
instruments,  or  by  the  surgeon  in  operating.  The  artery  may  be  incised 
longitudinally,  transversely,  or  obliquely.  Longitudinal  wounds  gape  very 
little,  and  may  heal  promptly.  Transverse  wounds,  if  completely  severing 
the  artery,  are  accompanied  by  marked  contraction  of  the  ends  of  the  vessel 
and  their  retraction  within  the  sheath. 

Symptoms. — Incised  wounds  of  arteries  are,  as  a  rule,  accompanied  by 
free  hemorrhage.  In  longitudinal  and  small  incised  wounds  the  primary 
hemorrhage  may  not  be  great,  but,  as  the  lumen  of  the  vessel  is  not  occluded, 
the  bleeding  is  apt  to  be  continuous,  and  a  diffused  aneurism  is  likely  to 
form.  In  incised  wounds  of  small  arteries,  hemorrhage  may  be  arrested  by 
the  formation  of  a  clot  in  the  retracted  end  of  the  vessel.  In  incised  wounds 
of  the  larger  arteries  the  hemorrhage  is  so  profuse  that  a  fatal  result  quicklj^ 
follows.  When  the  main  artery  of  a  part  is  partially  or  completely  divided, 
the  parts  supplied  by  it  become  cold  and  blanched,  and  the  vitality  in  these 
tissues  is  determined  by  the  promptness  with  which  the  collateral  circula- 
tion is  established ;  if  this  is  not  accomplished,  or  is  incompletely  established, 
gangrene  of  the  parts  to  a  greater  or  less  extent  occurs. 

Treatm.ent. — In  incised  wounds  of  arteries  hemorrhage  may  be  con- 
trolled by  torsion  or  the  application  of  ligatures  ;  torsion  seems  most  appli- 
cable to  division  of  the  smaller  vessels ;  in  any  vessel  of  considerable  size 
a  ligature  should  be  applied  to  both  ends  of  the  divided  vessel.  If  the 
vessel  has  been  only  incompletely  divided,  it  should  be  comx^letely  divided 
after  the  ligatures  have  been  applied.  Small  incised  and  lateral  wounds 
of  arteries  should  be  treated  in  the  same  manner.  In  the  treatment  of  a 
wounded  artery,  it  has  always  been  the  rule  that  the  safety  of  the  patient 
demanded  the  obliteration  of  the  vessel  at  the  seat  of  injury.  Eecent 
experimental  investigations  and  clinical  experience,  however,  have  shown 
that  it  is  possible  to  close  wounds  of  arteries  by  sutures,  or  in  cases  of  com- 
plete division  to  invaginate  the  upper  portion  of  the  artery  into  the  lower 
portion,  and  thus  prevent  obliteration  of  the  vessel  at  this  point. 

Gunshot  Wounds  of  Arteries. — These  are  occasionally  seen  in 
civil  practice,  but  are  frequent  in  military  sm'gery.  A  bullet,  according  to 
its  velocity,  may  simply  contuse  an  artery,  may  tear  away  a  portion  of  it, 
or  may  j)erforate  it  or  completely  divide  it.  If  the  vessel  has  been  simply 
contused,  no  hemorrhage  results,  and  if  the  wound  remains  aseptic  the 


HEMOERHAGE.  325 

vitality  of  the  vessel  may  be  retained,  and  repair  take  place  without  marked 
change  in  its  lumen.  Contused  wounds  of  arteries,  if  infection  and  sloughing 
0CCU1-,  are  usually  followed  by  secondary  hemorrhage  within  a  few  days. 
Laceration  or  complete  division  of  the  artery  causes  profuse  primary  hemor- 
rhage, the  blood  escaping  from  the  external  wound,  or  in  wounds  of  deep 
vessels  it  may  be  estravasated  in  the  tissues,  giving  rise  to  a  diffused  aneu- 
rism. Gunshot  wounds  of  large  arteries,  if  complicated  by  wounds  of  the 
accompanying  veins,  are  likely  to  be  followed  by  gangrene.  Gunshot 
wounds  of  arteries  are  often  complicated  by  the  presence  of  foreign  bodies 
driven  into  the  tissues  with  the  ball,  such  as  portions  of  the  clothing,  and 
may  be  further  complicated  by  coincident  fracture  of  the  bones  and  wounds 
of  nerves.  Infection  of  the  wound  may  result  from  the  introduction  of 
foreign  bodies. 

Treatment. — In  gunshot  wounds  accompanied  by  free  hemorrhage,  if 
involving  the  large  vessels  of  the  extremities,  an  Esniarch's  bandage  should 
be  apjjlied,  and  incision  should  be  made  exposing  the  wound  in  the  artery, 
and  the  vessel  should  be  secured  by  two  ligatures  applied  above  and  below 
the  wound  ;  if  the  accompanying  vein  is  only  nicked  or  partially  divided,  a 
lateral  ligature  or  sutures  should  be  applied  ;  if  extensively  injured  or  com- 
pletely divided,  it  should  be  secured  by  two  ligatures  applied  above  and 
below  the  wound.  Where  there  is  little  external  hemorrhage,  but  bleeding 
into  the  tissues,  as  evidenced  by  change  in  color  of  the  limb  and  swelling 
near  the  seat  of  injury,  the  artery  should  be  exposed  by  incision  at  the  point 
of  injury,  the  blood-clot  should  be  turned  out,  and  the  vessel  ligated  as 
l^reviously  described.  If  gunshot  contusion  of  an  artery  is  not  followed  by 
immediate  occlusion  of  the  vessel  at  the  seat  of  injury,  the  part  should  be 
put  at  rest  and  the  wound  kept  aseptic.  Under  such  treatment  repair  may 
take  place  in  the  wounded  artery  without  the  development  of  serious 
symptoms.  If  secondary  hemorrhage  occurs,  the  arterj^  should  be  exposed 
in  the  wound  and  ligated  at  each  side  of  the  wound.  If  this  cannot  be 
satisfactorily  done,  it  should  be  exposed  and  ligated  above  the  wound. 

Traumatic  gangrene  following  a  gunshot  wound  of  an  artery  of  the 
extremities,  if  rapidly  developed,  usually  requires  amputation  of  the  limb 
at  as  high  a  point  as  the  injury  of  the  artery.  If  gangrene  occurs  later,  after 
the  artery  has  been  secured  in  the  wound,  and  is  localized,  the  surgeon 
should  wait  for  the  formation  of  the  lines  of  demarcation  and  sej)aration 
before  resorting  to  amputation. 

HEMORRHAGE. 

Hemorrhage  always  occurs  after  wounds  of  the  blood-vessels,  and  may 
be  so  slight  in  amount  as  to  produce  little  local  or  constitutional  disturb- 
ance, but  if  large  vessels  are  injured  it  may  be  profuse,  and  attended  with 
great  danger  to  life.  The  blood  may  escape  through  an  open  wound,  or 
be  estravasated  into  the  tissues  or  into  some  of  the  cavities  of  the  body. 
In  either  event  the  danger  depends  upon  the  amount  of  blood  which  escapes 
from  the  circulation  and  the  rapidity  with  which  it  is  lost.  Profuse  hemor- 
rhage is  the  most  alarming  and  trying  emergency  that  comes  under  the  care 
of  the  surgeon,  and  its  prompt  and  proper  treatment  requires  presence  of 


326  HEMORRHAGE. 

mind  and  judgment.  In  no  class  of  cases  in  surgery  are  these  attributes  of 
the  surgeon  better  shown  than  in  the  management  of  this  emergency. 

The  varieties  of  hemorrhage  are  classified,  according  to  the  source  of 
the  bleeding,  as  Arterial,  Yenotis,  Capillary,  and  Parenchymatous,  and  also 
according  to  the  time  of  the  bleeding,  as  Primary,  Intermediary  or  Consecu- 
tive, and  Secondary. 

Arterial  Hemorrhage. — This  occurs  from  a  wounded  artery,  and  the 
blood  is  scarlet  in  color,  and  escapes  in  jets  from  the  proximal  end  of  the 
vessel  synchronously  with  the  cardiac  pulsations.  Blood  from  the  distal 
end  of  the  artery  does  not  escape  in  jets,  but  flows  in  a  continuous  stream. 
Although  arterial  hemorrhage  is  generally  characterized  by  a  bright  red 
color,  it  should  be  borne  in  mind  that  in  cases  where  the  proper  aeration 
of  the  blood  does  not  take  place,  and  carbonic  oxide  is  present  in  excess, 
dark-colored  blood  may  escape  from  arteries.  This  is  often  observed  in 
operating  upon  patients  who  present  profound  narcosis  from  an  anaesthetic, 
or  marked  respiratory  obstruction. 

Venous  Hemorrhage. — This  variety  of  hemorrhage  is  characterized 
by  the  escape  of  dark-colored  blood  in  a  continuous  stream  from  the  injured 
vein,  due  to  the  fact  that  there  is  no  cardiac  jpulse  in  the  veins. 

Capillary  Hemorrhage. — In  this  variety  of  hemorrhage  there  is 
oozing  of  blood  from  numerous  points  uj)on  the  surface  of  a  wound,  and, 
although  the  amount  of  blood  escaping  from  each  j)oint  is  small,  if  the 
bleeding  continues  for  any  considerable  time  and  the  wound  surface  is 
extensive,  a  sufScient  amount  of  blood  may  be  lost  to  endanger  the  life  of 
the  patient.  Wounds  of  the  mucous  membranes,  where  the  capillaries  are 
large  and  abundant,  are  often  followed  by  free  caijillary  hemorrhage. 

Parenchymatous  Hemorrhage. — This  occurs  from  wounds  of 
tissues  which  j)resent  certain  anatomical  peculiarities  of  arrangement  of  the 
blood-vessels ;  for  instance,  in  erectile  tissue,  where  the  arteries  terminate 
in  the  veins  without  the  intermediate  cai^illary  system,  or  in  tissues  in  which 
the  normal  vascular  arrangement  is  altered  by  disease.  Parenchymatous 
hemorrhage  is  observed  in  wounds  of  the  spleen  and  of  the  corpora  caver- 
nosa, and  in  organs  whose  structure  is  changed  by  the  presence  of  carci- 
nomatous or  sarcomatous  growths. 

Primary  Hemorrhage.— This  may  be  arterial,  venous,  or  capillary, 
and  occurs  immediately  upon  the  injury  of  the  vessels. 

Intermediary  or  Consecutive  Hemorrhage. — In  this  variety  of 
hemorrhage  the  bleeding  occurs  a  few  hours,  usually  within  twenty-four 
hours,  after  the  operation  or  injury,  when  reaction  is  established,  and  results 
from  detachment  of  occluding  clots  from  the  vessels,  which  are  forced  out 
as  the  arterial  pressure  increases.  Consecutive  hemorrhage  may  also  result 
from  the  detachment  of  improperly  applied  ligatures  and  from  the  disturb- 
ance of  ligatures  by  the  movements  of  the  patient. 

Secondary  Hemorrhage. — This  may  occur  at  any  time  after  twenty- 
four  hours  following  the  wound  of  the  vessel ;  it  is  most  common  from  the 
beginning  to  the  end  of  the  second  week,  and  results  from  incomplete  repair 
of  the  injured  or  ligated  vessel,  or  from  ulceration  of  the  injured  vessel 
due  to  a  septic  arteritis.     This  condition  may  arise  from  the  introduction  of 


CONSTITUTIONAL  SYMPTOMS   OF  HEMORRHAGE.  327 

infective  material  by  tlie  instrument  causing  the  wound,  or  by  an  imxDcr- 
fectly  sterilized  ligature.  Secondary  hemorrhage  may  also  arise  from  rup- 
ture of  a  woxmded  artery  by  increase  of  the  blood-pressure  before  the  cica- 
trix is  firm  enough  to  resist  the  pressure.  Atheroma  of  the  arteries  and 
certain  constitutional  conditions,  as  diabetes  and  advanced  renal  disease, 
diminish  the  resistance  of  blood-vessels  to  septic  infection  and  thus  predis- 
pose to  secondary  hemorrhage.  Secondary  hemorrhage  was  formerly  one 
of  the  most  common  and  dangerous  of  wound  complications,  but  now,  when 
aseptic  healing  of  wounds  is  very  general,  it  is  rarely  seen. 

Constitutional  Symptoms  of  Hemorrhage.— Excessive  hemor- 
rhage is  marked  by  a  rapid,  small,  quick,  and  weak  pulse,  which  may  not 
be  observed  in  the  small  arteries,  such  as  the  radial  or  the  ulnar,  but  may 
be  feebly  felt  in  the  femoral  or  the  carotid.  The  skin  becomes  white,  cold, 
and  bathed  in  sweat ;  the  mucous  membranes  become  blanched.  The 
breathing  is  rapid,  and  the  patient  complains  of  shortness  of  breath  and 
great  thirst ;  nausea  and  vomiting  may  be  present.  The  voice  is  feeble, 
muscular  weakness  is  marked,  the  patient  becomes  restless,  and  has  severe 
cramp-like  pain  in  the  limbs,  convulsions  may  occur,  and  finally  syncope 
develops.  The  temperature  is  subnormal.  In  recurrent  hemorrhage  the 
total  amount  of  blood  lost  may  be  very  great  before  death  occurs ;  the 
patient  loses  blood,  until  syncope  results,  and  then  jjartially  reacts  before 
hemorrhage  recurs.  After  repeated  hemorrhages  the  blood  becomes  thin 
and  watery,  oedema  of  the  eyelids,  scrotum,  and  extremities  is  usually  devel- 
oped, and  the  feeble  action  of  the  heart  may  be  suddenly  ari-ested  if  the 
patient  makes  any  severe  exertion  or  is  raised  suddenly  in  bed.  After 
recovery  from  serious  hemorrhage  there  is  often  developed  a  condition 
known  as  hemorrhagic  fever,  which  is  characterized  by  an  elevation  of  the 
temperature  and  increase  and  u-regularity  in  the  pulse-rate,  thirst,  and 
scantiness  of  the  urine  ;  the  patient  is  in  an  asthenic  condition  and  presents 
marked  disturbance  of  the  nervous  system,  as  shown  by  low,  muttering 
delirium.  The  condition  is  not  the  eifect  of  septic  poisoning,  but  results 
from  the  absoristiou  of  febrin  ferment  and  the  imperfect  supply  of  blood  to 
the  great  nerve-centres.  After  excessive  loss  of  blood  the  patient  is  often 
left  in  an  anfemic  condition,  from  which  he  recovers  very  slowly.  Eecovery 
from  this  condition  is  rarely  complete  in  advanced  life. 

Spontaneous  Arrest  of  Hemorrhage.-— In  a  large  number  of  cases 
spontaneous  arrest  of  hemorrhage  takes  place  before  the  loss  of  blood  is  fatal. 
When  an  artery  is  completely  severed  the  muscular  coat  contracts,  aud  nar- 
rows or  completely  closes  its  orifice  ;  this  contraction  is  due  to  direct  stimu- 
lation of  the  muscular  fibres  of  the  artery.  At  the  same  time  the  divided 
artery  retracts  within  its  sheath ;  the  contraction,  •  which  is  both  circular 
and  longitudinal,  tends  to  narrow  the  orifice  of  the  vessel  and  also  draw  it 
away  from  the  surface  of  the  wound.  The  contraction  and  retraction  of  the 
ends  of  the  divided  artery,  with  narrowing  and  roughening  and  curling  uj) 
of  the  coats,  are  followed  by  the  development  of  a  blood-clot  or  coagulum, 
which  forms  first  in  the  sheath  of  the  artery  and  covers  the  end  of  the  ves- 
sel ;  this  constitutes  the  external  clot.  Blood  also  coagulates  within  the 
divided  artery,  and  often  extends  so  as  to  fill  the  vessel  to  the  first  large 


328  TREATMENT  OF  HEMORRHAGE. 

collateral  brancli ;  this  is  the  internal  clot.     (Fig.  258.)    The  portion  of  the 
clot  which  is  attached  to  the  end  of  the  divided  vessel,  between  the  external 
and  the  internal  clot,  is  known  as  the  central  clot.     The  presence  of  these 
clots  causes  the  temiDorary  arrest  of  the  bleeding,  and 
Fig.  258.  by  their  subsequent  organization  hemorrhage  is  per- 

manently arrested  and  the  artery  is  obliterated  at  the 
seat  of  injury.  Syncope,  which  diminishes  the  cardiac 
action  and  reduces  the  force  of  the  blood-current,  favor- 
ing the  coagulation  of  blood  in  the  divided  vessel,  is 
often  an  important  factor  in  the  spontaneous  arrest  of 
hemorrhage.  Complete  division,  contusion,  or  lacera- 
tion of  an  artery  favors  the  spontaneous  arrest  of  hem- 
orrhage, whereas  incomplete  division  of  the  vessel, 
adhesion  of  the  vessel  to  its  sheath,  movements  of  the 
patient  displacing  the  forming  clot,  and  stimulation 
of  the  heart  all  tend  to  prevent  the  arrest  of  bleeding. 

Coaguliim  in  divided  ar-     -^  n     n         ■  j-i  j.  j.      n  ^ 

tery:  a,  internal,  6,  central    ^^  wounded  veins  the  Spontaneous  arrest  of  hemor- 
c,  external  clot.  rhage  occurs  very  much  in  the  same  manner :   con- 

traction and  retraction  of  the  veins  are  not  marked, 
but  the  walls  of  the  cut  vein  collaiise,  which  serves  the  same  purpose,  and 
the  coagulation  of  blood  takes  i)lace,  forming  an  external,  an  internal,  and  a 
central  clot.  Where  the  walls  of  a  vein  are  attached  to  firm  tissue  and 
cannot  collapse,  as  in  the  venous  sinuses  in  the  skull,  spontaneous  arrest  of 
hemorrhage  cannot  occur.  The  presence  of  valves  in  veins  between  the 
wound  and  the  heart  also  prevents  the  iiow  of  blood  from  the  cardiac  end 
of  the  vein. 

Diagnosis  of  Hemorrhage.— This  is  a  matter  of  little  difficulty  if 
blood  escapes  from  an  open  wound,  but  when  a  vessel  has  been  injured  sub- 
cutaneously,  or  blood  escapes  into  the  great  cavities  of  the  body,  constituting 
what  is  known  as  concealed  hemorrhage,  it  is  often  dilficult  to  recognize 
the  condition.  If  in  the  latter  case  the  escape  of  blood  is  profuse,  the 
patient  soon  exhibits  the  constitutional  symptoms  of  hemorrhage,  which 
are  often  associated  with  the  presence  of  a  swelling,  giving  rise  to  certain 
mechanical  disturbances,  which  lead  the  surgeon  to  the  proper  solution  of 
the  problem.  The  greatest  confusion  is  apt  to  arise  in  cases  of  hemorrhage 
into  the  pelvic,  pleural,  abdominal,  and  cranial  cavities,  where  the  symp- 
toms presented  closely  resemble  those  of  shock ;  and  as  both  conditions 
follow  similar  injuries  and  may  coexist,  their  differentiation  is  often  a 
matter  of  the  greatest  difficulty,  and  the  diagnosis  can  be  arrived  at  only 
by  a  careful  study  of  the  special  symptoms  and  physical  signs  presented  in 
each  case. 

TFvEATMENT   OF   HEMOPvEHAGE. 

Constitutional  Treatment  of  Hemorrhage. — The  first  indication 
in  the  constitutional  treatment  of  hemorrhage  is  to  put  the  injured  part  at 
rest  and  secure  for  the  patient  complete  rest  in  the  horizontal  position,  which 
lessens  cardiac  action,  diminishes  arterial  tension,  and  prevents  cardiac 
exhaustion  and  displacement  of  blood-clots  which  have  formed  in  the  vessel. 

If  hemorrhage  is  taking  place,  this  should  be  controlled  before  attempts 


LOCAL  TREATMENT  OF  HEMORRHAGE.  329 

are  made  to  bring  about  reaction.  After  serious  bleeding  the  temperature 
is  usually  subnormal,  and  the  patient  should  therefore  be  surrounded  by  hot 
cans  or  water-bottles  and  covered  with  woollen  blankets,  to  maintain  the 
temperature  and  bring  about  reaction.  Care  should  be  taken  that  the 
patient  is  not  so  heavily  covered  that  his  respiratory  movements  are  inter- 
fered with ;  while  he  is  warmly  covered,  he  should  be  supplied  with  an 
abundance  of  fresh  air.  The  patient  should  be  given  strychnine  hypoder- 
mically,  gr.  zk,  or  ether,  m  x  to  xx,  and,  as  soon  as  he  is  able  to  swallow,  car- 
diac stimulants,  such  as  tincture  of  digitalis,  carbonate  of  ammonium,  gr.  v, 
whiskey,  or  brandy,  should  be  administered.  The  head  should  be  placed 
low,  to  prevent  syncope,  and  in  extreme  cases,  where  the  tendency  to  cere- 
bral antemia  is  marked,  it  should  be  placed  lower  than  the  body  and  the 
procedure  known  as  auto-transfusion  may  be  practised — the  limbs  being- 
raised  and  firmly  bandaged,  to  force  the  blood  from  them  and  thus  increase 
the  supply  of  blood  to  the  brain.  In  cases  in  which  a  large  amount  of  blood 
has  been  lost  and  the  constitutional  symptoms  of  hemorrhage  are  marked, 
the  intravenous  injection  or  infusion  of  saline  solution,  should  be  practised. 
The  haemostatic  properties  of  gelatin  have  led  to  its  use  in  various  forms  of 
internal  hemorrhage.  A  sterilized  aqueous  solution,  containing  two  per 
cent,  of  gelatin  in  normal  salt  solution,  is  injected  into  the  loose  subcutaneous 
tissue  of  the  abdominal  wall  or  buttock,  about  two  hundred  cubic  centi- 
metres being  used.  Large  enemata  of  hot  water  may  also  be  given  with 
good  results.  Stimulants  should  be  used  cautiously  if  the  bleeding  has  not 
been  controlled  by  ligation  of  the  wounded  vessels,  as  otherwise  their  use 
may  cause  a  renewal  of  the  hemorrhage.  The  drugs  which  may  be  used 
with  most  benefit  are  opium,  ergot,  and  extract  of  suprarenal  capsule. 
The  patient  should  also  be  given  hot  water,  milk,  or  concentrated  beef 
extracts  or  beef  tea. 

Local  Treatment  of  Hemorrhage, — This  consists  in  the  employ- 
ment of  measures  which  either  temporarily  or  permanently  control  the 
bleeding  ;  the  procedure  adopted  in  special  cases  depends  upon  the  size  of 
the  vessel  from  which  the  bleeding  comes,  the  origin  of  the  bleeding, 
whether  arterial,  venous,  or  capillary,  and  whether  it  be  primary  or 
secondary. 

Temporary  Control  of  Arterial  Hemorrhage. — Position. — In  arte- 
rial hemorrhage  from  wounds  of  the  extremities  elevation  of  the  part  will 
diminish  materially  or  arrest  the  bleeding  ;  in  hemorrhage  from  wounds  of 
the  hand,  forearm,  foot,  and  leg,  forcible  flexion  of  the  forearm  on  the  arm, 
or  of  the  leg  on  the  thigh,  will  diminish  the  force  of  the  blood- current. 

Compression. — This  may  be  applied  directly  to  the  bleeding  vessel  in 
the  wound,  or  to  the  main  artery  between  the  wound  and  the  centre  of  circu- 
lation ;  compression  may  be  made  by  the  fingers,  digital  compression,  by 
tourniquets,  by  elastic  constriction,  or  by  hwmostatic  forceps. 

Digital  Compression. — This  constitutes  one  of  the  most  valuable  means 
employed  for  the  temporary  control  of  hemorrhage.  The  finger  or  fingers 
are  pressed  directly  upon  the  bleeding  vessel  in  the  wound,  or  hold  a  com- 
press in  the  wound,  or  make  compression  upon  the  artery  from  which  the 
bleeding  arises  at  some  point  between  the  wound  and  the  centre  of  circula- 


330 


LOCAL  TREATMENT  OF  HEMORRHAGE. 


Digital    compression   of    the 
femoral  artery.    (Agnew.) 


Spanish  windlass  applied  to  the 
femoral  artery.    (Agnew.) 


tiou.     (Fig.   259.)     Control  of  liemorrliage  by  digital  compression  can  be 
maintained  for  only  a  few  minutes,  as  the  fingers  soon  become  tired. 

Compresses. — The  temporary  control  of  arterial  hemorrhage  may  also 
be  secured  by  the  use  of  compresses  placed  directly  in  the  wound  or  applied 

to  the  vessel  from  which  the 
^''  ^°'^  ^^^  ^^°  bleeding  arises,  between  the 

wound  and  the  centre  of  cir- 
culation, and  securely  held 
in  position  by  a  bandage. 
If  a  compress  is  applied  in 
the  wound  it  should  be  made 
of  sterilized  gauze. 

Tourniquets.  —  These 
instruments  are  used  for 
the  temporary  control  of 
hemorrhage,  but  if  their 
use  is  continiied  for  any 
considerable  time  they  are 
apt  to  cause  great  pain,  and 
they  should  be  dispensed 
with  as  soon  as  means  can  be  employed  for  the  permanent  control  of  the 
bleeding. 

The  Spanish  Windlass. — This  is  an  improvised  tourniquet  which  may 
be  employed  in  cases  of  emergency,  and  is  prepared  by  folding  a  handker- 
chief or  a  piece  of  muslin  into  a  cravat  and  placing  a  com]3ress  or  a  smooth 
pebble  in  the  body  of  the  cravat ;  this  is  placed  over  the  artery  to  be  con- 
trolled, and  the  ends  of  the  handkerchief  are  tied  loosely  around  the  limb  ; 
a  short  stick  is  passed  through  this  loop,  and  by  twisting  the  stick  the  loop 
is  tightened  and  the  compress  is  forced  down  upon  the  artery.     (Fig.  260) . 

Petit's  Tourniquet. — This  consists  of  two  metal  plates  connected  by 
a  strong  linen  or  silk  strap  with  a  buckle,  the  distance  between  the  plates 
being  regulated  by  a  screw.  To  apply  this  tourniquet,  a  compress  or  roller 
bandage  is  placed  directly  over  the  artery  and  held  in  j»osition  by  a  few 
turns  of  a  roller  bandage.  The  lower  plate  of  the  tourniquet  is  placed 
directly  over  this  pad,  and  the  strap 

is  securely  buckled  around  the  limb.  Fig.  261. 

The  screw  is  then  turned  so  as  to  sepa- 
rate the  plates  and  tighten  the  strap, 
thus  forcing  the  compress  or  pad  upon 
the  artery  and  controlling  its  circula- 
tion. This  instrument  is  especially  use- 
ful in  controlling  the  circulation  in 
wounds  of  the  extremities,  and  is  often 
emjjloyed  in  amputations  of  these  parts, 
being  placed  over  the  main  artery  some  Elastic  strap. 

distance  above  the  seat  of  operation. 

Elastic  Constriction. — The  elastic  tube  or  strap  of  Esmarch's  appa- 
ratus is  now  very  widely  employed  for  the  temporary  control  of  hemorrhage 


CONTROL   OF  ARTERIAL   HEMORRHAGE. 


331 


Fig.  262. 


Hsemostatic  forceps. 


(Fig.  261),  but,  if  it  is  not  at  hand,  a  very  satisfactory  substitute  may  be 
improvised  from  elastic  suspenders  or  garters,  or  from  a  rubber  drainage-tube. 
In  liemorrhage  from  wounds  of  tlie  extremities,  and  in 
operations  upon  the  bones,  or  for  the  removal  of  tumors, 
or  in  amputations,  elastic  constriction  is  employed  with 
most  satisfactory  results.  By  the  use  of  the  elastic  strap 
or  tube  the  circiilation  can  be  absolutely  controlled  ;  but 
care  should  be  exercised  in  using  this  appliance  to 
adjust  it  with  just  enough  firmness  to  control  the  bleed- 
ing, and  also  to  allow  it  to  remain  in  jDlace  as  short  a 
time  as  possible,  for  from  its  too  firm  application  the 
muscles  have  been  divided,  and  nerve-trunks  have  been 
so  sevei'ely  compressed  that  permanent  paralysis  has 
resulted.  Paralysis  of  the  vasomotor  nerves  following 
elastic  constriction  of  a  part  is  very  common,  and  is 
marked  by  free  capillary  bleeding. 

Haemostatic  Forceps. — The  employment  of  htem- 
ostatic  forceps  for  the  control  of  hemorrhage  during 
oijerations  is  very  general ;  the  forcej)S  is  a  self-retain- 
ing instrument  which  is  clamxsed  upon  the  bleeding- 
vessel  during  the  operation,  and  is  allowed  to  remain 
in  position  until  the  operation  is  completed,  when  the 
vessel  may  be  permanently  secured  by  a  ligature  or  by  torsion.  (Fig.  262.) 
Permanent  Control  of  Arterial  Hemorrhage. — This  may  be  accom- 
plished by  the  use  of  pressure,  cauterization,  the  ligature,  torsion,  or  suture ; 
cold,  heat,  and  styptics  may  also  be  employed  for  this  purxjose. 

Pressure. — Pressure  may  be  employed  to  control  arterial  hemorrhage  by 
means  of  comxDresses  of  antiseptic  gauze  applied  to  the  sm-face  of  the  wound, 
or  by  means  of  strips  of  gauze  packed  firmly  into  the  cavity  from  which  the 
bleeding  arises.  It  may  be  used  with  the  best  results  where  the  proximity 
of  a  bone  furnishes  a  firm  substance  upon  which  the  vessel  may  be  com- 
pressed, as  is  the  case  in  the  vessels  of  the  scalp.  Pressure  applied  by 
strips  of  antiseptic  or  sterilized  gauze  will  be  found  a  most  ef&cient  means 
of  controlling  bleeding  from  cavities  such  as  the  nose,  the  vagina,  or  the 
rectum,  and  in  cavities  resulting  from  the  removal  of  necrosed  bone.  In 
bleeding  from  a  bony  canal,  such  as  the  inferior  dental  canal,  a  piece  of 
catgut  ligature  may  beforced  into  the  canal,  or  a  piece  of  Horsleifs  wax — 
which  is  composed  of  wax,  7  parts ;  oil,  2  parts  ;  carbolic  acid,  1  part — 
may  be  forced  into  the  opening  of  the  bone,  and  will  control  the  bleeding  in 
a  satisfactory  manner.  A  material  known  as  gut  icool  has  been  introduced 
by  Halsted,  which  is  prepared  from  the  same  material  from  which  catgut  is 
made.  This  is  cut  in  strips  and  is  jjacked  into  the  cavity  or  canal  in  the 
bone  from  which  the  bleeding  arises.  If  gauze  packing  has  been  used  to 
control  bleeding,  it  should  be  allowed  to  remain  for  some  days,  until  it 
becomes  loose  by  the  development  of  granulations  in  the  woiind,  when  it 
may  be  removed  without  dif(ici;lty. 

Cauterization. — The  use  of  the  actual  cautery,  applied  by  means  of  the 
hot  iron,  or  Paqueliu's  cautery,  is  an  efficient  means  of  controlling  bleeding. 


332 


CONTROL  OF  ARTEKIAL  HEMORRHAGE. 


Fig.  263. 


Torsion  of  an 
artery. 


The  iron  should  be  only  of  a  dull  red  heat,  as  the  result  desired  is  not  the 
destruction  of  the  tissues,  but  the  coagulating  effect  of  heat.  An  aseptic 
surface  results  from  the  application  of  the  cautery.  The  control 
of  arterial  bleeding  by  cauterization  is  often  made  use  of  in  oper- 
ations upon  bone,  or  in  those  upon  the  mouth,  pharynx,  or  ton- 
sil. It  is  also  employed  to  control  hemorrhage  in  operations 
u]pon  the  uterus  and  the  rectum. 

Torsion. — This  method  of  controlling  arterial  hemorrhage 
consists  in  grasping  the  end  of  the  vessel  with  artery  or  htemo- 
static  forceps,  and  drawing  it  slightly  out  of  its  sheath  and  twist- 
ing it  (Pig.  263)  ;  or  it  may  be  accomplished  by  the  use  of  two 
pairs  of  forceps,  the  vessel  being  held  at  a  little  distance  from 
its  orifice  by  one  pair  of  forceps  and  twisted  with  a  second  pair. 
Torsion  of  arteries,  preventing  the  occurrence  of  hemorrhage,  is 
often  observed  in  accidental  wounds,  such  as  avulsion  of  a  limb  ; 
arteries  as  large  as  the  femoral  or  brachial  may  in  these  accidents 
have  undergone  torsion  to  such  an  extent  that  no  blood  escapes 
from  them,  although  completely  torn  across.  Torsion  has  been 
employed  to  a  considerable  extent  to  control  bleeding  from  arte- 
ries, being  used  in  the  case  of  vessels  as  large  as  the  femoral  or 
the  axillary.  In  the  case  of  large  vessels  it  does  not  offer  the 
same  safety  as  the  application  of  an  asei^tic  ligature,  and  we  therefore  think 
its  most  satisfactory  application  is  to  small  or  moderate-sized  vessels. 

The  Ligature. — This  is  by  far  the  most  widely  employed 
method  of  controlling  arterial  hemorrhage.  The  materials  used  ^'*^-  ■'°*- 
for  ligatures  are  silk  or  catgut,  which  should  be  thoroughly 
sterilized  before  being  used.  In  securing  a  divided  vessel  by  a 
ligature  the  end  of  the  vessel  is  grasped  with  artery  (Fig.  264) 
or  haemostatic  forceps,  and  is  separated  from  the  surrounding 
tissues  and  slightly  drawn  out  of  its  sheath.  A  piece  of  catgut 
or  silk  about  ten  inches  in  length  is  then  firmly  tied  upon  the 
end  of  the  vessel,  and  is  secured  by  a  reef  or  surgeon's  knot. 
The  knot  should  be  made  with  firmness,  and  should  not  be 
secured  by  a  jerky  motion,  which  is  often  done  and  is  apt  to 
break  the  ligature.  The  ligature  should  be  tied  with  only 
enough  force  to  bring  the  coats  of  the  vessel  in  contact,  or  with 
sufficient  force  to  divide  the  inner  and  the  middle  coat.  The 
latter  method  is  the  safer  one.  When  the  knot  has  been  firmly 
tied  the  ends  of  the  ligature  are  cut  short  in  the  wound. 

In  very  dense  tissues  it  is  often  impossible  to  grasp  the  end 
of  the  divided  vessel  with  forceps.  In  such  cases  the  hemorrhage 
may  be  controlled  by  the  use  of  a  deep  suture.  (Fig.  265.) 
This  is  applied  by  threading  a  catgut  or  silk  ligature  into  a 
curved  needle,  then  passing  the  needle  deeply  into  the  tissues  on 
each  side  of  the  bleeding  vessel,  and  finally  securing  it  by  tying. 

Both  ends  of  a  divided  artery  should  be  secured  by  ligatures,  although 
the  distal  end  may  not  bleed  at  the  time  ;  when  the  collateral  circulation  is 
established,  hemorrhage  may  take  place  from  it.     In  the  case  of  a  partially 


Artery  forceps. 


( 


CONTROL   OF  ARTERIAL  HEMORRHAGE.  333 

divided  artery  ligatures  should  be  i:)laced  upon  the  vessel  on  each  side  of 
the  wound,  and  after  being  secured  the  division  of  the  vessel  should  be  com- 
pleted to  allow  contraction  and  retraction  of  the  ends  of  the  artery. 

Suture. — Wounds    of   arteries   have   been 
successfully  closed  by  sutures  both  in  man  and  ^"*-  '^^^■ 

in  the  lower  animals,  thereby  preserving  per- 
meability of  the  vessel  at  the  seat  of  injury. 
Invagination  has  been  recommended  when  more       '  '' 

than  two-thirds  of  the  circumference  of  the  ves- 
sel has  been  divided,  or  where  it  can  be  done 
without  removing  more  than  three-fourths  of 
an  inch  of  the  vessel.     Invagination  of  divided  W 

arteries  combined  with  the  use  of  sutures  has 

been  practised  with  success  in  a  few  cases.  '^°°'""'°utare"  (L.^aick )  '"^'^ 
When  invagination  is  done,  the  proximal  por- 
tion of  the  artery  should  be  invaginated  into  the  distal  portion,  and  secured 
by  sutures.  In  longitudinal  wounds  the  edges  may  be  brought  together  with 
fine  silk  sutures  introduced  by  means  of  a  fine  cambric  needle  ;  the  siitures 
should  be  inserted  from  one-sixteenth  to  one-twentieth  of  an  inch  apart  and 
one-sixteenth  of  an  inch  from  the  edges  of  the  wound,  and  should  include 
only  the  adventitia  and  media,  not  perforating  the  intima.  During  the 
operation  the  circulation  in  the  vessel  should  be  controlled,  both  above  and 
below  the  wound,  by  forceps  covered  with  rubber  tubing,  and  where  a  dis- 
tinct sheath  is  present  it  should  be  sutured,  or,  where  this  is  not  present, 
muscle  or  fascia  should  be  sutured  over  the  closed  wound  in  the  vessel.  The 
principal  dangers  of  this  procedure  are  thrombosis  or  embolism,  and  later 
the  develoi^ment  of  aneurism. 

Styptics. — These  are  agents  which  have  a  marked  asti'ingent  or  coagu- 
lating effect  upon  the  tissues,  such  as  Monsel's  solution,  antipyrin,  acetic 
acid,  dry  or  moist  heat,  and  cold.  Styptics,  at  the  present  time,  are  not 
much  used,  except  for  the  control  of  capillary  or  parenchymatous  hemor- 
rhage. 

Hot  Water. — Hot  water  is  often  employed  as  a  styptic,  and  controls 
bleeding  by  producing  contraction  of  the  tissues  and  coagulation  of  the  albu- 
min :  it  should  be  used  at  a  temi>erature  of  115°  to  130°  F.  (45.1°  to  54.4°  C.) 
to  obtain  the  best  effects.  Hot  water  is  not  employed  to  control  hemorrhage 
when  arteries  of  any  considerable  size  are  injured,  but  may  be  used  with 
advantage  in  capillai-y  or  j)arenohymatous  bleeding.  Water  which  has  been 
sterilized  by  boiling  and  cooled  down  to  the  proper  temperature  is  a  per- 
fectly safe  application  to  wounds.  In  cases  where  large  oozing  surfaces  are 
exposed,  as  often  happens  in  extensive  wounds  or  in  operations  upon  the 
abdominal  cavity,  hot  water  acts  well  as  a  styptic,  and  has  the  additional 
advantage  of  furnishing  heat,  which  diminishes  the  shock  of  the  operation. 
Gauze  compresses  wrung  out  of  hot  water  may  be  packed  into  wounds  to 
control  bleeding,  combining  the  effects  of  pressure  and  heat. 

Cold  Water  or  Ice. — These  may  be  used  as  styptics,  and  act  by  pro- 
ducing reflex  vascular  contraction,  being  used  in  the  form  of  irrigation  or  an 
ice-bag.     Cold  applied  in  this  way  is  not  as  efficient  as  hot  water ;  it  also  has 


334  TEEATAIENT  OF  VENOUS  HEMOERHAGE. 

tlie  disadvantage  of  cliilling  the  patient  and  increasing  the  shock,  wjiicii  may 
be  a  serious  matter  in  cases  in  which  profuse  hemorrhage  has  occurred. 

Gelatin. — This  substance  in  a  five  to  ten  per  cent,  solution  in  normal 
salt  solution  may  be  used  locally ;  it  is  applied  by  irrigating,  injecting,  or 
tamponing  the  bleeding  area ;  it  has  been  used  successfully  in  epistaxis, 
vesical  hemorrhage,  and  htematemesis,  and  in  superficial  wounds  in  patients 
suffering  from  htemophilia. 

Antipyrin. — A  solution  of  antipyrin,  five  per  cent.,  in  sterilized  water 
possesses  marked  styptic  action.  As  it  also  possesses  antiseptic  properties 
and  is  not  toxic,  it  may  be  iised  to  control  capillary  bleeding  from  the  surfaces 
of  the  brain,  intestines,  and  peritoneum,  and  from  bone  cavities. 

Adrenalin. — A  solution  of  adrenalin  chloride  1  part  to  normal  salt  solu- 
tion 1000  to  4000  parts  has  decided  haemostatic  properties.  It  has  been  used 
with  good  results  in  capillary  bleeding,  and  in  the  oozing  from  large  surfaces. 

Treatment  of  Venous  Hemorrhage. — Spontaneous  arrest  of  venous 
bleeding  may  occur  from  the  same  causes  that  result  in  the  arrest  of  arterial 
hemorrhage.  Bleeding  from  small  veins  is  usually  arrested  spontaneously, 
unless  there  is  some  jDressure  upon  the  wounded  veins  oh  the  cardiac  side  of 
the  wound,  in  which  case  continuous  bleeding  is  apt  to  occur.  Venous 
hemorrhage  may  be  controlled  by  pressure,  by  the  use  of  the  hwmostatic 
forceps,  the  ligature,  the  lateral  ligature,  or  by  suture  of  the  wounded  vessel. 

Pressure. — This  may  be  applied  for  the  temporary  control  of  venous 
hemorrhage  by  the  fingers,  or  by  the  use  of  a  compress  held  firmly  over  the 
wounded  vessel  by  a  bandage.  Packing  the  wound  with  strijis  of  gauze  is 
often  employed  for  the  isermanent  control  of  venous  bleeding  from  deep  cavi- 
ties, or  from  the  great  venous  sinuses  within  the  skull,  where  a  ligature 
cannot  be  easily  used.  After  venesection,  or  in  cases  of  rupture  of  varicose 
veins,  the  bleeding  is  controlled  by  the  use  of  a  compress,  which  is  allowed 
to  remain  in  place  until  the  wound  is  healed. 

Ligature. — In  wounds  of  large  veins  the  bleeding  should  be  controlled 
by  the  use  of  ligatures,  the  distal  end  of  the  vein  being  first  secured,  as  it 
usually  bleeds  more  freely  ;  the  proximal  end  of  the  vein,  if  supplied  with 
valves  beyond  the  wound,  may  not  bleed,  but  in  all  cases  of  iujm-ies  of  large 
veins  it  is  wise  to  follow  the  rule  of  practice  emj)loyed  in  wounded  arteries 
and  secure  both  ends  of  the  vein  by  ligatures. 

Lateral  Ligature. — In  punctured  wounds  or  incomplete  division  of 
large  veins  it  has  been  found  that  the  hemorrhage  may  be  safely  controlled 
without  obliteration  of  the  vein  at  the  seat  of  injury  by  the  application  of  a 
lateral  ligature  ;  the  walls  of  the  vein,  including  the  wound,  are  picked  up 
with  forceps,  and  a  delicate  catgut  or  silk  ligature  is  firmly  tied  around  the 
base  of  the  tissues  held  in  the  forceps.  The  lateral  ligature  has  frequently 
been  resorted  to  in  wounds  of  the  femoral,  jugular,  and  axillary  veins,  as 
well  as  in  wounds  of  the  venous  sinuses  within  the  skull ;  and  the  occurrence 
of  secondary  hemorrhage  after  this  form  of  ligature,  if  the  wound  remains 
aseptic,  has  been  found  no  more  frequent  than  after  the  application  of  a 
circular  occluding  ligature. 

Suture. — Billroth,  Schede,  and  others  have  successfully  practised  sutur- 
ing of  wounded  veins,  thereby  preserving  permeability  of  the  vein  at  the 


TREATMENT  OF  SECONDARY   HEMORRHAGE.  335 

seat  of  injury.  Invagination  of  divided  veins,  combined  with  the  use  of 
sutures,  has  also  been  practised  successfully.  The  procedure  is  similar  to 
that  for  wounded  arteries  with  the  exception  that  the  distal  portion  is 
invaginated  into  the  x)roxinial. 

Haemostatic  Forceps. — In  cases  of  venous  hemorrhage,  especially  when 
it  is  from  the  deep  parts  of  a  wound  or  cavity,  or  from  the  great  venous 
sinuses  of  the  head,  it  may  be  impossible  to  apply  a  ligature  ;  in  such  a  case  one 
or  moi-e  pairs  of  htemostatic  forceps  may  be  clamped  upon  the  injured  vein  or 
sinus,  and,  the  wound  around  the  forceps  being  loosely  jpacked  with  gauze, 
the  forceps  are  allowed  to  remain  in  jilace  for  four  or  five  days,  at  the  end 
of  which  time  they  can  generally  be  removed  without  any  recurrence  of 
the  bleeding.  When  forceps  are  used  in  this  way,  care  should  be  taken  to 
protect  the  projecting  handles,  so  that  the  patient  cannot  disi^lace  them  or  do 
additional  injury  to  the  vessel  and  surrounding  parts  by  forcing  the  instru- 
ments into  the  tissues.  The  process  of  rei^air  in  wounded  or  ligated  veins 
is  similar  to  that  which  takes  place  in  arteries  under  the  same  conditions. 

Treatment  of  Capillary  Hemorrhage.— This  hemorrhage  is  usu- 
ally spontaneously  arrested  by  the  exposure  of  the  surface  of  the  wound 
to  the  air,  but  when  this  does  not  occur  the  bleeding  may  be  arrested  by 
2)ressu7'e,  employed  by  means  of  sterilized  gauze  pads,  which  are  firmly 
packed  into  the  wound  and  allowed  to  remain  for  a  few  minutes.  One  of 
the  best  means  of  arresting  caijillary  bleeding,  however,  is  the  use  of  Jiot 
ivater  or  a  hot  bichloride  solution  at  a  temperature  of  120°  to  150°  P.  (60°  to 
65°  C);  the  water  should  not  be  used  at  a  higher  temj)erature  than  this,  as 
damage  to  the  tissues  may  result.  The  employment  of  a  five  per  cent,  anti- 
pyrin  or  a  1  to  1000  to  4000  adrenalm  chloride  solution,  or  a  five  to  ten  per 
cent,  gelatin  solution,  also  acts  well.  Monsel's  solution  and  other  styptics 
may  also  be  used.  If  these  measures  fail  to  control  the  bleeding,  the  wound 
should  be  firmly  packed  with  strips  of  sterilized  or  antiseptic  gcmze.  The 
latter  dressing  is  also  fi'equently  used  to  control  hemorrhage  from  mucous 
cavities,  such  as  the  mouth,  nose,  rectum,  vagina,  or  uterus.  The  jjacking 
should  not  be  removed  too  soon,  but  should  be  allowed  to  remain  for  from 
three  to  six  days,  and  can  then  be  removed  without  fear  of  recurrence  of 
the  bleeding. 

Treatment  of  Parenchymatous  Hemorrhage. — The  amount  of 
blood  lost  in  this  variety  of  hemorrhage  is  often  very  great,  and  its  control 
is  sometimes  a  matter  of  difficulty.  Pressure  applied  as  for  the  control  of 
caj)illary  hemorrhage,  or  hot  water,  may  arrest  the  bleeding  ;  if  this  fails,  the 
actual  cautery  or  Paquelin's  cautery  at  a  dull  red  heat  may  be  applied  with 
satisfactory  results ;  or  in  other  cases  the  application  of  a  few  deep  sutures  of 
catgut  or  silk,  including  the  tissues,  to  the  depth  of  the  wound,  may  con- 
trol the  bleeding.  In  wounds  of  the  liver,  spleen,  kidney,  or  tongue,  and 
in  tissues  whose  vascularity  is  increased  by  the  presence  of  new  growths, 
bleeding  is  best  arrested  by  the  application  of  sutures. 

Treatment  of  Secondary  Hemorrhage.— Profuse  secondary  arte- 
rial hemorrhage  is  usually  preceded  bj^  the  occurrence  of  one  or  more  slight 
hemorrhages,  which  may  recur  at  intervals  of  a  few  hours  or  days ;  the 
amount  of  blood  lost  at  these  times  may  be  slight,  but  their  occurrence 


336  TREATMENT  OF  SECONDARY   HEMORRHAGE. 

sliould  always  excite  tlie  suspicion  of  the  surgeon,  and  lie  should  have  the 
patient  carefally  watched  by  a  skilled  attendant  who  is  competent  to  act  in 
case  the  bleeding  becomes  excessive.  Elevation  of  temperature  and  a  feeling 
of  tension  in  the  wound,  caused  by  effusion  of  blood  around  the  artery,  are 
symptoms  which  often  j)recede  secondary  hemorrhage. 

In  arteries  ligated  in  their  continuity,  the  bleeding  often  arises  from  the 
distal  side  of  the  ligature ;  this  has  been  accounted  for  by  the  facts  that  the 
distal  clot  is  less  in  extent  and  is  slower  in  forming  than  the  proximal  clot, 
and  that  the  ligature  diminishes  the  vitality  of  the  vessel  walls  immediately 
below  the  seat  of  the  ligature  by  obstructing  the  vasa  vasorum,  or  the 
obstruction  in  the  capillaries  below  the  seat  of  the  ligature  may  be  greater 
than  that  in  the  anastomosing  vessels,  and  the  blood-pressure  may  be  greater 
in  the  vessel  at  the  distal  than  at  the  proximal  side  of  the  ligature. 

Secondary  hemorrhage  demands  prompt  treatment.  In  secondary  hemor- 
rhage from  a  wound,  digital  or  instrumental  i^ressure  should  be  made  above 
and  below  the  wound,  and  if  the  bleeding  be  from  a  vessel  of  one  of  the 
extremities,  an  elastic  tube  should  be  placed  around  the  limb  some  distance 
above  the  wound,  to  control  it  temporarily.  The  wound  should  be  opened 
and  blood- clots  turned  out,  and  it  should  be  enlarged,  if  necessary,  to  expose 
the  source  of  the  bleeding,  and  if  it  is  found  that  the  hemorrhage  has  arisen 
from  the  distal  end  of  the  vessel,  this  should  be  secured  by  a  ligature  ai^plied 
to  the  vessel  at  a  point  where  its  walls  are  in  a  healthy  condition  ;  if  the 
bleeding  has  arisen  from  the  proximal  end  of  the  vessel,  this  should  be 
ligated  in  the  same  manner  with  silk  or  catgut.  The  wound  should  next  be 
carefully  cleared  of  blood-clots,  and  freely  irrigated  with  bichloride  or  saline 
solution.  If  the  hemorrhage  recurs  after  a  few  days,  the  same  procedures 
should  be  adopted.  If  the  bleeding  again  recurs,  the  surgeon  should  ligate 
the  artery  of  supply  at  some  distance  above  the  wound,  or,  in  the  case  of 
the  extremity,  amputate  the  limb  above  the  source  of  bleeding  ;  this  latter 
procedure,  which  seems  a  most  radical  one,  is  attended  with  better  results 
in  cases  of  repeated  secondary  hemorrhages  than  the  application  of  a  liga- 
tui-e  to  the  vessel  above  the  source  of  the  hemorrhage,  for  it  removes  the 
infected  vessel  and  surrounding  tissues  and  leaves  a  clean  wound,  and  at  the 
same  time  the  artery  diminishes  in  size  as  the  demand  for  blood  to  the  part 
is  lessened  by  the  removal  of  the  limb. 

In  certain  cases  of  secondary  hemorrhage  the  vessel  and  surrounding  tis- 
sues are  found  in  such  a  sloughing  condition  that  a  ligature  cannot  be  made 
to  hold,  or  the  vessel  may  be  injured  at  a  point  where  a  ligature  cannot  be 
applied  ;  in  such  cases  the  actual  cautery  may  be  employed,  which  produces 
firm  temporary  closure  of  the  vessel  and  at  the  same  time  sterilizes  the 
wound  ;  if  this  is  not  used,  firm  packing  with  antiseptic  gauze  may  be 
resorted  to,  and  the  packing,  when  it  is  possible,  should  be  covered  with  an 
antiseptic  dressing  held  firmly  in  place  by  a  bandage.  The  packing  should 
not  be  distui'bed  for  some  days,  and  then  should  be  carefully  removed,  and 
the  wound  should  be  repacked  in  the  same  manner.  These  methods  of  treat- 
ment, which  are  resorted  to  only  when  ligatures  cannot  be  applied,  are  often 
successful  in  arresting  the  bleeding,  and  should  not  be  lost  sight  of. 

In   secondary  venous    hemorrhage  firm   compression    may   first    be 


WOUNDS  OF  SPECIAL  ARTERIES.  337 

resorted  to,  and  if  this  fails  to  arrest  the  bleeding  the  wound  should  be 
opened  and  the  bleeding  vein  exi^osed  and  ligated  or  cauterized,  or  the 
hemorrhage  may  be  arrested  by  firmly  packing  the  wound  with  antiseptic 
gauze. 

At  the  same  time  that  any  of  these  various  procedures  is  practised  for 
the  control  of  secondary  hemorrhage  the  patient  should  be  most  carefully 
watched,  and  should  be  placed  upon  the  constitutional  treatment  which  has 
been  previously  described  as  of  value  in  cases  of  hemorrhage. 

Simultaneous  Wounds  of  the  Main  Artery  and  the  Main 
Vein  of  a  Limb. — These  are  most  serious  injuries,  from  the  risk  of  gan- 
grene. If  the  main  artery  and  main  vein  are  both  injured,  both  should  be 
secured  by  ligatures,  or  sutures  may  be  applied  to  the  wounds  of  both  vessels 
if  they  are  not  extensive,  and  if  the  collateral  circulation  is  jiromptly  estab- 
lished, gangrene  will  not  occur.  If  the  wound  of  the  vein  is  not  extensive, 
it  should  be  closed  by  a  lateral  ligatirre.  In  a  wound  of  the  main  vein, 
ligation  of  the  accompanying  artery  has  been  practised,  with  the  idea  of 
diminishing  the  vis  a  tergo  of  the  circulation.  This,  however,  in  practice 
has  not  been  found  to  be  of  advantage.  After  dressing  the  wound  the  limb 
should  be  carefully  bandaged  and  elevated. 

Wounds  of  Special  Arteries. — Common  Carotid  Artery. — 
Wounds  of  this  artery  may  result  from  stab  or  gunshot  injury,  or  from 
operations  upon  the  neck,  and,  if  not  immediately  fatal,  should  be  treated 
by  the  application  of  a  ligature  to  the  vessel  on  each  side  of  the  wound,  and 
if  the  vessel  has  not  been  completely  severed,  its  division  should  be  com- 
pleted after  the  application  of  the  ligatures.  If  secondary  hemorrhage 
occurs,  the  ends  of  the  vessel  should  again  be  secured  by  ligatures  if  possible, 
or  the  wound  sliould  be  firmly  packed  with  sterilized  gauze. 

Internal  Carotid  Artery. — Wounds  of  this  vessel  should  be  treated,  if 
possible,  by  the  application  of  two  ligatures,  one  on  each  side  of  the  wound, 
but  if  the  wound  is  close  to  the  skull,  so  that  its  ligation  would  be  imi^os- 
sible,  or  in  cases  of  secondary  hemorrhage  from  the  internal  carotid,  the 
common  carotid  should  be  tied,  and  a  ligature  should  also  be  applied  to 
the  external  carotid  artery,  near  its  origin  from  the  common  carotid. 

External  Carotid  Artery. — In  case  of  wound  of  this  artery,  ligatures 
should  be  placed  ujion  the  proximal  and  distal  ends  of  the  divided  vessel, 
and  if  secondary  hemorrhage  occurs  the  ends  of  the  vessel  should  again  be 
secured  by  ligatures.  Ligation  of  the  common  carotid  artery  will  probably 
arrest  the  bleeding  only  temporarily,  as  the  anastomosis  of  the  terminal 
branches  of  the  external  carotids  is  very  free,  and  it  should  be  practised  only 
when  it  is  impossible  to  tie  the  ends  of  the  external  carotid  in  the  wound. 

Internal  Maxillary  Artery. — As  it  is  impossible  to  expose  this  vessel, 
the  external  carotid  artery  should  be  ligated,  and  if  hemorrhage  recurs 
after  tliis  procedure  it  has  been  recommended  that  the  external  carotid 
upon  the  opposite  side  be  tied,  as  the  blood  reaches  the  injured  vessel  by 
anastomosing  vessels  from  the  opposite  side  of  the  neck. 

Lingual  Artery. — In  woands  of  the  tongue  the  bleeding  vessel  should 
be  secured  in  the  wound,  if  possible,  by  ligatures  or  deep  sutures  ;  if  this 
cannot  be  accomplished,  the  vessel  should  be  ligated  in  the  neck. 

22    . 


338  WOUNDS   OF  SPECIAL  ARTERIES. 

Middle  Meningeal  Artery. — This  vessel  is  usually  injured  by  falls  or 
blows  upon  the  head,  or  it  may  be  wounded  in  fracture  of  the  skull.  In 
bleeding  from  this  vessel  in  compound  fractures  of  the  skull  the  fragments 
should  be  removed  and  the  artery  exposed  and  secured  by  a  ligature  ; 
if  this  is  impossible,  the  bleeding  should  be  controlled  by  i^acking  the 
wound  firmly  with  sterilized  gauze,  which  should  not  be  disturbed  for  some 
days.  Trephining  is  required  for  exposure  of  the  vessel  in  simple  frac- 
tures of  the  skull  or  in  cases  where  the  vessel  has  been  ruptured  without 
fracture. 

Vertebral  Artery. — Injuries  of  this  artery  are  very  rare,  but  may 
result  from  stab  or  gunshot  wounds.  Hemorrhage  from  this  vessel  may  be 
controlled  by  packing  the  wound  with  gauze,  or  the  wound  may  be  enlarged 
and  the  vessel  exposed  and  secm-ed  by  two  ligatures. 

Subclavian  Artery. — This  vessel  may  be  injured  in  stab  or  gunshot 
wounds,  or  by  a  fragment  of  a  fractured  clavicle,  and  if  the  wound  is  exten- 
sive the  patient  will  probably  die  from  loss  of  blood  before  surgical  treat- 
ment can  be  applied.  If  the  patient  survives  the  accident,  the  wound 
should  be  enlarged  and  the  vessel  secured  by  two  ligatures.  If  a  traumatic 
aneurism  forms,  this  should  be  treated  by  opening  the  sac  and  securing  the 
vessel  by  ligatures  applied  on  each  side  of  the  wound. 

Internal  Mammary  Artery. — Bleeding  from  this  vessel  should  be 
arrested  by  the  application  of  ligatures,  which  can  best  be  done  by  a  blunt 
curved  needle. 

Intercostal  Arteries. — Hemorrhage  from  these  vessels  may  be  arrested 
by  enlarging  the  wound  and  securing  the  vessel  by  two  ligatm-es,  even  if  it 
is  necessary  to  resect  a  portion  of  the  rib  to  expose  it,  or  by  introducing  a 
firm  compress  of  gauze  into  the  wound  between  the  ribs. 

Axillary  Artery. — This  vessel  may  be  injured  by  gunshot  and  stab 
wounds,  or  in  removing  tumors  from  the  axilla,  and  has  been  ruptured  in 
reducing  old  dislocations  of  the  shoulder.  As  it  is  a  large  vessel,  the  bleed- 
ing may  be  so  profuse  as  to  be  rapidly  fatal ;  temporary  control  of  the 
hemorrhage  may  be  effected  by  compressing  the  third  part  of  the  subclavian. 
The  vessel  should  be  exj)Osed  by  incision,  and,  if  the  rupture  be  a  high  one, 
to  expose  its  seat  a  portion  of  the  pectoral  muscle  may  have  to  be  divided  ; 
and  when  the  wound  is  reached  two  ligatures  should  be  applied,  one  to  the 
distal  and  one  to  the  proximal  end. 

Brachial,  Radial,  and  Ulnar  Arteries. — Wounds  of  these  vessels 
should  be  treated  by  the  application  of  two  ligatures  to  the  vessel,  one  on 
each  side  of  the  wound. 

Palmar  Arch. — Wounds  of  the  vessels  of  this  arch  often  give  rise  to 
persistent  and  serious  hemorrhage,  which  should  be  treated  by  enlarging 
the  wound  and  api^lying  two  ligatures  to  the  ends  of  the  divided  arch.  If 
secondary  hemorrhage  occurs,  an  attempt  should  be  made  again  to  secure 
the  bleeding  vessels  in  the  wound  with  ligatures,  and  if  this  fails  the 
brachial  artery  should  be  ligated  at  the  elbow.  The  use  of  pressure  by 
means  of  a  graduated  compress  applied  in  the  wound  may  arrest  the  bleed- 
ing temporarily,  but  is  neither  so  safe  nor  so  efficient  as  ligation  of  the 
bleeding  vessels  in  the  wound  or  ligation  of  the  brachial  artery. 


INJURIES   OF  VEINS.  339 

Gluteal  and  Sciatic  Arteries.— Wounds  of  these  arteries  may  arise 
from  stab  or  gunshot  wounds,  and  the  arteries  may  be  injured  outside  or 
within  the  pelvis.  In  treating  hemorrhage  from  these  vessels  the  wound 
should  be  enlarged,  and,  if  it  is  found  to  involve  the  vessel  outside  of  the 
pelvis,  two  ligatures  should  be  applied  to  the  injured  vessel.  If  on  exam- 
ination it  is  found  that  the  bleeding  comes  from  within  the  pelvis,  the  most 
satisfactory  method  of  controlling  it  consists  in  ligating  the  internal  iliac 
artery,  from  which  the  wounded  vessels  arise.  Either  the  intra-  or  the  extra- 
peritoneal method  may  be  employed  in  ligating  this  vessel. 

Femoral  Artery. — This  vessel  is  frequently  injured,  and,  as  the  hemor- 
rhage following  is  very  profuse,  it  may  prove  rapidly  fatal.  The  bleeding 
should  be  arrested  by  digital  pressure  applied  to  the  vessel  as  it  passes  over 
the  rim  of  the  pelvis,  and  two  ligatures  should  be  applied  to  the  artery,  one 
to  each  side  of  the  wound;  and  the  division  of  the  artery  should  be  completed 
if  it  has  not  been  entirely  severed.  Secondary  hemorrhage  should  be  con- 
trolled by  again  securing  the  bleeding  ends  of  the  vessel  in  the  wound.  If 
bleeding  recurs,  the  external  iliac  may  be  tied ;  but  this  procedure  is  apt 
to  be  followed  by  gangrene  of  the  limb,  so  that  it  is  generally  considered 
a  safer  procedure  after  repeated  secondary  hemorrhage  from  the  femoral 
artery  to  amputate  the  limb  at  the  seat  of  the  bleeding. 

Popliteal  and  Tibial  Arteries.— Hemorrhage  from  these  vessels  should 
be  controlled  by  the  application  of  two  ligatures  to  the  wounded  vessel,  one 
on  each  side  of  the  wound,  and  if  the  artery  has  not  been  completely  divided 
its  division  should  be  completed  between  the  ligatures. 

INJURIES  OP  VEINS. 

Contusions  of  Veins. — These  may  result  from  the  same  causes  that 
produce  a  similar  condition  in  arteries,  but,  as  a  rule,  they  are  much  less 
serious  injuries,  from  the  fact  that  the  blood-pressure  is  much  lower  and 
primary  and  secondary  hemorrhage  are  much  less  severe.  Thrombosis 
of  a  vein  may  occur  at  the  seat  of  injury,  but,  as  the  collateral  circulation 
is  usually  very  free  between  the  veins,  the  return  circulation  is  soon  estab- 
lished. Septic  infection  of  a  thrombosed  vein  is,  however,  a  very  serious 
and  often  fatal  complication. 

Laceration  or  Complete  Rupture  of  Veins. — These  injuries,  if 
large  veins  are  involved,  may  cause  rapid  and  excessive  loss  of  blood  ;  pro- 
fuse and  rapidly  fatal  hemorrhage  may  result  from  wounds  of  the  femoral, 
iliac,  or  hepatic  veins,  as  well  as  from  the  venous  sinuses  of  the  cranium. 
Bleeding  from  small  veins  is  usually  not  profuse,  and  may  be  spontaneously 
arrested,  or  may  continue  for  some  time,  from  the  fact  that  the  walls  of  veins 
do  not  contain  as  much  elastic  and  muscular  tissue  as  those  of  arteries,  so 
that  contraction  of  the  ends  of  the  wounded  vein  does  not  take  place  to 
fiivor  the  arrest  of  hemorrhage.  Exteusive  extravasation  of  blood  often 
follows  the  subcutaneous  rupture  of  comparatively  small  veins. 

Symptoms. — In  venous  hemorrhage  dark-colored  blood  escapes  in  a 
continuous  stream,  and  the  bleeding  is  controlled  by  pressure  applied  to  the 
vessel  at  the  distal  side  of  the  wound,  and  is  increased  by  pressure  applied 
at  the  x)roximal  or  cardiac  side  of  the  wound. 


340  ENTBAKCE   OF  AIR  INTO  VEINS. 

Treatment. — In  punctured  or  longitudinal  wounds  of  small  veins,  as  the 
blood-pressure  is  low,  pressure  may  be  relied  upon  to  control  the  bleeding  ; 
in  larger  veins,  if  the  wound  in  the  vein  be  a  small  one,  a  lateral  ligature 
should  be  applied  if  possible,  or  the  wound  may  be  clamped  by  hfemostatic 
forceps,  which  are  allowed  to  remain  in  place  for  three  or  four  days,  or  the 
wound  may  be  closed  by  fine  silk  or  catgut  sutures  introduced  with  a  fine 
sewing-needle.  Eepair  of  the  wounded  A^ein  should  take  place  without 
obliteration  of  its  lumen.  Complete  rupture  or  extensive  wounds  require 
the  application  of  ligatures  to  the  ends  of  the  vein  ;  and  although  the  appli- 
cation of  a  ligatui-e  to  the  cardiac  side  of  the  vein  may  be  necessary  only  in 
the  case  of  veins  in  the  axilla  and  the  neck,  or  where  there  is  veiy  free  com- 
munication of  the  veins  at  a  distance  from  valves,  we  consider  it  safer  to 
^-PPly  two  ligatures  to  the  divided  vein  in  any  location,  if  it  be  a  large  one. 

Entrance  of  Air  into  Veins. — Air  Embolism. — This  accident, 
which  is  a  rare  one,  has  occurred  when  large  veins  have  been  opened  in 
operations  upon  the  axilla,  neck,  and  brain,  and  has  been  attended  by  alarm- 
ing symptoms  and  often  fatal  results.  Hare,  from  experiments  upon  animals, 
concludes  that  death  from  this  accident  could  result  only  when  enormous 
quantities  of  air  had  been  forced  into  a  vein,  and  is  inclined  to  think  that 
the  accident  is  not  likely  to  happen  during  operations,  and  that  deaths  attrib- 
iited  to  this  cause  are  due  to  other  conditions.  Be  this  as  it  may,  careful 
and  com]jetent  observers,  during  operations  upon  the  neck,  the  axilla,  and 
brain,  in  which  large  veins  were  opened,  have  observed  the  development  of 
alarming  symptoms,  or  sudden  death  from  cardiac  paralysis,  which  i^he- 
nomena  are  diificult  of  explanation  upon  any  other  hypothesis.  When  a 
large  vein  near  the  heart,  such  as  the  axillary,  internal  jugular,  or  sub- 
clavian, is  opened  and  remains  patulous,  from  mechanical  or  pathological 
causes,  air  is  sucked  into  the  vein  by  the  aspirating  action  of  the  chest  and 
carried  to  the  right  auricle,  and  death  may  result  from  cardiac  paralysis,  or 
from  syncope  if  the  presence  of  air  in  the  heart  interferes  with  its  action  so 
markedly  that  sufficient  blood  is  not  sent  to  the  brain. 

Symptoms. — The  entrance  of  air  into  the  veins  is  accompanied  by  a 
hissing  sound,  and  frothy  blood  may  issue  from  the  vessel.  The  patient 
becomes  pale,  the  pupils  are  dilated,  the  pulse  is  feeble  and  flickering,  the 
respiratory  movements  are  exaggerated,  and  upon  auscultation  a  chm'uing 
sound  may  be  heard  over  the  heart.  The  patient  may  die  from  syncope,  or 
the  alarming  symptoms  may  gradually  siibside,  and  recovery  follow.  We 
have  seen  a  patient  during  an  amputation  of  the  shoulder-joint  present 
these  alarming  symptoms  for  a  few  minutes  and  eventually  recover. 

Treatment. — With  the  possibility  of  this  serious  complication  in  view, 
in  operating  ujion  the  neck  and  the  axilla,  in  the  dangerous  area,  as  it  is 
termed,  care  should  be  taken  to  secure  veins,  if  possible,  on  the  cardiac  side 
by  forceps  or  ligatures  before  they  are  divided  ;  incomiDlete  division  of  the 
veins  should  also  be  avoided.  If,  however,  the  accident  occurs,  as  evidenced 
by  the  symptoms  presented,  the  wounded  vein  should  be  closed  by  pressure 
of  the  finger  until  it  can  be  secured  by  forceps  or  ligatures  ;  or,  if  this  cannot 
be  accomplished,  the  wound  should  be  kept  filled  with  normal  salt  solution 
or  sterilized  water,  to  prevent  the  further  entrance  of  air.     The  patient's 


AVOUKDS   OF  SPECIAL  ^'EINS.  ,  341 

Lead  should  be  lowered,  to  prevent  syncoi^e,  and  tlie  heart  should  be  stimu- 
lated by  the  administration  of  ammonia  and  stimulants  and  the  hypodermic 
use  of  strychnine  and  digitalis.  The  legs  and  arms  should  be  elevated,  and 
the  femoral  and  axillary  vessels  may  be  compressed,  to  increase  the  amount 
of  blood  sent  to  the  brain.  Artificial  respiration  has  been  recommended, 
but  the  value  of  this  procedure  is  questionable. 

Wounds  of  Special  Veins.— Internal  Jugular  Vein.— A  wound 
of  the  internal  jugular  vein  is  usually  quickly  fatal  from  the  i:)rofuse  hemor- 
rhage ;  the  entrance  of  air  into  the  vein  may  cause  death.  This  vein  may 
be  wounded  in  stab  or  gunshot  wounds  of  the  neck,  and  is  often  accidentally 
or  intentionally  divided  in  removing  tumors  from  the  neck.  In  the  latter 
case  the  vein  should  be  previously  ligated  at  two  points  and  then  divided 
between  the  ligatures.  If  the  wound  be  a  small  one,  it  should  be  closed  by 
a  lateral  ligature  or  by  sutures  ;  and  while  the  vessel  is  being  secured  firm 
pressure  should  be  made  upon  it  at  the  cardiac  side  of  the  wound,  to  prevent 
the  entrance  of  air.  In  complete  divisions  of  the  vein  both  ends  should  be 
secured  by  ligatures. 

Wounds  of  the  Venous  Sinuses  of  the  Skull. — These  are  occasion- 
ally seen  in  cases  of  injuries  of  the  head  with  or  without  fracture  of  the 
cranial  bones.  When  associated  with  simple  or  compound  fracture,  the 
fragments  should  be  removed,  and  a  lateral  ligature  applied  if  jpossible ; 
if  the  wound  be  a  small  one,  this  may  be  accomijlished,  or  the  wounded 
portion  of  the  sinus  may  be  grasped  with  haemostatic  forceps,  and  these 
allowed  to  remain  in  place  for  a  few  days.  Trephining,  with  the  removal  of 
a  considerable  portion  of  the  skull,  may  be  required  to  exj^ose  the  wound  in 
the  sinus.  If  the  wound  is  extensive,  the  bleeding  may  be  arrested  by 
packing  the  wound  firmly  with  sterilized  or  iodoform  gauze,  which  should 
not  be  disturbed  for  some  days,  and  when  it  is  removed  a  fresh  packing 
should  be  applied. 

Subclavian  Vein. — Wounds  of  this  vein  may  result  from  stabs  or  gun- 
shot wounds,  or  may  occur  in  the  removal  of  tumors  from  the  neck,  and  are 
attended  by  a  high  mortality.  If  the  wound  or  laceration  of  the  vein  is 
extensive,  the  hemorrhage  is  so  profuse  that  a  fatal  result  will  probably 
occur  before  the  bleeding  can  be  arrested.  If  the  wound  is  a  small  one, 
attempts  should  be  made  to  apply  a  lateral  ligature  or  suture,  or  to  apply 
two  ligatures  to  the  vein,  one  on  each  side  of  the  wound.  If  these  pro- 
cedures fail,  it  may  be  possible  to  grasp  the  wounded  part  of  the  vein  with 
haemostatic  forceps  and  thus  control  the  bleeding.  The  forceiJS  should  be 
allowed  to  remain  in  place  for  a  week  or  more,  and  the  wound  should  be 
carefully  packed  around  the  forceps  with  sterilized  or  iodoform  gauze  and 
covered  with  a  gauze  dressing. 

Axillary  Vein. — This  vein  has  been  ruptured  in  the  reduction  of  old 
dislocations  of  the  shoulder,  and  in  wounds  of  the  axilla,  stab  or  gunshot, 
or  accidentally  in  removal  of  tumors  from  the  axillary  space,  and  has  been 
completely  severed  in  cases  of  avulsion  of  the  arm  at  the  shoulder -joint.  In 
subcutaneous  wounds  of  the  vein,  such  as  occur  in  reduction  of  dislocations 
of  the  shoulder,  a  compress  should  be  placed  in  the  axilla,  and  the  arm 
should  be  bound  to  the  side  ;  if  this  controls  the  bleeding,  as  shown  by  the 


342  THEOMBOSIS. 

fact  that  the  swelling  from  effused  blood  does  not  increase  in  size,  the  arm 
should  be  kept  in  this  position  for  a  week  or  two.  If,  however,  the  swelling- 
increases,  the  axilla  should  be  opened  by  an  incision,  and  the  wound  in  the 
vein  exposed  and  secured  by  ligatures  or  clamped  with  forceps.  In  small 
wounds  a  lateral  ligature  or  suture  should  be  applied,  but  if  the  wound  be 
extensive  two  ligatures  should  be  aj)plied,  one  on  each  side  of  the  wound. 
In  cases  where  the  injury  is  high  up  it  may  be  impossible  to  apply  two 
ligatures  ;  in  such  cases  the  distal  end  may  be  secured  by  a  ligature  and  the 
proximal  end  grasped  by  haemostatic  forceps,  which  ai-e  left  in  place,  the 
wound  being  j)acked  with  iodoform  or  sterilized  gauze. 

Iliac  Veins. — Wounds  of  these  veins,  either  the  common,  the  internal, 
or  the  external,  may  be  produced  by  stab  or  gunshot  wounds,  or  they  may 
be  accidentally  injured  in  abdominal  operations.  Bleeding  from  these  veins 
is  generally  so  profuse  that  it  is  quickly  fatal.  If,  however,  the  wound  is 
a  small  one  and  the  blood  escai^es  slowly,  the  wound  in  the  abdominal  walls 
should  be  enlarged,  and  the  wound  in  the  vein  closed  by  a  lateral  ligature 
or  suture,  if  possible,  or  clamped  with  haemostatic  forceps  ;  if  not,  the  vein 
should  be  ligatured  upon  each  side  of  the  wound. 

Femoral  Vein. — This  vein  may  be  injured  in  incised,  lacerated,  or 
gunshot  wounds  of  the  groin,  or  at  other  parts  of  the  thigh.  In  the  removal 
of  enlarged  glands  and  malignant  tumors  from  the  groin  it  is  also  occasion- 
ally injured.  Small  wounds  of  the  femoral  vein  should  be  treated  by  the 
application  of  a  lateral  ligature  or  suture.  More  extensive  wounds  require 
the  application  of  two  ligatures,  one  on  each  side  of  the  wound. 

Eepair  of  wounded  blood-vessels  is  considered  on  page  82. 

Thrombosis. — This  consists  in  the  coagulation  of  blood  in  a  blood- 
vessel, the  blood-clot  remaining  at  its  point  of  origin.  A  thrombus  is 
the  blood-clot  which  forms  in  a  blood-vessel  during  life.  Thrombosis  may 
involve  either  arteries  or  veins,  and  the  occlusion  of  the  vessel  by  the 
thrombus  may  be  partial  or  complete,  and  is  an  essential  process  in  the 
arrest  of  hemorrhage. 

Causes. — When  the  white  blood-corpuscles  or  the  blood-plaques  lose 
their  vitality,  or  are  brought  into  contact  with  devitalized  tissue,  fibrin 
ferment  is  formed,  which  produces  fibrin  and  causes  the  formation  of  a 
coagulum  or  clot  by  the  union  of  the  fibrinogen  of  the  liquor  sanguinis  with 
the  paraglobulin  of  the  white  corpuscles.  Coagulation  of  blood,  resulting 
in  the  formation  of  a  thrombus,  is  not  due  solely  to  slowing  of  the  blood- 
current,  as  was  formerly  supposed,  but  requires  also  roughening  of  the 
inner  wall  of  the  vessel  from  injury  or  septic  infection.  When  these  con- 
ditions exist,  the  blood-plaques  leave  the  centre  of  the  stream,  and,  with  the 
leucocytes,  become  arrested  upon  the  roughened  surface  of  the  vessel. 
Thrombosis  may  arise  from  the  application  of  a  ligature,  from  injuries  of 
the  blood-vessels,  from  pressure  upon  a  vessel  by  a  splint  or  a  bandage,  or 
from  the  presence  in  it  of  foreign  bodies ;  atheroma  of  the  arteries  may  also 
cause  thrombosis.  Septic  processes  may  give  rise  to  this  condition,  as  well 
as  certain  diseases,  such  as  typhoid  fever,  pneumonia,  phlebitis,  and  arte- 
ritis ;  the  affection  in  these  conditions  is  probably  always  due  to  the  entrance 
of  pyogenic  or  specific  organisms.     A  thrombus  when  once  formed  at  the 


THROMBOSIS.  343 

seat  of  injury  or  irritation  of  a  vessel  tends  to  spread,  and  usually  extends 
to  the  next  large  collateral  branch.  A  rapidly  formed  thrombus  consists  of 
a  clot  made  up  of  fibrin  with  red  and  white  blood-corpuscles,  and  constitutes 
Avhat  is  known  as  a  red  thrombus.  When,  however,  the  blood  is  in  rapid 
motion,  and  a  roughened  surface  of  the  wall  of  the  vessel  is  present,  or  a 
foreign  body  is  introduced  into  the  vessel,  the  white  corpuscles  alone 
become  attached  to  it,  and  there  results  a  white  thrombus.  In  some 
cases,  after  the  formation  of  a  white  thrombus,  the  red  corpuscles  may 
become  entangled  in  it,  and  a  thrombus  composed  of  red  and  white  cor- 
puscles— a  mixed  thrombus — results.  A  thrombus  when  once  formed  may 
undergo  organization,  calcification,  disintegration  or  red  softening,  or  yellow 
or  puriform  softening. 

Organization. — The  process  of  organization  of  a  thrombus  in  a  vein 
is  similar  to  that  observed  in  the  healing  of  a  ligated  artery  (page  82). 
Embryonic  and  fibrous  tissue  replacing  the  blood-clot,  the  vein  may  be 
obliterated,  or  the  channel  may  be  restored  to  a  greater  or  less  extent  by 
the  spaces  in  the  clot  enlarging  and  coalescing  and  communicating  with  the 
vein  beyond.     The  clot  is  then  said  to  be  canalized. 

Calcification. — Occasionally  after  thrombosis  of  veins,  especially  those 
which  are  varicose,  small,  lime-like  bodies  are  observed  to  the  distal  side 
of  the  valves,  which  are  known  as  phleboliths,  and  are  composed  of 
phosphate  and  sulphate  of  lime  and  sulphate  of  potash.  These  bodies 
may  be  free  in  the  channel  or  may  be  attached  to  the  vein  by  a  narrow 
pedicle. 

Disintegration,  or  Red  Softening. — A  thrombus  may  soften  and  be 
changed  into  a  grayish-red  pulp,  the  process  beginning  in  the  centre  of 
the  clot,  and  the  softened  material  being  emptied  into  the  circulation  and 
deposited  in  various  organs  and  tissues  ;  but,  as  the  material  is  not  infective, 
it  produces  no  symptoms  of  localized  inflammation  in  the  tissues. 

Yellow  or  Puriform  Softening. — When  the  thrombus  becomes  infected 
with  septic  micro-organisms  from  the  walls  of  the  vein  or  from  the  circula- 
tion, the  softened  clot  contains  broken-down  leucocytes  and  bacteria,  and 
the  process  which  is  known  as  yellow  or  jinriform  softening  takes  place,  the 
clot  being  converted  into  a  reddish-yellow,  creamy  pulp.  This  process  is 
always  associated  with  septic  phlebitis.  In  this  variety  of  softening  the 
broken-down  clot  passes  into  the  circulation,  and  jjarticles  of  the  softened 
clot  as  infective  emboli  find  their  way  to  the  lungs,  liver,  and  other  organs, 
giving  rise  to  metastatic  or  secondary  abscesses.  Puriform  softening  of 
thrombi  is  an  important  factor  in  j^ysemia.  The  most  favorable  termination 
of  an  infected  thrombus  is  the  formation  of  a  localized  abscess,  which  may 
occur  if  the  infected  material  is  shut  off  by  coagulation. 

Symptoms. — The  symptoms  observed  in  thrombosis  will  depend  upon 
the  seat  of  the  obstruction.  In  sujierficial  vessels  the  position  of  a  clot  can 
usually  be  seen  and  felt ;  if  an  artery  be  involved,  the  absence  of  pulse  and 
antemia  of  the  tissues  below  the  obstruction  can  generally  be  observed  ;  in 
veins,  swelling  and  CBdema  of  the  tissues  drained  by  the  veins  are  very 
marked.  When  thrombosis  involves  important  organs,  impairment  of  func- 
tion results  in  proportion  to  the  amount  of  the  organ  involved.     Pain  in  the 


344  PHLEBITIS. 

course  of  the  vessel  is  a  common  symptom.  Anaestliesia  may  also  be  present 
in  the  swollen  tissues,  presenting  a  form  of  infiltration  anaesthesia. 

Embolism. — The  process  of  the  passage  of  a  foreign  body  or  blood- 
clot  and  its  deposit  in  a  different  portion  of  the  vascular  system  is  known  as 
embolism.  An  embolus  consists  of  a  detached  portion  of  a  thrombus,  a 
globule  of  fat,  a  vegetation  from  the  valves  of  the  heart,  or  a  portion  of  a 
tumor,  -which  is  swept  into  the  circulation  and  is  ultimately  arrested  in  some 
portion  of  the  arterial  or  A^enous  system,  where  it  causes  plugging  of  the 
vessel.  Emboli  may  arise  either  in  the  venous  or  in  the  arterial  system. 
An  embolus  is  arrested  when  it  reaches  a  vessel  whose  diameter  is  less  than 
its  own,  and  is  apt  to  lodge  in  a  vessel  at  a  point  where  its  diameter  very 
suddenly  diminishes, — for  instance,  after  a  bifurcation.  When  an  embolus 
lodges  it  may  partially  or  completely  obstruct  the  circulation  in  the  parts 
sui)plied  by  the  obstructed  vessel.  Tlie  results  following  embolism  depend 
upon  the  size  of  the  embolus  and  the  site  of  its  arrest,  as  well  as  upon 
whether  it  is  infective  or  non-infective.  A  small  non-infective  embolus  may 
be  arrested  in  a  vessel  and  give  rise  to  no  marked  symptoms,  or  may  be 
lodged  in  the  pulmonary  artery,  giving  rise  to  dyspnoea,  haemoptysis,  and  a 
localized  pneumonia.  On  the  other  hand,  an  embolus  may  be  arrested  in 
one  of  the  cerebral  vessels  and  cause  paralysis  or  subsequent  degenerative 
changes  in  the  cerebral  tissue,  or  a  large  embolus  may  be  arrested  in  the 
heart,  pulmonary  or  cerebral  arteries,  and  cause  sudden  death. 

Treatment. — In  view  of  the  possibility  of  embolism  which  may  be  rap- 
idly fatal  or  may  result  in  permanent  impairment  of  function,  the  greatest 
care  should  be  exercised  in  every  case  of  thrombosis  to  prevent  this  com- 
plication. A  patient  with  a  thrombosed  vein  should  be  kept  at  rest,  and 
the  part  shoiild  also  be  kept  entirely  at  rest  for  two  or  three  weeks  until 
sulficient  time  has  elapsed  for  the  organization  of  the  clot,  or  until  it  has 
been  absorbed  or  disintegrated.  The  detachment  of  a  portion  of  the  clot 
takes  j)lace  without  warning,  often  upon  some  slight  exertion.  Sudden 
death  from  cardiac  arrest  in  these  cases  has  generally  occurred  in  patients 
who  were  considered  out  of  danger  ;  therefore  the  surgeon  should  keep  the 
patient  at  rest  for  a  suflicient  time  to  avoid  this  danger. 

PHLEBITIS. 

This  consists  in  an  inflammation  of  the  coats  of  a  vein,  which  is  followed 
by  changes  in  these  structures,  and  may  exist  as  a  plastic  and  as  a  suppura- 
tive phlebitis. 

Plastic  Phlebitis. — This  consists  in  an  inflammation  of  the  coats  of 
a  vein  in  which  there  is  an  effusion  of  plastic  lymph,  and  may  arise  from 
injury,  giving  rise  to  a  traumatic  phlebitis,  or  from  a  perivascular  inflamma- 
tion ;  from  the  presence  of  a  thrombiis  in  a  vein,  thromho-'phlebitis ;  or  from 
gout,  gouty  phlebitis.  A  form  of  chronic  plastic  phlebitis  is  also  occasionally 
seen,  in  which  the  inflammation  spreads  slowly  along  the  vein  in  the  direc- 
tion of  its  current  and  the  vessel  is  finally  converted  into  a  firm  fibrous 
cord.  Plastic  phlebitis  may  terminate  in  resolution  without  marked  alter- 
ation in  the  lumen  of  the  vessel,  or  may  cause  its  obliteration  at  the  seat  of 
disease. 


SUPPUEATIVE  PHLEBITIS.  345 

Pathology. — In  all  cases  of  phlebitis  there  is  observed  marlted  change 
iu  the  intima  ;  in  thrombo-phlebitis  the  proliferation  of  the  endothelial  cells 
is  very  active,  and  they  may  extend  into  the  thrombus.  In  cases  resulting 
fi'om  injury  or  extension  of  iniiammatiou  from  iierivascular  structures,  the 
outer  and  middle  coats  present  softening  and  cell  infiltration  and  the  deposit 
of  plastic  lymph ;  the  endothelium  is  involved  to .  a  less  degree.  Plastic 
phlebitis  i)reseuts  little  tendency  to  extension,  and  is  usually  limited  to  the 
portion  of  vein  injured  or  to  the  region  of  the  thrombus.  Gouty  phlebitis  is 
generally  symmetrical. 

Symptoms. — In  plastic  phlebitis  pain  and  tenderness,  and  sometimes 
discoloration  are  noticed  over  the  inflamed  vein,  and  it  can  be  felt  as  a  hard, 
knotted  cord.  GEdema  of  the  tissues  drained  by  the  vein  is  very  marked  ; 
more  or  less  constitutional  disturbance,  as  evidenced  by  elevation  of  the 
temperature  and  acceleration  of  the  pulse,  may  be  present,  but  the  consti- 
tutional disturbance  in  this  form  of  phlebitis  is  not  so  marked  as  in  septic 
or  suj)purative  phlebitis. 

Treatment. — The  patient  should  be  put  at  rest  in  bed,  and  the  inflamed 
part  should  be  supported  and  raised  upon  a  liillow,  to  favor  the  return  of 
venous  blood.  Absolute  rest  of  the  part  and  as  little  manipulation  as  pos- 
sible are  the  chief  indications  to  be  followed,  for  the  greatest  danger  is  from 
embolism.  The  tissues  over  the  inflamed  vein  should  be  covered  by  a  strip 
of  lint  spread  with  ointment  of  belladonna  and  mercury  equal  parts,  and 
over  this  should  be  placed  a  layer  of  cotton  batting,  which  may  be  made  to 
cover  the  whole  limb  ;  a  flannel  bandage  should  next  be  evenly  applied  to 
the  part,  from  its  lowest  extremity  to  a  point  some  distance  above  the  seat 
of  the  disease.  This  dressing  should  be  allowed  to  remain  for  four  or  five 
days  ;  subsequent  dressings  should  be  made  as  infrequently  as  possible,  and 
the  greatest  care  as  regards  manipulation  and  movement  of  the  parts  should 
be  exercised,  on  account  of  the  risk  of  embolism. 

The  patient's  constitutional  condition  should  also  receive  attention.  The 
use  of  saline  purgatives  is  often  followed  by  good  results,  and  in  gouty  cases 
the  regulation  of  the  diet  is  a  matter  of  great  importance.  The  solid  oedema 
of  the  lower  extremities,  which  often  persists  long  after  the  inflammatory 
symptoms  have  subsided,  is  a  troublesome  feature.  Hot  douches  and  gentle 
friction  or  massage  will  generally  be  of  service  in  relieving  this  condition, 
but  in  many  cases  the  patient  will  get  relief  only  by  the  wearing  of  a  well- 
fitting  elastic  stocking,  or  an  elastic  webbing  bandage,  the  use  of  which  may 
have  to  be  continued  for  months. 

Suppurative  Phlebitis. — This  condition  results  from  infection  of 
the  walls  of  a  vein  by  pyogenic  organisms,  which  may  reach  the  vein  from 
infected  perivascular  tissues,  or  by  way  of  the  circulation,  or  by  means  of 
an  infected  embolus  which  becomes  lodged  in  the  vein.  This  form  of  phle- 
bitis, which  is,  fortunately,  much  less  frequent  since  the  imjiortance  of 
asepsis  in  wound  treatment  has  been  fully  recognized,  is  followed  by  the 
development  of  a  thrombus  at  the  seat  of  inflammation,  which  is  itself  soon 
infected.  This  disease  often  follows  septic  wounds,  and,  as  in  most  cases  of 
septicaemia  and  pyaemia  the  infection  occurs  by  means  of  the  veins,  this 
affection  bears  a  very  close  relation  to  these  diseases. 


346 


SUPPURATIVE  PHLEBITIS. 


Fig.  266. 


Pathology. — The  walls  of  the  inflamed  vein  present  the  appearances 
common  in  suppurative  inflammation  ;  the  infected  thrombus  becomes  soft- 
ened and  purulent,  and  the  broken-down  material  and  the  ptomaines  result- 
ing enter  the  circulation ;  an  abscess  may  form,  or  septic  emboli  may  pass 
into  the  circulation,  causing  metastatic  abscesses  in  other  parts  of  the  body  ; 
or  septicaemia  may  result  from  the  toxic  products  which  have  entered  the 
circulation. 

Symptoms. — In  suppurative  phlebitis  of  superficial  veins  the  veins 
become  hard  and  tender  on  pressure,  the  surrounding  parts  are  swollen 

and  painful,  and  oedema  is  present  in 
the  parts  drained  by  the  veins.  The 
phlebitis  may  be  localized  and  the  skin 
may  become  red,  and  soon  the  pres- 
ence of  an  acute  abscess  can  be  recog- 
nized, or  the  disease  may  involve  the 
entire  vein,  in  which  case  the  whole 
limb  may  be  riddled  with  suppurating 
tracts.  The  patient  also  suffers  from 
elevation  of  temperature  and  increase 
in  the  pulse-rate,  the  tongue  becomes 
coated,  and  delirium  soon  develops.  If 
the  abscess  is  opened  or  discharges  spon- 
taneously, the  local  and  constitutional 
symptoms  may  rapidly  improve.  On 
the  other  hand,  the  above  symptoms 
may  be  followed  by  rigors  and  profuse 
sweating,  and  pytemia  may  occur.  If 
the  disease  involves  deep-seated  veins 
or  the  venous  sinuses  of  the  cranium, 
the  local  symptoms  may  not  be  marked, 
with  possibly  the  exception  of  oedema, 
and  the  occurrence  of  septicaemia  or 
pyaemia  may  first  call  attention  to  the 
condition. 

Treatment. — Suppurative  phlebitis 
is  always  a  grave  affection,  and  often 
gives  rise  to  a  fatal  septicaemia  or  pyae- 
mia, although  a  moderate  infection  may 
be  recovered  from,  or  the  amount  of  infection  may  be  limited  by  treatment. 
The  prompt  removal  of  the  infected  material  from  the  vein  before  the  blood 
has  been  widely  infected  offers  the  patient  the  best  chance  of  recovery.  As 
soon  as  the  condition  is  recognized,  the  inflamed  vein  should  be  laid  freely 
open,  and  the  infected  clot  removed  with  a  curette,  the  walls  of  the  vein 
being  carefully  swabbed  with  a  thirty-grain  solution  of  chloride  of  zinc  or 
pure  carbolic  acid,  and  the  cavity  packed  with  iodoform  gauze.  (Fig.  266.) 
Hemorrhage  is  not  usually  troublesome,  but  if  this  occurs  when  the  vein 
is  opened,  a  ligature  should  be  applied  to  a  healthy  portion  of  the  vein  on 
each  side  of  the  infected  area,  which  will  serve  the  double  purpose  of 


Cicatrices  of  incisions  made  in  suppurative 
phlebitis. 


VARICOSE  VEINS. 


347 


cutting  off  tlie  vessel  from  tlie  circulation  and  thus  preventing  septic  emboli 
from  entering  the  circulation,  and  of  controlling  the  bleeding.  Another 
method  consists  in  ligating  the  vein  above  at  a  point  where  it  is  healthy, 
and  subsequently  laying  it  open  from  this  point  downward,  as  well  as  all 
branches  which  are  inflamed,  and  irrigating  them  freely  with  au  antiseptic 
solution.  If  the  operation  is  done  ijromptly,  mai-ked  improvement,  both 
local  and  constitutional,  is  iisually  quickly  observed.  If  secondary  or  meta- 
static abscesses  develop  in  the  course  of  the  disease,  they  should  be  promptly 
opened  and  sterilized.  A  patient  suffering  with  septic  or  suppurative 
phlebitis  should  be  given  a  nourishing  diet,  stimulated  freely,  and  given 
such  tonics  as  quinine,  iron,  and  strychnine  in  appropriate  doses. 

VARIX,    OR  VARICOSE   VEINS. 

A  varis  is  a  permanent  pathological  dilatation  of  a  vein.  Veins  which 
are  so  affected  are  said  to  be  varicose,  and  present  an  enlai'ged,  elongated, 
tortuous,  and  knotted  condition.  The  superficial  veins  of  the  lower  extremity 
are  those  most  commonly  involved, 
the  internal  saphenous  vein  and  its 
branches  being  most  often  affected 
(Fig.  267)  ;  but  the  veins  of  the 
labia,  those  of  the  spermatic  cord, 
and  the  hemorrhoidal  veins,  as 
well  as  those  of  the  trunk  and  the 
upper  extremity,  may  present  this 
condition.  The  deep  veins  are 
usually  free  from  the  disease,  but 
occasionally  the  communicating 
branches  between  the  deep  and 
the  superficial  veins  are  involved, 
and  a  varix  is  not  infrequently 
observed  at  this  point. 

The  disease  begins  with  a  slow 
dilatation  of  the  vein ;  it  is  not 
only  enlarged  transversely,  but  is 
also  elongated,  and,  as  the  ends 
of  the  vein  are  fixed  points,  the 
increase  in  length  causes  it  to  be- 
come very  tortuous.  In  other  cases 
dilatation,  or  increase  transversely, 
is  most  marked,  and  elongation  or 
lengthening  does  not  occur  to  any 
extent.  The  coats  of  the  involved 
veins  are  markedly  thickened,  the 

endothelial  coat  presents  longitudinal  strine,  and  in  long-standing  cases 
atheromatous  change  or  calcification  may  sometimes  be  observed ;  the 
external  coat  is  also  very  much  thickened,  by  reason  of  connective- tissue 
infiltration  and  inflammatory  new  formation  to  which  the  name  periphle- 
bitis is  attached.     The  valves  are  shortened,  or  often  almost  disappear,  and 


Varicose  veins  of  the  legs. 


348  VARICOSE  VEINS. 

become  insufficient  to  support  the  column  of  blood.  The  thickening  and 
dilatation  may  not  uniformly  involve  the  whole  vein,  so  that  at  points  the 
thinned  wall  bulges  beyond  the  line  of  the  vessel,  giving  rise  to  a  condition 
known  as  a  venous  cyst. 

Causes. — Pathological  changes  in  the  walls  of  veins  and  any  causes 
which  produce  increased  intravenous  pressure  tend  to  the  production  of 
varicose  veins.  The  affection  is  seldom  seen  in  youth,  but  is  very  common 
in  middle  and  advanced  age  and  in  gouty  subjects.  Women  are  much  more 
apt  to  suffer  from  varicose  veins  than  men ;  the  disease  in  this  class  of 
patients  arises  from  interference  with  the  free  return  of  venous  blood  from 
the  obstruction  offered  by  the  physiological  or  pathological  enlargement  of 
the  uterus ;  the  venous  obstruction  caused  by  tight  garters  is  also  a  factor 
in  the  production  of  this  lesion.  Constipation  is  considered  by  some  author- 
ities a  potent  cause  of  this  affection,  a  distended  colon  causing  obstruction 
of  the  iliac  veins,  but  the  direct  relationship  between  varicose  veins  and 
constipation  has  not  been  clearly  proved,  for  many  cases  of  the  most  obsti- 
nate constipation  are  entirely  free  from  this  affection.  Occupation  plays  an 
important  part  in  the  production  of  varicose  veins  :  those  whose  occupation 
keeps  them  habitually  upon  their  feet  are  ax5t  to  present  this  condition. 
Gravity  increases  the  intravenous  pressure,  and  its  effects  are  most  marked 
at  the  lower  end  of  the  blood-column.  The  obstruction  caused  by  abdominal 
tumors  and  effusions,  and  diseases  of  the  heart  and  lungs,  in  which  a  feeble 
circulation  removes  the  vis  a  tergo  frova.  the  venous  blood-current,  are  well 
recognized  as  imijortant  factors  in  the  production  of  varicose  veins. 

Symptoms. — Extensive  varicosity  of  the  veins  may  exist  and  yet  no 
marked  symptoms  be  present.  Superficial  varicose  veins  are  recognized  by 
their  tortuous  outline  and  bluish  color.  Patients  who  suffer  from  varicose 
veins  usually  complain  of  a  sense  of  fulness  or  tension  and  more  or  less 
dull  pain  in  the  enlarged  veins  upon  walking  or  standing ;  this  is  quickly 
relieved  if  the  limb  is  raised  or  the  patient  assiimes  the  horizontal  posture. 
Wlien  venous  cysts  exist,  they  can  be  emptied  by  pressure  or  by  raising 
the  i^art  which  contains  them.  They  are  often  situated  near  the  saphenous 
opening,  and  give  a  distinct  impulse  upon  coughing,  so  that  they  have  some- 
times been  mistaken  for  femoral  hernia. 

Rupture  of  Varicose  Veins. — One  of  the  most  serious  symptoms  which 
may  arise  from  varicose  veins  is  hemorrhage,  which  usually  follows  a  scratch 
or  bruise  over  a  thinned  portion  of  the  vein  ;  the  bleeding  is  profuse,  and 
unless  checked  may  cause  a  fatal  result.  In  the  treatment  of  bleeding  from 
this  source,  elevation  of  the  part  will  often  arrest  the  hemorrhage,  or  per- 
manent control  of  the  bleeding  can  be  secured  by  elevating  the  part,  and, 
after  sterilizing  the  wound  and  the  surrounding  skin  with  bichloride  solu- 
tion, placing  over  it  a  compress  of  iodoform  or  sterilized  gauze,  held  firmly 
in  place  by  a  bandage,  including  the  liinb  from  the  toes  to  a  point  some  dis- 
tance above  the  wound.  This  should  be  allowed  to  remain  in  place  for  a 
week  or  more,  and  wben  removed  the  wound  will  usually  be  healed. 

Thrombosis. — This  is  a  frequent  comj)lication  in  varicose  veins,  and 
results  from  the  changes  in  the  inner  coats  of  the  veins  and  slowing  of  the 
blood- current,  or  from  contusion  or  laceration  of  the  enlarged  veins. 


TREATMENT  OF  VARICOSE  VEINS.  349 

Phlebitis. — This  may  arise  in  varicose  veins  from  infection,  and  may  be 
a  dangerous  complication.  According  to  Bennett  the  most  dangerous  region 
is  the  inner  side  of  the  leg  from  three  inches  belovr  the  knee  to  the  middle 
of  the  thigh,  where  the  main  trunks  unite  to  form  the  internal  saphena, 
because  of  connection  with  the  ijopliteal  vein  at  this  point. 

CEdema. — This  may  be  marked  in  the  parts  surrounding  the  vaiicose 
veins,  and  ipresent  the  characteristics  of  a  solid  induration  ;  upon  this  indu- 
rated tissue  there  frequently  develops  a  chronic  and  oistinate  eczema. 

Ulceration. — This  may  occur  in  the  indurated  tissues  surrounding  vari- 
cose veins  from  a  slight  wound,  or  from  rupture  of  a  thinned  portion  of  a 
vein,  and  if  healing  is  not  promptly  obtained  the  ulceration  may  extend 
and  give  rise  to  frequent  bleeding,  which  eventually  may  cause  a  condition 
of  chronic  antemia,  or  even  death.  Ulcfers  occurring  in  connection  witli 
varicose  veins  are  often  spoken  of  as  varicose  ulcers,  but  the  relation  of  the 
ulcer  to  the  varicose  veins  seems  rather  to  be  accidental  than  causal ;  the 
diminished  nutrition  of  the  indiirated  tissues  caused  by  the  varicose  veins 
predisposes  to  ulceration  after  slight  traumatism,  and  also  renders  the 
reparative  process  slow ;  bleeding  arises  only  when  a  vein  is  opened  by  a 
wound  or  by  the  ulcerative  process. 

Treatment. — The  treatment  of  varicose  veins  is  both  local  and  con- 
stitutional, and  consists  in  removing  as  far  as  possible  the  local  as  well  as 
the  constitutional  causes  which  maintain  the  condition. 

Palliative  Treatment. — This  aims  at  the  removal  of  the  causes  which 
produce  venous  obstruction,  and  in  the  majority  of  cases  is  followed  by  so 
much  improvement  that  operative  procedures  are  not  required.  It  consists 
in  the  removal  of  constricting  clothing,  causing  obstruction 
of  the  veins,  change  of  occupation,  rest  in  the  recumbent  ^^^-  ^*^®- 

posture,  and  out-door  exercise ;  the  condition  of  the  general 
health,  and  of  the  bowels  and  liver,  should  also  receive 
attention.  If  the  circulation  is  at  fault,  the  administration 
of  digitalis  and  stryclinine  will  often  be  followed  by  marked 
improvement.  The  use  of  fluid  extract  of  hamamelis  in 
from  fifteen-  to  twenty-minim  doses  seems  to  exert  a  bene- 
ficial effect  in  varicose  veins. 

Local  Treatment. — This  consists  in  the  use  of  an 
elastic  webbing  bandage  applied  evenly  to  the  part,  or  a  , 

neatly  fitting  silk  elastic  stocking.  These  elastic  appliances 
support  the  part  and  prevent  further  dilatation  of  the  veins, 
besides  tending  to  prevent  stagnation  of  the  blood  in  the 
veins  and  diverting  it  from  the  sujierficial  into  the  deep 
veins.  In  using  either  the  elastic  bandage  or  the  elastic 
stocking,  it  should  be  so  applied  that  it  will  make  pressure  ^'plTed 'tothTieg^^ 
upon  the  limb  from  the  lower  part  of  the  foot  to  a  point 
some  distance  above  the  seat  of  the  enlarged  veins.  (Fig.  268.)  The 
bandage  or  stocking  should  be  removed  at  night  when  the  patient  is  recum- 
bent. In  some  instances  it  is  necessary  to  include  the  limb  from  the  toes 
to  the  groin  in  the  stocking  or  bandage.  Before  applying  the  elastic 
stocking,  a  thin  cotton  stocking  should  be  placed  upon  the  limb. 


350  TEEATMEXT   OF  YAEICOSE   ^-EES'S. 

Operative  Treatment. — Where  comfort  or  relief  does  not  follow  tlie  lase 
of  tlie  measures  mentioned  above,  operative  treatment  should  be  resorted  to. 

In  all  operations  upon  veins  it  is  essential  that  the  greatest  care  should 
be  taken  as  regards  asepsis,  for  a  septic  jihlebitis  may  arise  from  careless- 
ness in  this  respect,  and  be  followed  by  most  serious  consequences.  The 
operations  which  are  now  most  widely  employed  for  the  relief  of  varicose 
veins  are  multi])le  ligature,  excision  of  a  portion  of  the  diseased  veins,  and 
Trendelenhurg^ s  or  Schede's  operations. 

Multiple  Ligature. — This  is  accomplished  by  making  a  small  incision 
over  the  enlarged  vein,  and  passing  around  the  vein  a  sterilized  silk  or  catgut 
ligature,  and  tying  it  securely  :  the  ends  of  the  ligature  should  be  cut  short, 
and  the  small  wound  should  be  closed  by  a  suture.  A  number  of  ligatures 
may  be  applied  in  this  manner  :  twenty  or  thirty  may  be  applied  to  veins 
of  the  leg  and  thigh  at  one  time.  After  closing  the  wounds  the  limb  should 
be  enveloped  in  an  antiseptic  di-essing  and  elevated,  and  the  patient  should 
be  kept  at  rest  in  bed  for  ten  days  or  two  weeks.  Satisfactory  obliteration 
of  the  veins  will  often  follow  this  procedure. 

Excision. — This  method  is  practised  when  there  are  tumor-like  masses 
of  varicose  veins  at  one  or  more  places,  the  rest  of  the  limb  being  healthy, 
and  consists  in  exposing  the  enlarged  veins  by  an  incision  three  or  four 
inches  in  length,  and,  after  dissecting  them  out,  applying  proximal  and 
distal  ligatures,  and  excising  the  portion  of  the  veins  between  the  ligatui-es. 
The  only  bleeding  that  is  likely  to  arise  is  that  following  the  division  of 
veins  communicating  with  the  deep  veins ;  if  such  bleeding  occurs,  the 
communicating  veins  should  be  secured  by  ligatures.  The  wounds  should 
be  closed  by  sutures,  a  sterilized  or  antiseptic  gauze  dressing  applied,  and 
the  limb  elevated,  and  the  patient  should  be  kept  in  bed  for  ten  days  or  two 
weeks.  The  results  following  this  method  of  treatment  are  most  satisfactory 
if  care  is  observed  to  prevent  infection  of  the  wound. 

Trendelenburg's  Operation. — This  operation  is  based  upon  the  fact 
that  insufGiciency  in  the  valves  of  the  long  saphenous  vein  allows  the  column 
of  blood  in  it  and  in  the  femoral  and  iliac  veins  to  cause  an  increased 
pressure  in  its  branches  when  the  person  stands.  The  operation  consists  in 
applying  two  ligatures  to  the  vein  at  the  juncture  of  the  upper  and  middle 
thirds  of  the  thigh  and  dividing  the  vein  between  the  ligatures.  The  results 
of  this  operation  ai'e  excellent,  seventy -iive  per  cent  of  cases  being  cured. 

Schede's  Operation. — This  consists  in  making  an  incision  around  the 
leg  at  the  junction  of  the  middle  and  upper  thirds,  dividing  the  skin  and 
subcutaneous  tissues,  including  the  enlarged  veins,  down  to  the  deep  fascia, 
ligatiug  all  divided  veins,  and  closing  the  incision  with  sutures.  This 
operation  has  the  disadvantage  that  it  leaves  a  circular  scar  and  is  apt  to  be 
followed  by  permanent  oedema  of  the  leg. 

AETEEIAL   VAEIX,    CIESOID    AXEUEISM,   PLEXIE0E:M    ANGIOMA. 

These  are  irregular  vascular  tumors  caused  by  a  circumscribed  dilatation 
and  elongation  of  one  or  more  arteries.  The  elongation  of  the  arteries  causes 
them  to  present  a  tortuous  appearance,  and  the  convoluted  vessels  ai'c  held 
together  by  a  small  amount  of  connective  tissue. 


CIRSOID  ANEURISM.  351 

Arterial  Varix. — This  consists  of  an  elongation  and  dilatation  of  a 
single  artery,  which  presents  the  tortuous  and  pouched  appearance  of  a 
varicose  vein,  and  also  well-defined  pulsation.  The  skin  over  the  dilated 
vessel  becomes  thin,  and  if  injured,  or  if  ulceration  occurs,  serious  or  fatal 
hemorrhage  may  take  place.  The  arteries  in  which  this  condition  is  most 
frequently  found  are  the  occipital,  temporal,  and  posterior  auricular. 

Cirsoid  Aneurism. — This  consists  of  an  Irregular  swelling  made  up 
of  tortuous  vessels,  which  can  be  plainly  seen  under  the  skin.     (Fig.  269.) 
The  skin  over  the  vessels  may  be  thin  or  thick, 
and  may  be  pigmented  or  of  a  dull  bluish  color.  ^'*'-  -'"'^■ 

The    tumor    may   present    well-marked    or    ill-  ,  -i^ 

defined  pulsation.     If  the  pulsation  is  forcible,  a         /  wi 

thrill  and  bruit  may  also  be  present.  The  pul- 
sation and  thrill  may  sometimes  be  diminished 
or  arrested  by  compressing  the  tortuous  arteries 
or  the  main  artery  from  which  they  are  de- 
rived ;   but,  owing  to  the  fact  that  the  vessels 

making  up  the  growth  are  derived  from  many        __^  \ 

sources,  it  is  often  difficult  to  arrest  the  pulsa-     ,  "  ' 
tion  by  pressure.  /     *  __ 

Plexiform  Angioma,  or  Aneurism  by  'a»    ^^ 
Anastomosis. — When  vascular  dilatation  in-  ^^^y  \ 

volves  not  only  the  arteries,  but  also  the  cap  ilia-         ^-^y     do- 
ries and  veins,  the  condition  resulting  is  known  as        cirsoid  anem-ism.    (Brans.) 
a  plexiform  angioma,  or  aneurism  by  anastomosis. 

Pathology. — In  all  these  varieties  of  vascular  growth  the  arteries  are 
dilated  and  present  a  varicose  condition ;  the  walls  are  much  thinned, 
atrophy  of  the  middle  coat  being  very  marked.  The  disease,  which  is  con- 
sidered to  arise  from  injury  or  disease  of  the  vasomotor  nerves,  producing 
a  localized  paralysis,  generally  involves  the  arteries  alone,  but  may  also 
involve  the  capillaries  and  veins.  The  skin  covering  the  vessels  may  be 
pigmented,  thickened,  or  thinned  ;  it  may  ulcerate  at  points,  giving  rise  to 
serious  hemorrhage. 

Diagnosis. — Cirsoid  aneurism  may  be  confounded  with  aneurism,  but  is 
distinguished  from  this  affection  by  the  situation  of  the  growth,  the  super- 
ficial pulsation  and  bruit,  the  appearance  and  number  of  vessels  involved, 
the  doughy  or  spongy  feeling,  and  the  difference  in  pressure  effects.  When 
a  cirsoid  aneurism  follows  an  injury  it  is  likely  to  be  confused  with  varicose 
aneurism,  as  pulsation,  bruit,  and  thrill  are  present  in  both  affections.  The 
diagnosis  of  these  conditions  may  be  made  by  observing  that  in  cirsoid 
aneurism  the  tumor  is  not  so  well  defined  as  in  varicose  aneurism,  and  that 
the  pulsation,  bruit,  and  thrill  are  not  arrested  by  compressing  a  single 
arterial  trunk,  as  is  the  case  in  varicose  aneurism.  In  aneurismal  varix  the 
pulsation  can  be  arrested  by  compression  of  a  single  arterial  trunk. 

Treatment. — The  treatment  of  these  forms  of  vascular  growths  is  diffi- 
cult, and  often  fails  from  the  fact  that  the  blood-supply  is  not  derived  from 
one  distinct  vessel,  but  from  numerous  vessels.  If  the  disease  involves  a 
limited  area,  the  continuous  wearing  of  a  metallic  shield  will  protect  the 


352  AETERITIS. 

part  from  injury,  and  may  be  followed  by  a  cure.  If,  howeyer,  it  is 
increasing,  operative  treatment  should  be  undertaken,  consisting  in  ligation 
of  tlie -supplying  vessels,  strangulation  of  the  mass  by  a  ligature,  ligation 
of  the  main  artery  of  the  part,  excision  of  the  diseased  tissues,  or  the  employ- 
ment of  electrolysis.  All  methods  of  operative  treatment  except  the  use  of 
the  ligature  and  electrolysis  are  accompanied  by  considerable  hemorrhage. 
If  hemorrhage  can  be  controlled  by  elastic  constriction  bj^  an  Esmarch  strap 
or  tube,  and  the  disease  is  not  too  extensive,  excision  is  the  most  satisfactory 
method ;  the  incisions  should  be  made  well  away  from  the  growth.  The 
application  of  a  number  of  ligatures  to  the  vessels  at  the  margin  of  the 
growth  and  ligation  of  the  main  artery  supplying  the  growth  have  beeu 
attended  with  only  moderate  success.  The  strangulation  of  the  whole  mass, 
if  moderate  in  extent,  by  one  or  more  ligatures  has  been  employed. 

Electrolysis  may  be  employed  in  cases  where  the  vessels  are  not  excessively 
dilated,  and  the  results  following  its  use  seem  to  indicate  that  it  is  a  safe  and 
reliable  method.  The  needles  passed  into  the  growth  are  attached  to  the 
positive  pole,  and  a  surface  electrode  is  attached  to  the  negative  pole  and 
placed  upon  the  surface  of  the  body.  A  strong  current  of  one  hundred  and 
fifty  or  two  hundred  milliamperes  is  required.  The  application  may  have  to 
be  repeated  a  number  of  times,  and,  as  the  operation  is  painful,  anaesthesia 

is  required. 

AKTEEITIS. 

Arteritis  is  an  inflammation  of  the  coats  of  an  artery,  and  the  terms 
endarteritis,  mesarteritis,  and  perictrteritis  are  used  to  designate  inflammation 
respectively  of  the  inner,  the  middle,  and  the  external  coat  of  the  vessel. 
Arteritis  may  be  either  acute  or  chronic.  Acute  arteritis  may  exist  in  several 
varieties, — acute  plastic  arteritis,  suppurative  arteritis,  and  embolic  arteritis. 

Acute  Plastic  Arteritis. — This  is  the  condition  which  develops  after 
wounds  or  ligation  of  arteries  in  which  aseptic  conditions  obtain,  and  rep- 
resents a  reparative  process  which  can  scarcely  be  classified  under  the  head 
of  a  disease.  The  process  has  been  described  under  the  repair  of  wounded 
arteries.  This  condition  gives  rise  to  no  marked  symptoms  and  requires  no 
special  treatment. 

Suppurative  Arteritis. — This  consists  in  an  acute  inflammation  of 
the  coats  of  an  artery,  the  infection  arising  from  the  presence  of  pyogenic 
organisms.  The  disease  usually  begins  as  a  periarteritis,  the  external  coat  of 
the  artery  being  infected  by  exijosure  in  an  unclean  wound,  by  the  presence 
of  a  contiguous  abscess,  or  by  the  api)lication  of  an  infected  ligature  or 
instrument.  In  the  case  of  an  artery  containing  a  thrombus  the  infection 
may  arise  from  the  blood,  in  which  case  an  endarteritis  will  be  developed 
which  will  rapidly  involve  the  remaining  coats  of  the  vessel.  The  process 
is  attended  by  softening  of  the  coats  of  the  vessel,  the  exudation  of  serum, 
and  the  migration  of  leucocytes,  and  as  a  result  of  these  changes  ulceration 
or  sloughing  of  the  walls  of  the  artery  occurs. 

Suppurative  arteritis  is  the  most  common  cause  of  secondary  hemorrhage  ; 
this  complication  following  wounds  or  the  ligation  of  arteries  was  very  fre- 
quent before  the  introduction  of  asepsis  iu  wound  treatment.  The  forma- 
tion of  a  blood-clot  at  the  seat  of  inflammation  in  the  vessel,  which  in  many 


CHRONIC  ARTERITIS.  353 

cases  extends  up  the  vessel  well  beyond  the  infected  area,  probably  explains 
the  fact  that  secondary  hemorrhage  does  not  occur  in  all  cases  of  supf)ura- 
tive  arteritis.  Arteries  which  have  been  contused  or  partially  lacerated,  if 
exposed  to  infection  in  a  wound,  are  less  able  to  resist  this  process  than 
uninjured  vessels ;  hence  in  such  cases  the  greater  liability  to  suppui-ative 
arteritis  and  secondary  hemorrhage.  The  surgeon  should  bear  in  mind  the 
possibility  of  the  development  of  this  affection  from  the  presence  of  abscess 
in  close  proximity  to  large  arteries,  which  should  lead  him  to  open  and 
disinfect  such  abscesses  at  the  earliest  possible  time.  Almost  every  surgeon 
has  seen  deep-seated  abscesses  of  the  neck  or  thigh  followed  by  secondary 
hemorrhage  from  the  carotid  or  femoral  artery. 

Embolic  Arteritis. — This  form  of  arterial  inflammation,  which  is 
extremely  infrequent,  resiilts  from  the  lodgement  in  an  artery  of  an  infected 
embolus,  which  sets  up  an  infective  endarteritis,  the  intima  becoming 
cedematous  and  infiltrated  with  pus-cells,  and  the  infective  process  extend- 
ing to  the  other  coats  of  the  vessel,  resulting  in  the  formation  of  an  abscess  ; 
or  the  softening  effect  of  the  inflammation  upon  the  intima  and  the  other  coats 
may  cause  them  to  become  dilated  by  the  pressure  of  blood  within  the  vessel, 
producing  an  aneurism.  Eupture  of  an  abscess  or  of  an  aneurism  formed 
in  this  manner  is  usually  attended  by  a  fatal  result. 

Chronic  Arteritis  or  Endarteritis.— This  is  au  affection  of  the 
larger  arteries  which  occurs  in  advanced  age,  or  at  an  earlier  period  in  alco- 
holics, and  is  characterized  by  the  appearance  of  areas  of  degeneration  in 
the  coats  of  the  artery,  known  as  atheroma.  The  disease  begins  in  the 
deeper  layers  of  the  intima,  and  may  involve  segments  or  small  patches  of 
the  wall  of  the  vessel,  consisting  in  a  proliferation  of  the  small  flattened 
cells  lying  between  the  layers  of  fibrous  tissue.  Hyperplasia  of  the  connec- 
tive tissue  may  partially  or  completely  occlude 
the  lumen  of  the  vessel,  giving  rise  to  a  condi-  ^^°-  270. 

tion  known  as  obliterating  arteritis.  The  athero- 
matous areas  further  undergo  fatty  or  calcareous 
degeneration.  Fatty  degeneration  is  attended  with 
softening  and  liquefaction  of  the  tissues  and  the 
formation  of  the  so-called  atheromatous  al)scess,  the 
contents  of  which  are  not  pus,  but  fatty  matter 
and  cholesterin  :  the  cavity  resulting  gives  rise 
to  the  atheromatous  nicer.  Calcareous  degeneration 
may  follow  fatty  degeneration  or  occur  indepen- 
dently of  it,  and  consists  in  the  deposit  of  fine 
granules  of  carbonate  and  phosphate  of  calcium, 

°      .    -,  ,  .J       „    ,       ,    ,  ,-„.        „„„.  Atheroma  of  the  arch  of  the  aorta. 

which  coalesce  into  flat  plates,  (Fig.  270)  or  an-  (After  Agnew.) 

nular  bands,  constituting  laminar  or  annular  cal- 
cification.    Partial  or  complete  separation  of  these  plates  sometimes  gives 
rise  to  thrombosis  or  embolism. 

Atheromatous  degeneration  of  an  artery  is  an  important  factor  in  the  causa- 
tion of  an  aneurism,  as  the  vessel  is  apt  to  yield  at  the  situation  of  an  athero- 
matous ulcer.  The  atheromatous  condition  of  superficial  vessels,  such  as  the 
radial,  the  femoral,  and  the  temporal,  can  often  be  distinctly  felt  by  the  finger. 


354  ANEURISMAL  VARIX. 

Treatment. — There  is  no  treatment  that  can  restore  to  its  normal  con- 
dition an  artery  in  which  atheromatous  changes  have  taken  place,  but  a 
patient  j> resenting  such  conditions  should  avoid  arterial  strains  and  excesses 
of  all  kinds. 

Syphilitic  Arteritis. — This  form  of  arteritis  may  affect  all  of  the  arte- 
ries ;  the  vessels  become  thickened,  indurated,  and  narrowed,  and  as  the 
result  of  these  vascular  changes  cerebral  softening  and  gummatous  degenera- 
tion of  the  tissues  occur.  The  only  treatment  which  is  of  value  in  these 
cases  is  the  use  of  iodide  of  potassium,  or  of  this  drug  combined  with  mer- 
cury. The  arterial  changes  resulting  from  syphilis  are  considered  by  some 
authorities  to  be  imjjortant  factors  in  the  production  of  aneurism. 

Tuberculous  Arteritis. — In  this  condition  the  inner  coat  of  the 
artery  is  very  much  thickened,  the  other  coats  present  inflammatory  changes, 
and  the  lumen  of  the  vessel  may  be  much  diminished.  The  condition  results 
from  the  tubercle  bacilli  infiltrating  the  walls  of  the  artery. 

AETEEIOVENOUS    ANEUKISM. 

This  affection  consists  in  an  abnormal  communication  between  a  vein 
and  an  artery,  and  is  recognized  as  existing  in  two  forms,  mieurismal  varix 
and  varicose  aneurism. 

Aneurismal  Varix. — This  consists  in  a  direct  communication  between 
an  artery  and  an  adjacent  vein,  the  arterial  blood  passing  freely  into  the 
vein.  This  condition  most  commonly  results  from  simultaneous  wounding 
of  the  vein  and  the  artery,  resulting  from  stab  or  gunshot  wounds :  very 
rarely  it  is  congenital.  This  affection  was  formerly  often  seen  at  the  elbow, 
resulting  from  puncture  of  the  artery  and  vein  by  the  lancet  in  bleeding, 
when  this  procedure  was  very  generally  practised.  It  has  also  been  ob- 
served in  vessels  of  the  head,  neck,  axilla,  abdomen,  and  thigh.  As  the 
pressure  of  the  blood  is  greater  in  the  artery  than  in  the  vein,  the  blood  is 
forced  into  the  vein,  and  causes  its  dilatation  near  the  seat  of  communication, 
as  well  as  dilatation  of  the  vein  to  the  distal  side  of  the  wound  by  obstruc- 
tion of  the  free  retiirn  of  the  venous  blood. 

Symptoms. — This  condition  is  marked  by  an  ill-defined  or  oblong 
compressible  tumor  with  expansile  i)ulsation,  thrill,  and  bruit ;  the  latter 
is  characterized  by  a  peculiar  purring  or  buzzing  sound,  which  closely 
resembles  that  j)roduced  by  a  fly  confined  in  a  paper  bag.  The  bruit,  thrill, 
and  pulsation  are  transmitted  for  some  distance  along  the  distended  veins. 
If  the  part  containing  the  varix  is  raised,  the  pulsation  becomes  weaker 
and  the  tumor  shrinks ;  if  the  part  is  lowered,  the  tumor  increases  in  size 
and  the  pulsation  becomes  more  ai^parent.  If  the  artery  is  compressed 
siif&ciently  to  shut  off  its  current,  the  pulsation  ceases  and  the  tumor  dis- 
aj)pears.  The  patient  often  complains  of  pain  in  the  tumor  and  of  a  sense 
of  numbness  in  the  parts  below.  If  the  venous  return  is  much  obstructed, 
the  parts  below  become  oedematous. 

Treatment. — In  many  cases  the  tumor  does  not  increase  in  size,  and 
causes  the  patient  so  little  inconvenience  that  it  is  necessary  only  to  wear  a 
compress  or  an  elastic  bandage  over  it.  If,  however,  pain  is  a  prominent 
symptom,  or  if  there  is  marked  obstruction  to  the  return  of  the  venous  blood, 


TRAUMATIC  ANEURISM. 


355 


(Bell.) 


as  shown  by  oedema  and  ulceration  of  the  parts  below,  operative  interfer- 
ence is  demanded.  This  consists  in  the  application  of  two  ligatures  to  the 
artery,  one  above  and  one  below  the  seat  of  the  vascular  communication,  or 
excision  of  the  vessel  at  the  point  of  communication. 

Varicose  Aneurism. — In  this  affection  there  is  a  communication 
between  an  artery  and  a  vein  through  an  interposed  aneurismal  sac.     This 

form  of  arteriovenous  aneurism  re- 
FiG.  271.  suits  from  stab,  punctured,  or  gunshot 

wounds  of  an  artery  and  a  vein,  a 
circumscribed  aneurism  forming  be- 
tween the  artery  and  the  vein,  and 
communicating  with  both.  It  may 
develoiJ  from  an  aneurismal  varix  if 
the  tissues  uniting  the  vessels  yield 
slowly.  The  vein  becomes  dilated 
and  thickened,  as  in  varicose  veins. 
(Fig.  271.) 

Symptoms. — The  symptoms  are  those  of  aneurismal  varix,  with  the 
addition  of  those  of  aneurism.  Pulsation,  thrill,  and  a  buzzing  sound  are 
present,  and  in  addition  a  soft  aneurismal  bruit  can  often  be  distinguished. 
If  the  circulation  in  the  artery  is  arrested,  the  vein  collapses,  and  the  outline 
of  the  aneurism  can  often  be  made  out  as  a  firm  tumor. 

Treatment. — Operative  treatment  is  usually  required.  The  limb  should 
be  rendered  bloodless  by  Esmarch's  bandage,  and  the  artery  exposed  and 
ligated  above  and  below  the  seat  of  communication  ;  the  sac  and  its  com- 
munication with  the  artery  are  located,  and  two  ligatures  are  applied  to  the 
vein,  after  which  the  sac  is  removed.  The  results  following  ligation  of  the 
vessels  and  the  removal  of  the  sac  are  very  satisfactory. 

TRAUMATIC   ANEURISM. 

This  consists  of  a  subcutaneous  collection  of  arterial  blood  in  the  tissues 
communicating  with  a  wounded  artery,  and  in  the  strict  acceptation  of  the 
term  is  not  an  aneurism,  as  none  of  the  coats  of  the  artery  enclose  or  circum- 
scribe the  collection. 

A  traumatic  aneurism  may  be  diffused  or  circumsciibed,  and  may  result 
from  a  subcutaneous  rupture  or  from  a  punctured  wound  or  complete  or 
incomplete  division  of  an  artery.  It  may  occur  as  the  result  of  gunshot 
wound,  the  vessel  being  contused  at  the  time,  and  sloughing  later.  It  is 
also  seen  in  connection  with  open  wounds  of,  arteries,  where  the  external 
wound  has  healed  before  the  wound  in  the  artery  has  cicatrized.  As  the 
result  of  the  injury  to  the  walls  of  the  artery,  blood  escapes  into  the  sur- 
rounding tissues  in  greater  or  less  quantity,  according  to  the  extent  of  the 
wound  in  the  vessel ;  if  the  wound  is  an  extensive  one,  or  if  the  artery  is 
completely  ruptured,  blood  in  large  quantity  is  poured  out  in  the  tissues, 
and,  forcing  its  way  along  the  different  layers  of  fascise  and  muscles,  soon 
causes  marked  swelling  and  tension  of  the  parts ;  this  gives  rise  to  the  con- 
dition known  as  diffused  traumatic  aneurism.  If,  on  the  other  hand,  the 
wound  in  the  artery  is  a  small  one,  a  small  amount  of  blood  may  escape 


356  TRAUMATIC  ANEUEISM. 

gradually,  and  be  circumscribed  by  coagula  and  the  surrounding  tissues, 
whicli  form  an  adventitious  sac  ;  this  is  known  as  a  circumscribed  traumatic 
aneurism. 

A  diffused  traumatic  aneurism  usually  increases  rapidly  in  size,  and  may 
extend  widely  througli  the  tissues,  causing  much  swelling,  or  may  reach 
the  surface  and  rupture,  giving  rise  to  fatal  hemorrhage,  or  the  tissues  sur- 
rounding the  effused  blood  may  be  the  seat  of  acute  suppurative  inflamma- 
tion, which  gives  rise  to  abscess ;  when  this  opens  pus  is  discharged,  and 
this  is  followed  by  the  escape  of  clots  and  free  bleeding. 

A  circumscribed  traumatic  aneurism,  as  before  stated,  does  not  tend 
to  increase  rapidly  in  size,  as  the  sac  is  iirmer  and  stronger,  and  may  un- 
dergo spontaneous  cure  in  time,  but  is  liable  to  present  yielding  of  some 
portion  of  the  sac,  which  leads  to  a  rapid  enlargement  of  the  aneurism,  in 
which  case  the  conditions  are  similar  to  those  found  in  diffused  traumatic 
aneurism. 

Symptoms. — A  diffused  traumatic  aneurism  usually  presents  a  rapidly 
growing  swelling,  with  tension  of  the  overlying  tissues ;  there  may  be  feeble 
or  well-marked  expansile  pulsation  and  bruit,  and  a  thrill  can  usually  be 
detected.  The  pulse  in  the  artery  beyond  the  seat  of  swelling  may  be  feeble 
or  entirely  lost,  depending  u^jon  the  nature  of  the  wound  in  the  artei'y  and 
the  amount  of  pressure  produced  by  the  eifused  and  clotted  blood.  In 
diffused  traumatic  aneurism  of  the  extremities  the  parts  beyond  the  swelling 
become  oedematous  and  discolored  from  the  venous  obstruction  caused  by 
the  effnsed  blood.  Pain  at  the  seat  of  the  aneurism  and  numbness  in  the 
limb  are  also  marked  symptoms.  If  the  condition  is  not  promptly  treated, 
moist  gangrene  is  very  apt  to  occur.  In  circumscribed  traumatic  aneurism 
there  is  a  distinct  pulsating  tumor  ;  pressure-symptoms  are  not  always 
present,  and  the  symptoms  are  those  of  a  sacculated  aneurism. 

Diagnosis. — In  cases  of  traumatic  aneurism  the  diagnosis  is  generally 
not  diflELcult  unless  suppuration  in  the  tissues  around  the  effused  blood 
occurs,  giving  rise  to  the  formation  of  abscess.  The  diagnosis  can  usually 
be  easily  made  if  the  history  of  an  injury  is  elicited  which  was  followed  by 
rapid  swelling  and  oedema,  and  numbness  and  change  in  the  pulse  in  the 
vessels  of  the  parts  below  ;  but  every  case  should  be  carefully  examined  to 
determine  the  presence  in  the  swelling  of  pulsation,  bruit,  and  thrill. 

Treatment. — A  circumscribed  traumatic  aneurism,  if  the  swelling  does 
not  tend  to  increase  in  size,  may  be  cured  by  elevation  and  rest  of  the  part, 
with  moderate  pressure  at  the  seat  of  swelling  by  a  compress  and  bandage. 
If,  however,  this  fails  to  produce  a  cure,  compression  of  the  artery  upon  the 
f)roximal  side  close  to  the  sac  may  be  employed  ;  and  if  this  is  unsuccess- 
ful, a  proximal  ligature  should  be  applied  to  the  artery,  or  excision  of  the 
tumor,  with  ligation  of  the  vessel  above  and  below  the  aneurism,  must  be 
resorted  to. 

In  diffused  traumatic  aneurism  of  the  extremities,  where  the  circulation 
can  be  readily  controlled  by  a  tourniquet,  as  soon  as  the  nature  of  the  arte- 
rial lesion  is  apparent  i^romjit  treatment  should  be  instituted,  for  delay  is 
apt  to  result  in  gangrene.  The  circulation  having  been  controlled  by  a 
tourniquet  or  an  elastic  strap,  the  swelling  should  be  freely  incised,  blood- 


ANEURISM.  357 

clots  turned  out,  and  the  injured  vessel  songbt  for.  When  this  is  found,  if 
it  is  completely  divided,  both  ends  should  be  secured  by  ligatures,  or,  if 
incompletely  divided,  the  division  should  be  completed  and  the  ends  of  the 
vessel  ligated.  The  cavity  should  be  cleared  of  blood-clots,  a  drainage- 
tube  introduced,  and  the  wound  closed.  Care  must  be  taken  not  to  injure 
the  accomxianying  vein  in  exposing  and  ligating  the  artery. 

If  the  aneurism  arises  from  an  artery  in  which  it  is  impossible  to  control 
the  circulation  during  the  operation  by  pressure  or  by  a  tourniquet,  such  as 
the  common  carotid  or  the  iliac,  the  successful  exposure  and  ligation  of  the 
injured  vessel  is  one  of  the  most  difficult  and  anxious  operations  in  sur- 
gery. In  such  cases  free  incision  of  the  swelling  is  accompanied  by  such 
profuse  bleeding  that  it  is  apt  to  be  fatal.  It  is  therefore  better  to  make  a 
small  incision  into  the  swelling  and  introduce  a  finger  and  feel  for  the  wound 
in  the  artery ;  the  warm  currrent  of  blood  may  guide  the  surgeon  to  the 
position  of  the  wound.  When  this  is  found,  bleeding  is  controlled  by  press- 
ure with  the  finger  while  the  external  wound  is  enlarged,  and  after  turning 
out  the  coagula  the  artery  is  grasped  with  haemostatic  forceps  and  ligated, 
or  a  ligature  is  passed  around  the  vessel  with  an  aneurism  needle  and 
tied.  The  distal  end  of  the  vessel  should  also  be  secured  by  a  ligature,  and 
the  wound  then  cleansed,  drained,  and  closed. 

In  cases  of  diffused  traumatic  aneurism  of  the  extremities  in  which  gan- 
grene has  occurred,  amputation  at  the  seat  of  injury  of  the  artery  is  the  most 
satisfactory  treatment. 

ANEURISM, 

An  aneurism  is  a  circumscribed  dilatation  of  one  or  more  coats  of  an 
artery. 

Aneurisms  are  classified  according  to  their  origin,  shape,  and  the  struc- 
tures forming  their  walls.  The  first  classification  includes  sj)ontaneous  and 
traumatic  aneurisms,  the  former  occurring  primarily  as  the  result  of  disease, 
although  the  exciting  cause  may  have  been  a  single  severe  or  more  com- 
monly a  series  of  mild  traumatisms  applied  to  the  affected  part,  and  the 
latter  following  a  wound  of  one  or  more  of  the  coats  of  the  vessel  wall.  A 
second  classification  is  made  according  to  their  shape  into  tubular  or  fusi- 
form, sacculated,  and  dissecting.  A  third  classification  is  based  upon  their 
structure,  including  true  and  false  aneurisms.  In  the  true  variety  all  the 
three  coats  of  the  artery  are  represented  in  the  sac,  while  in  the  false  one  or 
more  of  the  coats  are  wanting.  This  is  a  ]30or  classification,  as  all  stages  of 
gradation,  from  true  to  false,  are  observed  in  aneurisms,  owing  to  the  ten- 
dency to  degeneration  of  some  of  the  coats  of  the  sac.  Aneurisms  are  also 
occasionally  classified  as  circumscribed  and  diffused, — a  division  of  little 
importance,  the  diffused  form  being  merely  the  condition  following  the 
internal  rupture  of  the  circumscribed  form. 

Tubular  or  Fusiform  Aneurism. — This  is  an  aneurism  in  which 
the  dilatation  of  the  artery  involves  the  entire  caliber  of  the  vessel ;  it  is  in 
this  form  that  the  so-called  true  aneurism  is  most  frequently  found,  biit  here 
also  the  middle  coat  very  frequently  is  the  seat  of  degeneration,  the  muscu- 
lar fibres  sometimes  entirely  disappearing  or  becoming  widely  separated  as 
the  disease  progresses.     (Fig.  272.)     It  is  frequently  converted  into  one  of 


358 


DISSECTING  ANEURISM. 


Fusiform  aneurism. 
(Agnew.) 


Sacculated  aneurism. 
(Agnew.) 


the  sacculated  variety  by  a  circumscribed  weakeuing  of  its  wall.    This  form 
of  aneurism  is  most  commonly  found  in  the  thoracic  and  abdominal  vessels, 
and  sometimes  in  the  arteries  at  the  base  of  the  brain. 
■^'°-  ^'^-  Sacculated  Aneurism. — This  is  one  in  which  the 

dilatation  is  found  on  one  side  of  the  vessel,  the  opening 
between  the  sac  and  the  vessel  being  called  the  mouth. 
(Fig.  273.)     It  may  originate  pri- 
iG.    16.  marily,  or  may  develop  from  the 

tubular  form,  and  varies  greatlj'  in 
size ;  in  the  larger  ones  all  dis- 
tinction as  to  original  coats  is  finally 
lost,  the  sac  being  composed  of 
fibrous  tissue  derived  from  the 
thictened  intima  and  adventitia 
incorporated  with  the  surrounding- 
tissues,  which  are  converted  into 
fibrous  tissue. 

Dissecting     Aneurism.  — 

This  results  from  ijerforation  of  the 
intima,  as  fi'om  laceration  or  rup- 
ture of  an  atheromatous  ulcer. 
There  is  an  extravasation  of  blood 

into  the  vessel  wall,  which  dissects  between  its  layers  for  a  varying  distance, 

and  finally  ruptures  internally  into  the  lumen  of  the  vessel  or  externally  into 

the  surrounding  tissue.     It  is  a  rare  form  of 

aneurism,  generally  occurring  in  the  aorta, 

especially  in  women,  and  may  exist  for  years. 

In  cases  in  which  it  opens  into  the  artery  at 

its  beginning  and  termination  a  double  tube 

is  present,  which  may  simulate,  and  has  in- 
deed been  mistaken  for,  the  rare  congenital 

anomaly  of  a  double  aorta.     (Fig.  274. ) 
Causes. — The  causes  of  aneurism  are 

predisposing  and  exciting. 

Predisposing  Causes. — These  include 

whatever  tends  to  decrease  the  strength  of 

the  vessel  wall  or  to  increase  the  strain  which 

it  is  forced  to  bear.     The  most  important 

predisposing  cause  is  atheroma,  especially 

in  its  earlier  stages,  when  there  have  already 

taken    place    infiltration    and    degeneration     Dissecting  aneurism  of  the  aorta.   (Agnew.) 

'  of  the  media  and  adventitia  without  coin- 
pen  sating  endarteritis,  which  develops  later.  In  the  later  stages,  when  cal- 
careous changes  are  present,  the  decreased  elasticity  of  the  vessels  causes 
increased  pressure  and  predisposes  to  dilatation.  All  diseases  which  give 
rise  to  atheroma,  such  as  alcoholism,  rheumatism,  syphilis,  and  gout,  are 
predisposing  causes.  Eheumatism  may  cause  aneurism  through  the  pro- 
duction of  emboli.     Individuals  are  occasionally  seen  who  have  a  tendency 


Fig.  274. 


PATHOLOGY   OF  ANEURISM.  359 

to  the  development  of  aneurisms  in  different  parts  of  the  body  without 
apparent  cause.  These  cases  of  so-called  cmeurismal  diathesis  are  explainable 
by  deficiency  in  the  development  of  the  arterial  coats. 

Sex. — Aneurism  is  more  common  in  males  than  in  females,  in  the  pro- 
portion of  seven  to  one.  This  is  due  to  the  greater  strain  on  the  vessels  in 
males  consequent  on  muscular  exertion,  and  to  their  more  frequent  exposure 
to  the  diseases  producing  atheroma.  Age. — Age  is  a  predisposing  factor  ; 
middle  life,  a  period  of  considerable  activity,  with  beginning  atheroma,  is 
the  period  at  which  aneurism  is  most  frequently  developed.  Aneurism 
occurring  in  childhood  and  youth  is  the  result  of  embolism  or  of  a  develop- 
mental weakness.  Occupation. — Occupations  involving  severe  muscular 
exertion  predisi^ose  to  aneurism  ;  thus,  soldiers  and  laborers  suffer  from  this 
affection.  Country. — Aneurism  is  usually  said  to  be  more  common  in  Eng- 
land and  Ireland  than  elsewhere.  Eldridge  has  recently  called  attention  to 
the  frequency  with  which  it  is  encountered  in  European  residents  in  Japan, 
a  fact  which  he  attributes  to  the  wide-spread  distribntion  of  syphilis  among 
the  earlier  residents.  Hypertrophy  of  the  Heart. — This  affection,  by  in- 
creasing blood-pressure,  may  act  as  a  predisi)osiug  cause. — Position  of  the 
Vessel. — This  is  an  active  predisposing  cause,  so  far  as  it  determines  the  site 
of  the  aneurism.  Thus,  large  vessels  situated  near  the  heart,  into  which  the 
blood  is  thrown  at  high  pressure,  often  increased  by  curves  in  the  vessel  itself, 
as  the  aorta,  innominate,  and  subclavian,  are  especially  liable  to  aneurism. 
It  also  occurs  in  those  positions  in  which  muscular  strains  are  greatest,  as 
shown  by  the  more  frequent  occurrence  of  aneurism  in  the  vessels  of  the 
right  arm  than  in  those  of  the  left,  and  where  vessels  are  exposed  to  trau- 
matism, as  in  the  femoral  and  popliteal  arteries.  There  is  also  a  disposition 
to  the  formation  of  aneurism  at  the  point  of  bifurcation  of  the  vessel ;  for 
examjple,  at  the  divisions  of  the  common  carotid  and  poi^liteal. 

Exciting  Causes. — These  are  severe  blows,  wounds,  or  violent  exer- 
tion ;  severe  concussion  of  the  mediastinal  region  may  give  rise  to  aortic 
aneurism,  and  strains  of  the  popliteal  artery  in  conjunction  with  dilatation 
of  that  vessel  have  especially  been  noted  as  causes  of  popliteal  aneurism.  A 
peculiar  exciting  cause  of  aneurism  occurs  in  acute  rheumatism  and  ulcera- 
tive endocarditis  :  emboli  are  liberated,  which  act  either  by  (1)  plugging  of 
the  artery,  with  subsequent  dilatation  to  the  cardiac  side  {embolic  aneurism^, 
or  (2)  by  carrying  micro-organisms,  which  set  up  degenerative  jirocesses  in 
the  vessel  wall  {mycotic  aneurism). 

Pathology. — Aneurisms  are  classified  according  to  their  patliology, 
into  aneurisms  by  dilatation  and  aneurisms  by  ru/pture.  The  first  class  is 
due  to  the  dilatation  of  all  the  coats  of  the  vessel,  and  embraces  the  fusiform 
and  a  few  of  the  sacculated  variety, — the  so-called  true  aneurisms.  In  the 
second  variety,  that  by  rupture,  which  includes  most  of  the  sacculated 
variety  and  all  of  the  dissecting  aneurisms,  the  initial  lesion  is  a  rupture  of 
the  intima  or  of  the  intima  and  media,  occurring  primarily  in  the  uudilated 
artery  or  secondarily  in  the  fusiform  variety.  This  rupture  may  be  due  to 
strain  acting  upon  the  slightlj'  thickened  intima,  or  to  the  rupture  of  an 
atheromatous  ulcer.  If  both  intima  and  media  be  ruptured,  as  bj'  the  burst- 
ing of  an  atheromatous  ulcer  the  edges  of  which  are  not  firmly  glued  together. 


360  SYMPTOMS  OF  ANEURISM. 

a  dissecting  aneurism  will  probably  result.  If  the  intima  alone,  or  the  intima 
and  elastic  coat  of  the  media,  be  torn,  unless  prompt  healing  takes  place, 
there  will  be  left  a  spot  of  lessened  resistance,  which  becomes  the  seat  of  a 
gradual  yielding  of  the  remaining  fibres  of  the  media  and  adventitia,  and  a 
sacculated  aneurism  results.  Where  a  sacculated  aneurism  develops  from 
a  fusiform  one,  it  is  known  as  a  mixed  aneurism. 

Structure. — The  wall  of  a  fusiform  aneurism  consists  at  first  of  all  the 
coats  of  the  vessel,  which  later  become  blended  with  one  another  and  with 
the  surrounding  structures.  In  sacculated  aneurisms  other  than  the  smallest 
the  same  condition  sooner  or  later  develops ;  the  surrounding  nerves,  fascia, 
cartilage,  and  even  bone,  with  much  inflammatory  tissue,  become  involved 
in  the  sac.  The  lining  of  the  sac  in  most  cases  consists  of  two  layers  of 
blood-clot :  the  outer,  that  in  contact  with  the  wall,  is  a  firm,  pale,  laminated 
layer  of  fibrin,  increasing  in  density  towards  the  periphery,  and  consti- 
tuting the  laminated,  fibrinous  or  active  clot.  It  is  derived,  according  to  some 
authorities,  from  the  blood-stream  in  its  passage  over  the  roughened  wall  of 
the  vessel,  which  acts  as  a  foreign  body  and  excites  clotting,  or,  according 
to  others,  from  the  quiet  blood  outside  of  the  main  stream,  as  an  ordinary 
clot,  subsequently  altered  by  pressure.  Inside  of  this  active  layer  is  a  soft, 
dark-red  coagulum  lining  the  channel,  which  is  the  passive  clot,  so  called 
because  of  the  minor  part  it  probably  plays  in  strengthening  and  curing 
the  aneurism.  The  deposition  of  the  laminated  clot  is  nature's  method  of 
effecting  a  cure,  and  acts  by  lessening  the  expansile  pressure  and  strength- 
ening the  wall  of  the  aneurism.  It  occasionally  becomes  organized  by  the 
migration  into  it  of  lymph-cells  from  the  sac,  and  upon  its  formation  several 
of  the  methods  adopted  for  the  cure  of  aneurism  depend  for  their  success. 
The  tendency  to  the  deposit  of  a  laminated  clot  is  poorly  developed  in  the 
fusiform  variety,  and,  other  things  being  equal,  those  aneurisms  in  which  it 
is  present  grow  more  slowly  than  those  in  which  it  is  absent. 

Symptoms. — These  are  subjective  and  objective. 

Subjective  Symptoms. — These  usually  result  from  pressure ;  pain  is 
generally  present  when  the  aneurism  reaches  any  size,  and  is  either  a  dull 
ache,  associated  with  a  feeling  of  weight  and  numbness  in  the  affected  part, 
or  is  neuralgic,  and  is  often  referred  to  the  distribution  of  the  nerve-trunks 
pressed  upon.  Pressure  on  bone  is  marked  by  a  severe  burning  or  boring 
pain.  Special  symptoms  are  often  due  to  pressure  on  important  structures, 
as  dysphagia,  from  j)ressure  on  the  oesophagus  ;  dyspncea,  from  obstruction 
of  the  trachea ;  cough,  croupy  in  nature,  and  change  in  the  voice,  from 
involvement  of  the  recurrent  laryngeal  nerve ;  pressui-e  u^jon  the  symjia- 
thetic  nerve  may  cause  dilatation  of  the  pupils  and  flushing  of  the  face. 
In  intracranial  aneurism  a  persistent  murmur  is  sometimes  complained  of, 
and  there  may  be  disturbances  of  the  special  senses. 

Objective  Symptoms. — External  aneurism  appears  as  a  rounded,  fluc- 
tuating, generally  non-inflammatory  swelling  in  the  course  of  the  artery. 
Palpation  shows  pulsation  synchronous  with  the  heart-beat,  and  different 
from  that  of  a  tumor  or  an  abscess  situated  over  the  artery  by  being  expansile 
in  character,  due  to  distention  of  the  sac  by  the  blood  passing  through  it. 
Pressure  on  the  artery  above  diminishes  or  checks  this  pulsation  and  causes 


COURSE  OF  ANEURISM.  361 

a  reduction  in  size.  Eemoval  of  the  pressure  causes  a  return  of  pulsation 
as  soon  as  the  sac  is  filled  ;  that  is,  after  one  or  two  heart-beats,  and  not 
immediately,  as  in  the  case  of  an  overlying  tumor.  As  deposition  of  clot 
takes  place,  pulsation  becomes  indistinct,  or  may  be  altogether  lost.  Fluc- 
tuation is  usually  present  early  in  the  case,  and  the  blood  can  be  easily 
squeezed  out ;  but  later,  as  a  clot  forms  inside  the  sac,  this  symptom  disap- 
pears. A  thrill  is  sometimes  felt,  but  is  not  constant,  as  is  the  case  in 
arteriovenous  aneurisms.  Auscultation  gives  a  peculiar  sound,  called  a 
bruit,  synchronous  with  the  heart-beat,  and  either  soft  and  blowing  or  loud 
and  rasping  in  natiire.  It  is  due  to  the  passage  of  blood  under  altered  con- 
ditions of  pressure,  and  is  transmitted  along  the  artery  beyond  the  aneurism. 
ComiDression  of  a  normal  vessel  will  often  cause  it,  and  it  is  heard  over  some 
vascular  malignant  tumors,  in  the  latter  case  not  being  transmitted.  The 
character  of  the  pulse  in  the  vessel  below  is  altered  ;  a  pulse-tracing  shows 
a  loss  of  the  impulse  and  of  the  dicrotic  wave,  and  a  diminution  in  the 
force  and  rapidity  of  the  tidal  wave.  This  is  due  to  the  conversion  of  the 
intermittent  current  into  a  continuous  one  by  the  pressure  of  the  blood  in 
the  elastic  sac.  The  circulation  in  the  limb  beyond  often  suifers  changes, 
due  to  pressure  of  the  aneurism  on  the  contiguous  veins,  causing  varicosities, 
oedema,  or  even  gangrene ;  or  these  symptoms  may  occasionally  be  due  to 
the  pressure  of  the  sac  upon  the  vessel  from  which  it  springs.  In  internal 
aneurism  many  of  the  objective  symptoms  are  wanting,  although,  if  it  attains 
large  dimensions,  it  may  become  subcutaneous  or  even  rupture  externally. 

Course  and  Termination. — The  tendency  of  an  aneurism  is  gener- 
ally towards  an  increase  in  size,  the  exception  being  in  the  case  of  a  few  of 
the  fusiform  variety.  This  enlargement  is  generally  more  rapid  in  the 
sacculated  form,  and  may  terminate  in  several  ways, — viz.,  inflammation, 
rupture,  gangrene,  syncope,  and  death  by  pressure  on  other  organs.  Si^on- 
taneous  cure  sometimes  takes  place,  either  by  the  formation  of  a  laminated 
clot  with  cessation  of  growth  and  disaj)pearance  of  jjulsation  followed  by 
contraction,  with  partial  or  complete  obliteration  of  the  vessel,  or  by  sudden 
plugging  of  the  artery  by  a  portion  of  the  detached  clot. 

Inflammation. — Mild  inflammation  is  a  not  infrequent  transitory  symp- 
tom, and  is  marked  by  slight  tenderness  and  redness.  In  its  suppurative 
form  it  is  an  exceedingly  dangerous  complication.  Suppuration  may  take 
place  either  in  or  around  the  sac,  and  is  indicated  by  a  lessening  of  pulsation 
and  bruit,  increase  of  cedema,  and  loss  in  distinctness  of  outline  ;  pain  and 
redness  are  present  in  a  more  marked  degree,  fever  and  chills  show  consti- 
tutional infection,  and  rupture  of  the  abscess  results  in  an  escape  of  choco- 
late-colored pus,  clotted  blood,  and  later  in  a  free  arterial  hemorrhage. 
The  artery  may  have  been  occluded  by  the  process,  and  a  cure  thus  be 
brought  about ;  this,  however,  is  not  common,  and  hemorrhage  in  such  cases 
is  a  frequent  cause  of  death. 

Rupture  of  the  Sac. — Diffused  aneurism  from  this  cause  is  attended 
by  mil  eh  the  same  symptoms  as  mark  the  onset  of  inflammation,  diminished 
Ijulsation,  loss  of  outline,  etc.,  except  that  the  temperature  of  the  part  is 
generally  reduced.  There  is  also  much  greater  obstruction  of  the  circulation 
beyond,  gangrene  often  ensuing  from  loss  of  the  arterial  circulation  and  the 


362  DIAGNOSIS  OF  ANEURISM. 

increased  venous  obstruction.  The  collection  of  blood  may  become  circum- 
scribed by  tlie  formation  of  an  adventitious  sac,  and  a  return  of  pulsation 
occm-.  More  commonly  suppuration  sets  in,  with  external  ruptui'e  and 
death  fi'om  hemorrhage.  If  ruj)ture  takes  place  into  a  cavity  or  on  the 
surface  of  the  body,  death  is  rapid.  On  mucous  siu'faces  there  is  generally 
a  prolonged  weeping  of  blood  before  the  final  rupture,  the  opening  being  of 
small  size  ;  whereas  on  serous  surfaces  it  is  large  and  stellate,  death  being 
correspondingly  rapid.  Gangrene  is  usually  preceded  by  venous  obstruc- 
tion, and  is  therefore  nearly  always  of  the  moist  variety,  and  is  not  an 
uucominon  comijlication  in  aneiirisms  of  the  extremities. 

Pressure. — Pressure  on  the  trachea,  oesophagus,  heart,  and  phrenic  and 
pneumogastric  nerves  sometimes  causes  death.  Syncope  as  a  cause  of  death 
is  most  frequent  in  aortic  aneurism,  and  is  due  to  sudden  failure  of  the  left 
ventricle  to  j)roi)el  the  great  quantity  of  blood  in  the  sac. 

Diagnosis. — ]S'umerous  cases  are  on  record  in  which  aneurisms  have 
been  mistaken  for  abscesses  and  opened  with  fatal  results.  Every  swelling, 
therefore,  in  the  line  of  an  artery  should  be  carefully  examined  with  a  view 
of  excluding  aneurism  before  an  operation  is  attempted.  Abscesses  and 
tumors  situated  over  blood-vessels  may  be  mistaken  for  aneurisms  by  reason 
of  transmitted  pulsation,  and  certain  malignant  pulsating  tumors,  as  osteo- 
sarcomata  and  encephaloids,  closely  simulate  aneurism.  From  a  tumor  or  an 
abscess  over  a  vessel  the  diagnosis  is  made  by  the  expansile  pulsation,  differ- 
ing from  the  up  and  down  movement  of  the  former,  the  j)ulsation  of  the 
tumor  disappearing  when  it  is  lifted  away  fi'om  the  vessel,  by  the  decrease 
in  size  when  the  artery  is  cpmi^ressed  above,  and  also  on  direct  pressure,  and 
by  the  bruit,  which  may  be  simulated  by  a  tumor  compressing  a  normal 
artery.  In  abscess,  signs  of  inflammation  aid  in  diagnosis.  A  diffused 
aneurism  with  loss  of  pulsation  and  beginning  inflammation  may  closely 
simulate  an  abscess,  but  is  commonly  attended  with  marked  obstruction  in 
the  circulation,  which,  with  the  history  of  the  case,  and  perhaps  recourse  to 
exploratory  puncture,  will  assist  in  a  correct  diagnosis.  Auscultation  and 
percussion,  with  secondary  pressure-symptoms  and  alterations  in  the  pulse, 
are  of  especial  value  in  the  diagnosis  of  intrathoracic  aneurism.  From  j)ul- 
sating  tumors  with  bruit  and  thrill  the  diagnosis  may  be  very  difficult.  They 
occur  in  early  life  and  often  in  other  regions  than  those  affected  by  aneurism, 
they  are  not  decreased  in  size  by  iDressure  on  the  artery  above,  nor  are  they 
much  altered  by  direct  pressure.  They  are  not  so  sharply  circumscribed, 
and  pulsation  and  bruit  vary  in  different  parts  of  the  tumor,  and  when  of 
bony  origin  the  bone  from  which  they  spring  is  commonly  altered  in  shape. 
In  the  abdominal  aorta  we  often  find  in  neurasthenic  females  a  violent  pulsa- 
tion or  throbbing,  which  has  frequently  led  to  the  diagnosis  of  aneurism  ;  but 
the  absence  of  a  definite  exi^ansile  tumor  is  the  all-imxDortant  diagnostic  sign. 

Arteriovenous  aneurisms  present  a  very  loud  bruit  and  a  constant  thrill, 
and  participation  of  the  veins  in  both  pulsation  and  bruit. 

In  most  of  the  fatal  accidents  from  mistaken  diagnosis  failure  to  use  the 
stethoscope  has  been,  according  to  Holmes,  the  principal  source  of  error. 

Treatment. — The  treatment  of  aneurism  is  both  medical  and  surgical, 
the  location  of  the  aneurism  largely  influencing  the  choice  of  method. 


TREATMENT  OF  ANEURISM.  363 

Medical  Treatment. — The  medical  treatment  commonly  known  as 
TufneWs,  is  especially  applicable  to  internal  aneurism,  and  is  used  also  in 
conjunction  with  surgical  methods  iu  external  aneurism.  It  is  most  useful 
in  the  sacculated  form  of  aneurism  with  a  narrow  mouth,  the  object  being 
by  absolute  rest  in  bed  to  diminish  the  force  and  number  of  heart-beats,  and 
by  low  diet  to  decrease  the  volume  of  the  blood  and  perhaps  increase  its 
fibrin-forming  constitiients.  Absolute  rest  in  bed  is  enforced  for  eight  or 
ten  weeks,  during  which  time  only  ten  ounces  of  solid  food  and  eight  ounces 
of  liquids  per  day  are  allowed,  according  to  Tufnell,  although  a  little  more 
latitude  in  the  case  of  solids  would  probably  be  advantageous.  Certain 
drugs  are  of  great  value.  Opium,  lactucarium,  and  lupulin  may  be  used 
for  restlessness  and  pain.  Iodide  of  potassium  is  one  of  the  most  important, 
although  its  beneficial  action,  aside  from  the  relief  of  pain,  is  not  well 
understood ;  from  ten-  to  twenty-grain  doses  three  times  a  day  are  indicated. 
Compound  jalap  powder  and  comj)ouud  rhubarb  pill  relieve  constipation 
and  have  a  depleting  effect.  Other  drugs  are  sometimes  beneficial,  such  as 
aconite  and  veratrum  viride,  acetate  of  lead,  and  chloride  of  barium.  For 
local  pain,  a  belladonna  plaster,  or  an  ice-cap,  is  useful.  Bleeding  is  called 
for  in  dyspnoea  and  venous  engorgement  from  pressure.  Patients  often  grow 
verjr  restive  under  this  treatment,  and  refuse  to  continue  it.  If  it  talis  and 
operative  treatment  is  impossible,  a  quiet  life  and  avoidance  of  excitement 
or  exertion  should  be  recommended. 

Surgical  Treatment. — The  methods  by  which  cure  is  effected  by 
nature  are  clotting  of  the  contained  blood,  either  (1)  slowly,  with  the  for- 
mation of  laminated  clot,  or  (2)  rapidly,  en  masse,  as  when  the  distal  orifice 
is  plugged  by  a  fragment  of  clot,  or  (3)  by  shutting  off  the  sac  from  the  gen- 
eral circulation,  as  sometimes  happens  in  supi)uration  and  sloughing.  The 
juethods  adopted  by  surgeons  also  effect  a  cure  in  one  of  these  three  ways. 
Those  which  act  by  producing  a  laminated  clot  are  (a)  slow  comjjression  on 
the  proximal  side,  and  (6)  two  forms  of  ligation, — Hunter'' s  (proximal)  and 
'Wardroi)''s  (distal).  Those  causing  rapid  clotting  are  (1)  rapid  compression, 
(2)  distal  compression,  (3)  Brasdor's  ligation,  (4!)  flexion,  (5)  Beid^s  method,  (6) 
injection  of  gelatin  solution,  (7)  galvano-puncture,  (8)  manipulation,  (9)  introduc- 
tion of  foreign  bodies,  (10)  acupuncture.  The  methods  of  attacking  the  sac 
itself  are  the  old  operation  {Antyllian)  and  the  modern  method  of  excision. 
Amputation  above  or  below  the  seat  of  disease  may  also  be  practised. 

Compression. — Compression,  which  is  the  ordinary  non-operative  form 
of  treatment,  is  especially  ai^plicable  to  aneurisms  of  the  extremities,  and 
embraces  comi^ression  of  the  artery  above  or  below  the  seat  of  the  aneurism, 
direct  compression  of  the  sac,  and  the  combination  of  the  two,  as  in  flexion 
and  Eeid's  method.  In  cases  forbidding  systematic  compression  or  opera- 
tion the  limb  may  be  simply  bandaged  and  elevated,  the  patient  being,  of 
course,  kept  at  rest.  This,  while  it  may  give  relief,  will  effect  a  cure  only 
in  aneurisms  of  small  vessels,  like  the  anterior  tibial. 

Proximal  Compression. — This  consists  in  compression  of  the  artery  at  a 
distance  from  the  aneurism,  and  may  be  digital  or  instrumental.  It  avoids 
the  necessity  for  operation,  involves  no  danger  of  secondary  hemorrhage, 
and  produces  a  fair  proportion  of  cures.     It  is  tedious,  often  painful,  and 


364  TREATMENT   OF  ANEURISM. 

■when  i^ractised  as  digital  compression  demands  a  number  of  skilled  assist- 
ants. It  is  contraindicated  in  rapidly  growing  aneurisms,  aneui'isms  threat- 
ening to  burst,  diffused  aneurisms,  and  those  in  which  venous  obstruction  is 
present.  It  is  most  useful  in  aneurisms  of  the  popliteal  and  brachial  arte- 
ries. In  certain  arteries,  as  in  the  abdominal  aorta  and  the  external  iliac, 
instrumental  comjsression  alone  is  practicable. 

Digital  Comj)res8ion. — The  skin  at  the  selected  x^oint  should  be  carefully 
dusted  with  boric  powder  or  French  chalk,  and  the  artery  firmly  pressed 
against  the  bone  until  pulsation  in  the  aneurism  is  arrested.  One  assistant 
compresses  the  vessel,  preferably  with  the  thumb,  being  relieved  at  intervals 
of  fifteen  minutes,  while  another  keeps  constant  watch  on  the  aneurism  to 
warn  the  compressor  of  any  return  of  pulsation.  The  pressure  must  be  con- 
tinuous for  from  forty-eight  to  seventy-two  hours.  Complete  occlusion  of 
the  vessel  is  not  necessary,  the  object  being  to  check  pulsation  and  allow  a 
small  amount  of  blood  to  pass  through  the  sac,  which  results  in  the  deposit 
of  a  laminated  clot  and  final  occlusion  of  the  vessel  and  in  the  slow  develop- 
ment of  the  collateral  circulation. 

Instrumental  Compression. — This  may  be  practised  in  two  ways, — either  as 
slow  compression  or  as  rapid  compression.  Slow  comj)ression  is  practised 
by  the  use  of  Lister's  or  Skey's  tourniquets.  Carte's  compressor,  or  in  the 
lower  extremity  Hopkins's  modification  of  Charridre's  instrument,  which 
possesses  numerous  pads,  by  means  of  which  the  seat  of  compression  can 
be  shifted.  If  after  two  or  three  days  there  is  no  evidence  of  cessation  of 
pulsation,  or  if  venous  congestion  shows  that  there  is  pressure  by  the  sac 
or  the  instrument  on  the  veins,  or  if  there  is  much  pain  or  restlessness  on 
the  part  of  the  patient,  this  treatment  should  be  discontinued.  A  compress 
may  be  placed  over  the  artery  and  the  limb  bandaged  and  elevated,  or,  if 
not  contraindicated,  the  limb  may  be  bandaged  in  the  position  of  fiexion. 
These  temporary  measures  allow  the  patient  to  rest  until  compression  is 
again  bearable ;  this  failing,  ligation,  or  other  operative  measures,  may  be 
employed. 

Rapid  Compression. — This  is  accomplished  by  temporary  complete  oblit- 
eration of  the  vessel,  and  effects  a  cure  by  causing  coagulation  en  masse  of 
the  contents  of  the  aneurism.  It  was  first  practised  for  aneurism  of  the 
abdominal  aorta,  and  is  employed  for  disease  of  that  vessel  and  for  iliac  and 
femoral  aneurisms.  It  requires  a  maintenance  of  anaesthesia  for  several 
hours,  and  is  attended  by  considerable  risk  of  injury  to  the  viscera  and  the 
sac,  and  of  peritonitis.  While  the  mortality  is  high  by  this  method,  it 
must  be  remembered  that  it  is  employed  only  in  those  desperate  cases  in 
which  other  treatment  is  impossible. 

Distal  Compression. — This  aims  at  causing  coagulation  en  masse,  and  is 
much  inferior  to  the  distal  ligature,  either  Wardrop's  or  Brasdor's,  as  it  per- 
mits a  speedy  dispersal  of  the  soft  coagulum  after  removal  of  the  j)ressure, 
time  not  being  given  for  permanent  contraction  and  obliteration.  It  also 
throws  great  strain  upon  the  sac.  It  is  applicable  only  to  some  cases  of 
aneurism  of  the  abdominal  aorta  or  at  the  root  of  the  neck. 

Direct  Compression  of  the  Sac. — This  method  of  treating  aneurisms  is  still 
occasionally  used  as  an  adjunct  to  other  modes  of  treatment. 


TREATMENT  OF  ANEURISM.  365 

Flexion. — This  method  is  applicable  to  popliteal,  inguinal,  axillary, 
and  brachial  aneurisms  at  the  elbow,  and  consists  in  flexing  the  limb  and 
bandaging  it  in  that  position.  It  is  fairly  successful,  especially  in  combi- 
nation with  other  measures,  and,  although  very  painful,  is  not  dangerous. 
It  is  contraindicated  in  large  aneurisms,  in  aneurisms  communicating  with 
joints,  and  in  cases  where  there  is  inflammation  of  the  sac  or  cedema  of  the 
limb. 

Raid's  Method. — This  is  applicable  only  to  aneurisms  of  the  extremi- 
ties, and  is  preferred  by  Stimson  to  any  other  form  of  compression  where  it 
can  be  practised.  The  patient,  after  a  preliminary  stage  of  dieting  and 
administration  of  potassium  iodide,  is  etherized,  and  an  Esmarch's  bandage 
is  evenly  and  firmly  applied  from  the  roots  of  the  digits  up  to  the  aneurism, 
which  is  either  jjassed  over  or,  when  large  and  rapidly  growing,  slightly 
compressed  without  being  emptied,  and  the  bandage  firmly  applied  up  to 
the  trunk.  If  pulsation  in  the  aneurism  is  not  checked,  the  Esmarch's  tube 
is  applied  immediately  above  the  bandage.  The  whole  apparatus  is  allowed 
to  remain  about  one  and  a  half  hours,  during  which  time  anaesthesia  is  kept 
up.  At  the  end  of  this  time  the  anaesthetic  is  discontinued,  the  bandage  and 
tube  are  removed,  and  a  Carte's  compressor  or  other  instrument  is  applied 
to  the  artery  above  the  aneurism  for  from  twelve  to  twenty-four  hours 
longer,  being  gradually  removed.  By  this  method  a  large  quantity  of  blood 
is  confined  in  the  sac  and  the  artery  leading  to  and  from  it,  which  undergoes 
rapid  coagulation,  the  clot  extending  into  the  artery  being  organized,  and 
that  in  the  sac  gradually  condensing. 

The  subsequent  compression  of  the  vessel  is  made  to  prevent  the  blood- 
stream from  washing  away  the  soft  clots  before  they  are  firmly  contracted. 
The  uncertainty  of  this  method  is  its  worst  feature,  only  fifty  per  cent,  of 
cures  being  recorded  and  a  few  deaths.  It  is  practicable  only  in  sacculated 
aneurisms  of  the  extremities.  It  does  not  lessen  the  prospects  of  success  by 
subsequent  ligation,  and  takes  a  comparatively  short  space  of  time. 

Ligation. — The  methods  of  ligation  are  four  in  number.  They  are 
classified  according  to  the  position  of  the  ligature  in  relation  to  the  sac,  and 
are  known  as  Hunter's,  Anel's,  Brasdor's,  and  War  drop's.  The  materials 
employed  for  ligatures  are  either  silk  or  catgut ;  the  former  is  often  preferred 
on  account  of  the  ease  and  certainty  with  which  it  can  be  sterilized. 

The  Hunterian  operation  is  considered  the  safest  and  most  satisfactory, 
and  consists  in  the  ligation  of  the  affected  vessel  at  a  considerable  distance 
to  the  cardiac  side  of  the  aneurism.  (Pig.  275,  A.')  This  procedure  gen- 
erally results  in  an  immediate  cessation  of  pulsation  in  the  sac  and  some 
shrinkage  in  its  size,  with  the  develoi^ment  of  two  sets  of  anastomosing  ves- 
sels. The  first  develops  around  the  ligature,  permitting  a  gentle  stream  of 
blood  to  flow  through  the  sac,  and  the  deposit  of  a  laminated  clot,  which 
fills  the  aneurism  and  extends  into  the  arterj^,  occluding  it.  The  occlusion 
of  the  artery  causes  the  development  of  a  second  set  of  anastomosing  vessels 
around  the  aneurism ;  the  latter  gradually  shrinks,  and  in  the  course  of 
three  or  four  weeks  is  usually  cured. 

Anel's  operation  differs  in  the  fact  that  the  ligature  is  apj)lied  just  above 
the  sac  (Fig.  275,  B),  and  only  one  anastomosis  is  established  around  both 


366 


LIGATION   IN   ANEURISM. 


Methods  of  applying  ligatures :  A,  Hunter's ;  B,  Auel's ;  C,  Bras- 
dor's  ;  D,  Wardrop's. 


the  sac  aucl  the  ligature.  The  blood  gains  admission  after  ligature  only  by 
flowing  backward  from  the  origin  of  the  first  anastomosing  branch  below. 
The  advantages  offered  by  the  Hunterian  method  are  :  (1)  the  seat  of  liga- 
ture is  at  a  point  where  the 
relations  are  but  little  dis- 
tui'bed  ;  (2)  the  sac  is  in  no 
danger  of  being  injvired ; 
(3)  coagulation  en  masse, 
with  its  subsequent  dan- 
£>'ers  of  inflammation  and 
sloughing,  is  generally 
ivoided.  Great  importance 
was  formerly  attached  to 
the  apj)lication  of  the  liga- 
ture at  a  distance  from  the 
aneurism,  where  the  walls 
of  the  vessel  were  healthy. 
Eecent  observations  have 
failed  to  show  any  greater 
liability  to  increased  athe- 
roma near  the  sac,  and, 
even  if  it  were  so,  aseptic 
ligation  of  an  atheromatous 
vessel  is  a  comparatively  safe  procedure.  This  fact,  coupled  with  the 
advantage  of  having  but  one  anastomosis  to  develop,  has  led  some  surgeons 
to  prefer  ligation  as  near  the  sac  as  possible. 

Brasdofs  operation  consists  in  ligating  the  artery  below  the  sac  (Fig.  275, 
O),  thus  entirely  arresting  the  circulation  through  it,  and  bringing  about 
a  cure  by  occluding  the  vessel  and  causing  the  formation  of  a  clot  extend- 
ing backward  from  the  ligature  to  the  sac,  which  gradually  contracts  and 
becomes  obliterated.  This  method,  however,  may  fail,  owing  to  a  par- 
tial filling  of  the  sac  with  a  coagulum,  when  the  aneurism  may  increase  in 
size,  or  sloughing  of  the  sac  may  occur.  Brasdor's  method  of  ligation  is 
applicable  to  aneurisms  at  the  beginning  of  the  carotid  and  subclavian 
arteries. 

Wardrop's  opemtion  is  also  a  method  of  distal  ligature,  but  consists  in 
applying  a  ligature  to  one  or  more  of  the  main  branches  below  the  sac  (Fig. 
275,  D),  not  completely  stopping  the  circulation  through  the  sac,  and  causes 
a  cure  of  the  aneuiism  by  diverting  the  current  of  blood  from  the  weaker 
portions  of  the  vessel,  or  by  an  extension  backward  of  the  clot  from  the 
seat  of  the  ligature.  In  this  method  a  cure  may  result  without  complete 
obliteration  of  the  circulation  through  the  sac.  Wardrop's  method  has  been 
practised  with  success  in  aneurisms  at  the  root  of  the  neck  involving  the 
innominate  artery  and  the  arch  of  the  aorta. 

Complications  after  Ligation. — Return  of  Pulsation. — This  may 
be  temporary,  disappearing  after  a  few  days ;  its  persistence  may  indicate 
an  imperfect  occlusion  of  the  vessel  by  the  ligature  at  the  time  of  operation, 
or  subsequent  slipping  of  the  knot,  especially  if  catgut  has  been  employed, 


TREATMENT  OF  ANEURISM.  367 

and  this  complication  should  be  treated  by  the  reapi^lication  of  the  ligature 
at  the  same  or  a  lower  point.  It  may  also  occur  as  the  result  of  a  too  free 
anastomosis  around  the  ligature,  which  permits  a  large  and  rapid  current  of 
blood  to  flow  through  the  sac,  interfering  with  the  deposit  of  a  laminated 
clot  and  favoring  disintegration  of  that  already  formed.  If  pulsation  per- 
sists, elevation  of  the  limb  and  compression  of  the  artery  and  sac  may  be 
tried,  or,  in  the  case  of  popliteal  aneurism,  flexion  may  be  useful.  If  these 
fail,  ligation  nearer  the  sac  or  excision  is  indicated. 

Secondary  hemorrhage  at  the  point  of  ligation  was  formerly  a  frequent 
cause  of  death,  and  arose  from  infection  of  the  wound,  but  is  now  an  infre- 
quent accident. 

Suppuration  or  sloughing  of  the  sac  is  a  very  dangeroTTS  complication, 
and  may  be  due  to  injury  of  the  sac  or  infection  of  the  wound  during  the 
operation,  to  failure  of  development  of  the  collateral  circulation  around  the 
sac,  to  coagulation  e?t  masse,  or  to  lack  of  supportiM/  tissue  around  the  sac,  as 
in  the  axilla  and  the  groin.  An  attempt  may  be  made  to  save  the  limb  by 
waiting  until  external  rupture  is  threatened,  and  then  incising,  first  apply- 
ing a  tourniquet  if  the  aneurism  still  pulsates,  turning  out  the  clots,  ligating 
the  vessel  above  and  below  if  it  is  still  pervious,  tying  all  bleeding  points, 
and  allowing  the  wound  to  granulate,  careful  watch  being  kept  for  the  occur- 
rence of  secondary  hemorrhage.  If  this  fails,  and  uncontrollable  hemorrhage 
sets  in,  amputation,  if  x)ossible,  should  be  performed. 

Gangrene. — This  dangerous  complication  generally  supervenes  from  the 
third  to  the  tenth  day,  is  especially  frequent  in  the  lower  extremity,  and  is 
usually  of  the  moist  variety.  After  ligation,  precautions  should  be  taken 
to  elevate  the  limb,  to  wrap  it  in  cotton,  and  to  surround  it  with  hot- water 
bottles,  to  assist  in  the  preservation  of  its  vitality  until  the  collateral  circu- 
lation is  established.  If  moist  gangrene  appears,  immediate  amj)utation  is 
the  best  treatment.  If  gangrene  of  the  dry  form  occurs,  amputation  may  be 
delayed  until  the  line  of  separation  has  formed. 

Indications  for  Ligation  in  Aneurism. — Ligation  is  indicated  (1) 
where,  although  comxjressiou  is  applicable,  a  scarcity  of  assistants  forbids  it ; 
(2)  in  old,  nervous,  or  intractable  patients  ;  (3)  where  compression  is  imj)os- 
sible,  as  in  the  carotids,  the  intracranial  vessels,  and  the  axillary  and  femoral 
arteries  near  their  origin  ;  (4)  in  diffused  or  rapidly  growing  aneurisms,  or 
those  accompanied  by  much  cedema  ;  (.5)  in  inflamed  aneurisms  ;  (6)  where 
milder  methods  have  resulted  in  failure. 

Contraindications  to  Ligation  in  Aneurism. — (1)  Atheroma  can 
no  longer  be  considered  a  positive  contraindication,  since  even  a  much- 
diseased  artery  permits  of  successful  aseptic  ligation.  (2)  The  existence  of 
other  aneurisms,  especially  internal,  sometimes  coutraindicates  the  appli- 
cation of  a  ligature,  on  account  of  the  danger  of  throwing  increased  strain 
upon  the  circulation.  (3)  In  ruptured  aneurisms,  or  in  those  in  which  gan- 
grene is  threatened,  amputation  should  be  jireferred  to  ligation. 

The  Old  Operation  and  Excision. — The  Antyllian  operation  con- 
sists in  opening  the  sac,  clearing  out  the  clots,  and  tying  the  vessel  above  and 
below.  (Fig.  276.)  The  moderu  method  of  excision,  which  is  a  reintro- 
duction  in  a  modified  form  of  the  old  operation  with  aseptic  methods,  has 


368 


TREATMENT  OF  ANEUEISM. 


Fig.  276. 


Antyllian  method. 


yielded  very  brilliant  results.  Thus,  a  series  of  twenty  cases  of  major  aneu- 
risms of  the  extremities  has  been  so  treated  without  a  death.  The  circula- 
tion is  first  controlled,  if  possible,  by  means  of  a  tourniquet,  an  incision  is 
made  over  the  aneurism,  the  affected  artery  is  then  ligated  above  and  below 
the  sac,  and  this  is  removed  by  dissection  ;  all  the  bleeding 
vessels  are  tied,  and  the  wound  is  closed,  great  attention 
being  given  to  the  prevention  of  infection  of  the  wound. 
This  operation  has  two  drawbacks, — the  dissection  is  diffi- 
cult, and  there  is  danger  of  wounding  other  important 
structures.  The  advantages  which  this  operation  offers  are 
complete  removal  of  the  sac  and  a  consequent  radical  cure, 
with  the  avoidance  of  a  soft  clot  which  may  disintegrate  and 
suppurate,  as  well  as  avoidance  of  the  pressure  of  cicatricial 
tissue  on  the  neighboring  nerves.  It  may  be  employed  in 
the  axilla  and  groin,  in  the  gluteal  region,  and  in  other 
regions  where  an  aneurism  has  become  diffused  and  the  alter- 
native is  amputation.  It  is  well  adapted  for  arteriovenous 
aneurisms  and  traumatic  aneurisms,  and  for  those  cases  in 
which  the  sac  remains  full  of  fluid  blood  after  ligation. 

Subcutaneous  Gelatin  Injection. — The  subcutaneous 
injection  of  gelatin  solution  has  recently  been  recommended 
by  Lancereaux  and  Paulesco  in  the  treatment  of  internal 
aneurism.  It  is  practised  by  injecting  250  c.c.  of  a  two  per 
cent,  solution  of  gelatin  in  normal  salt  solution  into  the  sub- 
cutaneous tissues  of  the  abdominal  walls,  buttocks,  or  thighs  at  intervals  of 
from  two  to  fifteen  days,  from  ten  to  twenty  injections  being  given.  The 
injections  are  not  given  in  the  neighborhood  of  the  sac.  They  are  often 
painful  and  may  cause  fever,  rigors,  or  insomnia,  and  too  rapid  coagulation 
of  the  blood  with  embolism.  The  results  are  better  in  sacculated  than  in 
fusiform  aneurisms. 

Galvano-Puncture. — This  is  practised  by  the  introduction  of  one  or 
more  fine  steel  needles,  trocar-shaped,  and  well  insulated  by  vulcanite  to 
one-third  of  an  inch  of  the  point,  into  the  sac,  and  connecting  them,  one 
after  the  other  for  five  minutes  with  the  positive  pole  of  a  galvanic  battery, 
the  negative  pole  being  attached  to  a  sponge-covered  plate  aijplied  to  the 
opposite  side  of  the  sac  or  held  in  the  patient's  hand.  A  current  of  five  or 
six  milliamperes  is  employed.  The  positive  pole  gives  a  firmer  coagulum 
than  the  negative,  which  should  never  be  introduced.  The  needles  are  left 
in  an  hour  or  more,  to  allow  the  clot  to  solidify,  and  are  then  cautiously 
withdrawn,  and  the  puncture  is  sealed  with  collodion,  bleeding  being  first 
checked  by  pressure.  There  is  often  an  evolution  of  gas  during  the  process, 
which  distends  the  sac,  and  perhaps  some  oedema  around  the  punctm-e. 
Statistics  are  not  very  favorable  as  regards  cure,  although  amelioration  of 
symptoms  may  result.  The  dangers  are  coagulation  en  masse,  sloughing  at 
the  point  of  puncture,  and  embolism. 

Galvanism  and  the  Introduction  of  Wire. — This  method  has  been 
employed  to  a  considerable  extent  during  the  last  few  years  for  internal 
aneurisms.     It  is  applicable  to  thoracic  aneurisms  presenting  externally, 


TREATMENT  OF  ANEURISM.  369 

and  abdominal  aneurisms  -which  can  be  exposed  by  laparotomy.  Silver, 
gold,  or  platinum  wire  is  iised.  It  should  be  drawn  fine  and  coiled  so  as  to 
assume  snarled  spiral  coils  after  introduction,  which  is  effected  through  an 
insulated  canula  under  strict  aseptic  precautions.  For  a  sac  three  inches  in 
diameter,  D.  D.  Stewart  recommends  from  three  to  five  feet ;  for  one  four  or 
five  inches,  from  eight  to  ten  feet.  The  positive  pole  is  connected  with  the 
wire,  the  negative  pole  to  a  clay  plate  or  wad  of  absorbent  cotton  on  the 
abdomen  or  back.  A  current  of  from  forty  to  eighty  milliamperes  is  then 
X)assed  for  from  three-quai'ters  to  one  and  one-half  hours,  after  which  the 
end  of  the  wire  is  cut  short  and  buried.  If  successful,  solidification  is 
usually  manifest  before  the  end  of  the  operation,  and  proceeds  until  the  sac 
subsequently  contracts  to  a  hard  nodule.  Some  very  encouraging  reports 
have  been  made  of  cases  treated  by  this  method. 

Manipulation. — This  method  consists  in  kneading  the  sac  with  a  view 
of  dislodging  a  portion  of  the  clot,  in  the  hope  that  it  will  occlude  the 
distal  orifice.  Although  occasional  cures  have  been  recorded,  it  is  too 
uncertain  and  dangerous  a  measure  to  be  recommended. 

Introduction  of  Foreign  Bodies. — This  consists  in  the  introduction  of 
some  substance  like  iron  or  steel  wire,  catgut,  or  horse-hair,  with  a  view  of 
exciting  coagulation.  The  results  thus  far  have  not  been  satisfactory.  The 
best  material  is  iron  or  steel  wire,  which  should  be  fine  and  flexible,  only  a 
small  piece,  carefully  sterilized,  being  introduced  at  a  time  through  a 
Southey's  canula,  the  end  being  buried.  Inflammation,  sloughing,  or  ruj)- 
ture  of  the  sac  is  the  usual  result. 

Acupuncture  and  Macewen's  Operation  (Needling). — Acupunc- 
ture consists  in  the  introduction  of  several  pairs  of  fine  sterilized  steel 
needles  (sometimes  gilded)  into  the  aneurism,  each  pair  crossing  in  the  sac, 
and  allowing  them  to  remain  in  place  for  several  days,  until  a  clot  has 
formed  around  them.  Macewen  also  introduces  a  long  stiff  needle  into  the 
sac  to  the  opposite  wall,  which,  vibrating  in  the  blood-current,  scratches  the 
wall,  or  is  moved  by  hand  for  a  few  minutes  so  as  to  scratch  the  sac  in  several 
places.  The  needles  are  allowed  to  remain  in  place  from  several  hours  to 
forty-eight  hours.  He  holds  that  this  procedure  is  followed  by  the  forma- 
tion of  a  white  clot.  This  operation  may,  if  necessary,  be  repeated  at 
intervals  of  several  weeks,  and  infection  should  be  carefully  guarded  against.. 
It  is  sometimes  followed  by  improvement,  but  is  to  be  recommended  only 
as  a  last  resort. 

Amputation. — This  may  be  called  for  in  aneurisms  of  the  extremities 
in  the  event  of  failure  of  other  means  of  cure,  or  because  of  complications 
which  develop  in  the  course  of  the  disease.  Thus,  internal  rupture  with 
threatened  gangrene,  external  rupture,  erosion  of  bone  or  involvement  of 
joints,  and  suppuration,  may,  after  resisting  other  treatment,  demand 
removal  of  the  limb.  Actual  gangrene,  of  course,  leaves  no  alternative. 
Secondary  hemorrhage  at  the  seat  of  ligature  may  be  checked  at  first  by 
religation  of  the  ends  of  the  vessel,  but  if  persistent  will,  in  the  lower 
extremity  at  least,  demand  amputation.  Amputation  below  the  sac  is 
sometimes  resorted  to  in  aneurism  of  the  subclavian,  and  acts  by  diverting 
the  blood-current,  by  diminishing  the  amount  of  blood  passing  through  the 

24 


370 


AOETIC  ANEUEISM. 


sac,  and  also,  -svliere  the  aneurism  is  situated  close  to  the  seat  of  amputation, 
by  euconraging  the  spreading  of  a  clot  from  the  point  of  ligation  of  the 
divided  vessel  backward  into  the  sac. 

TREATMENT  OF  SPECIAL  AKEUKISMS. 

Aortic  Aneurism. — The  aorta  is  the  most  common  seat  of  anem-ism. 
Anevirism  is  most  frequent  at  the  arch  and  rarest  in  the  abdominal  aorta. 
Aneurism  of  the  arch  may  grow  to  a  large  size  without  i^roducing  severe 
symiitoms,  which  are  mainly  due  to  pressure.  There  is  usually  dulness  over 
the  tumor ;  auscultation  may  be  negative,  or  there  may  be  a  systolic  murmur, 
a  double  murmur,  or  an  accentuation  of  the  second  sound.  Pulsation  is 
often  felt  through  the  chest  walls.  If  it  grows  anteriorly  it  causes  bulging 
and  perforation  of  the  ribs,  cartilages,  and  sternum  (Fig.  277)  ;  growing 

Fig.  278. 


Aortic  aneurism  bulging  anteriorly 
(German  Hospital  Jlnseum.j 


Aneurism  of  the  arch  of  the  aorta,  posterior 


posteriorly,  it  erodes  the  vertebrte  and  causes  compression  of  the  cord ; 
growing  upward,  it  produces  pulsation  at  the  root  of  the  neck  ;  the  heart  is 
often  displaced  downward  and  to  the  left.  (Fig.  278).  Venous  engorgement 
from  pressure  on  the  superior  vena  cava  and  its  branches  is  common  ;  ine- 
quality of  the  radial  pulses,  dyspnoea,  cyanosis,  and  congestion  of  the  lung 
are  often  seen.  Pain  of  a  boring  or  burning  character  is  produced  by  the 
erosion  of  bone.  Pressure  on  the  nerves  causes  a  neuralgic,  lancinating 
pain.  Dysphagia  and  dyspnoea,  cough  and  hoarseness  are  produced  by 
pressure  on  the  oesophagus,  the  trachea,  and  the  recurrent  laryngeal  nerve. 
Pressure  upon  the  phrenic  and  pneumogastric  nerves  may  cause  disturbances 
in  their  distribution.  Death  follows  mixture  externally  or  into  the  pleura, 
pericardium,  oesophagus,  or  trachea,  from  pressure  on  the  surrounding  struc- 
tures, and  from  syncope  due  to  failure  of  the  left  ventricle  to  j^ropel  the 
large  amount  of  blood  in  the  sac.  Aneurism  of  the  aorta  must  be  diagnosed 
from  aortic  insufficiency,  solid  tumors,  pulsating  pleurisy,  and  the  marked 
aortic  piilsatiou  seen  in  neurotic  patients. 


INNOMINATE  ANEUEISM. 


371 


Fig.  279. 


Treatment. — Operative  treatment  is  very  tinpromisiug,  and  should  not 
be  undertaken  until  a  thorough  trial  has  been  given  to  medical  measures. 
If  these  fail,  we  have  the  choice  of  several  methods,  all  attended  by  danger. 
Simultaneous  ligation  of  the  right  carotid  and  right  subclavian  in  disease  of 
the  first  portion  of  the  arch,  and  of  the  left  carotid  in  disease  of  the  second 
and  third  portions,  sometimes  results  in  temporary  improvement.  Galvan- 
ism with  the  introduction  of  wire  has  been  recently  employed  with  encour- 
aging results. 

Innominate  Aneurism. — This  aneurism  may  be  confined  to  the 
innominate,  or  the  aorta,  the  subclavian,  or  the  carotid  may  also  be  involved. 
It  is  usually  sacculated.  It  presents  a  tumor  over  the  situation  of  the 
innominate,  growing  forward,  eroding  the  ribs  and  sternum,  and  displacing 
the  clavicle,  upward  over  the  carotid  artery,  or  backward  towards  the  ver- 
tebrae, with  alteration  of  the  pulse  on  the  right  side  in  the  arm  and  neck, 
and  with  oedema  of  the  same  region  and  the  right  side  of  the  face,  following 
pressure  on  the  neighboring  veins.  Dysphagia  and  dyspnoea  may  be  present, 
and  the  neighboring  nerves,  including  the  pneumogastric,  brachial,  and 
cervical,  may  suffer  from  pressure.  It  must  be  diagnosed  from  aneurism  of 
the  arch  of  the  aorta,  the  first  portion  of  the  subclavian,  and  the  carotid  at 
the  root  of  the  neck.  We  rely  mainly  on  the  j)rimary  point  at  which  the 
aneurism  appears, — that  is,  at  the  sternal  end  of  the  clavicle  and  between  the 
heads  of  the  sterno-cleido-mastoid  muscle, — the  direction  in  which  it  grows, 
the  pressure-symptoms,  and  the  pulse  in 
the  distal  branches  of  the  vessel.  Death 
follows  rupture  externally  or  into  the 
pleura,  trachea,  or  oesophagus. 

Treatment. — Medical  treatment  should 
first  be  given  a  careful  trial.  If  it  fails, 
distal  ligature  of  the  carotid  or  of  the  sub- 
clavian, or  preferably  of  both,  is  the  most 
promising  method.  (Fig.  279. )  A  number 
of  cures  have  been  reported  by  this  method. 
Ashhurst's  case  of  double  distal  ligature  of 
these  vessels  for  innominate  aneurism  was 
in  good  condition  and  able  to  do  light  work 
several  years  after  the  oiaeratiou.  Mac- 
ewen's  operation  has  been  employed,  and, 
although  the  x)atient  died,  the  post-mortem 
revealed  beginning  coagulation  in  the  sac. 
Ligation  of  the  innominate  itself  for  aneu- 
rism of  that  vessel  or  of  the  subclavian 
has  succeeded  in  a  few  cases,  but  is  a  dangerous  operation.  Galvano- 
puncture  with  or  without  the  introduction  of  wire  may  be  attempted  if 
other  means  fail. 

Common  Carotid  Aneurism. — Any  portion  of  the  carotid  may  be 
affected  by  aneurism,  but  the  root  of  the  neck  and  the  bifui-cation  are  the 
favorite  seats,  the  right  being  the  more  frequently  diseased,  while  that 
portion  of  the  left  in  the  thorax  is  peculiarly  immune.     It  is  almost  as 


Application  of  distal  ligatures  in  innom- 
inate aneurism :  a,  carotid ;  b,  subclavian ; 

vertebral ;  d,  thyroid  axis ;  e,  internal 
mammary ;  /,  superior  intercostal.   (Agnew.) 


372  ORBITAL  ANEURISM. 

frequent  in  women  as  in  men,  being  more  common  in  females  than  any  other 
variety  of  external  aneurism.  Besides  the  ordinary  symptoms  there  is  often 
a  disturbance  of  the  cerebral  circulation,  producing  giddiness,  tinnitus,  etc. 
Dysphagia,  dyspnoea,  and  cough  are  usually  present,  with  contraction  of 
the  pupil  from  irritation  of  the  cervical  sympathetic,  and  neuralgia  of  the 
cervical  nerves.  It  must  be  diagnosed  from  other  aneurisms  at  the  root  of 
the  neck,  from  overlying  tumors  and  abscesses,  and  from  pulsating  enlarge- 
ments of  the  thyroid  gland.  Euptiire  externally  or  into  the  trachea, 
oesophagus,  or  larynx  is  the  usual  terminatioa.  Cerebral  embolism  is  to  be 
feared,  and  may  cause  paralysis  and  death. 

Treatment. — Proximal  compression  is  possible  only  when  there  is  room 
between  the  aneurism  and  the  sterno-clavicular  articulation,  and  is  practised 
by  digital  pressure  against  or  above  the  carotid  tubercle  of  the  sixth  cervical 
vertebra.  It  causes  faintness  and  pain,  and  can  be  kept  up  for  only  a  few 
minutes  at  a  time.  Distal  ligature  is  applicable  to  aneurism  at  the  root  of 
the  neck,  and  in  eleven  cases  gave  five  deaths  (Bolton).  Proximal  ligature, 
when  there  is  room,  gives  a  fair  hope  of  success,  but,  as  in  all  cases  of 
ligation  of  the  carotid,  more  than  one-third  of  the  patients  die  from  cerebral 
softening.  Pulmonary  congestion  and  hypostatic  pneumonia  may  also  cause 
a  fatal  termination.  Simultaneous  ligation  of  both  carotids  is  a  uniformly 
fatal  operation.  The  old  operation  would  be  indicated  in  suppuration  or 
ruiDture  of  the  sac,  and  has  been  practised  in  traumatic  aneurism  at  the  root 
of  the  neck. 

Internal  Carotid  Aneurism. — The  internal  carotid  artery  may  be 
affected  without  or  within  the  cranium.  The  first  form,  which  is  rare,  pro- 
trudes into  the  pharynx,  and  must  be  diagnosed  from  tumor  and  abscess  in 
that  locality.  It  sometimes  produces  paralysis  in  the  distribution  of  the 
pneumogastric,  hypoglossal,  and  glosso  pharyngeal  nerves.  The  intra- 
cranial form  is  usually  small,  and  is  often  unassociated  with  symptoms  before 
ruiiture.  It  is  difficult  to  diagnose  from  other  aneurisms  at  the  base  of  the 
brain  developing  in  the  middle  cerebral  and  basilar  arteries.  Headache, 
giddiness,  paralysis,  and  optic  neuritis  have  been  observed,  and  a  murmur 
is  sometimes  complained  of  by  the  patient.  The  effect  of  compression  of 
the  common  carotid  on  this  murmur  has  been  suggested  as  an  aid  to  diag- 
nosis. Eupture  of  an  aneurism  of  the  internal  carotid  into  the  cavernous 
sinus  may  be  the  starting-point  of  an  intra-orbital  aneurism.  If  recognized 
as  an  affection  of  the  internal  carotid  or  middle  cerebral,  ligature  of  the 
common  or  internal  carotid  artery  would  be  indicated,  otherwise  medical 
means  must  be  the  limit  of  treatment. 

External  Carotid  Aneurism. — This  should  be  treated  by  ligation 
of  that  vessel  if  possible,  otherwise  the  ligature  must  be  applied  to  the  com- 
mon carotid  artery.  Excision  has  been  recommended  when  the  branches 
are  the  seat  of  the  dilatation. 

Orbital  Aneurism. — This  is  associated  with  protrusion  and  pulsa- 
tion of  the  eyeball,  loss  of  movement,  fixation  of  the  puf)il,  opacity  of  the 
media,  impairment  of  vision,  and  sometimes  enlargement  and  pulsation  of 
the  retinal  veins.  Frequently  there  appears  a  pulsating  tumor  at  either 
angle  of  the  orbit,  generally  the  inner  ;  there  are  thrill,  bruit,  and  sometimes 


SUBCLAVIAN  ANEUEISM. 


373 


Fig.  280. 


Orbital  aneurism.     (Morton.) 


involvement  of  the  veins  of  the  face.  (Fig.  280. )  This  condition  depends 
upon  one  of  several  pathological  lesions.  Aneurism  of  the  oj^hthalraic 
artery  may  produce  exophthalmos,  but  the  involvement  of  the  veins  is 
wanting.  This  is  brought  about  in  one 
of  several  ways  in  the  cranium.  An 
aneurism  of  the  internal  carotid  may 
burst  into  the  cavernous  sinus,  or  a 
communication  between  the  two  may  be 
established  by  traumatism,  as  a  punc- 
tured wound,  where  they  lie  in  intimate 
relationship  on  the  floor  of  the  cranium. 
Eivington  has  shown  this  to  be  the  Most 
frequent  lesion.  The  same  effect  may  be 
produced  by  an  aneurism  of  the  internal 
carotid  or  ophthalmic  artery  pressing  on 
the  cavernous  sinus,  forcing  the  blood 
backward  into  the  afferent  vessels  in  the 
orbit.  Congenital  cirsoid  aneurism  and 
thrombosis  of  the  cavernous  sinus  are 
also  given  as  causes  of  this  condition. 
The  other  eye  may  be  secondarily  affected  by  means  of  the  communication 
between  the  two  sinuses.  It  may  result  in  blindness  and  death  from  hemor- 
rhage.    Diagnosis  must  exclude  sarcoma  of  the  orbit. 

Treatment. — Medical  treatment  should  first  be  tried,  and  rest  in  bed, 
with  the  administration  of  iodide  of  potassium,  will  sometimes  effect  a  cure. 
Ligation  of  the  common  or  internal  carotid  is  quite  successful,  and  is  the 
oxDcration  of  choice.     Electrolysis  has  also  been  employed. 

Subclavian  Aneiirisra. — Any  of  the  three  portions  of  the  artery  may 
be  diseased,  the  second  portion,  however,  being  rarely  affected.  It  is  com- 
monest on  the  right  side.  It  pushes  forward  the  clavicle,  or  grows  upward 
into  the  subclavian  triangle,  or  downward  and  backward  against  the  pleura. 
It  is  usually  sacculated,  and  generally  ruptures  before  reaching  a  great  size. 
There  is  a  delay  in  the  pulse  of  the  corresponding  arm,  .but  no  change  in 
the  carotid  pulse  unless  the  innominate  is  also  involved.  Comi^ression  of 
the  internal  jugular  and  subclavian  veins  causes  oedema  in  the  neck  and  face 
in  the  case  of  the  first  vessel,  and  oedema  and  even  gangrene  of  the  arm  in 
the  second.  Pain  is  referred  to  the  arm,  and  is  due  to  pressure  on  the 
neighboring  brachial  plexus,  and  on  the  right  side  the  recurrent  larjmgeal 
may  be  affected  as  it  winds  around  the  first  portion  of  the  vessel,  producing 
a  brassy  cough.  Death  follows  rupture  externally  or  into  the  pleura  or 
trachea.     Spontaneous  cure  is  not  very  uncommon. 

Treatment. — In  view  of  the  danger  of  the  operation,  medical  treatment 
should  first  receive  a  thorough  trial.  In  disease  of  the  first  portion,  proxi- 
mal compression  is  impossible,  and  proximal  ligature  dangerous.  The  first 
portion  of  the  right  subclavian  has,  however,  been  successfully  ligated  by 
Chilton,  Halstead,  Allingham,  and  Curtis,  and  on  the  left  side  by  Schumpert. 
It  has  only  been  attempted  twice  uidou  the  left  side,  owing  to  its  supijosedly 
inaccessible  position.     Halstead  recommends  preliminary  resection  of  the 


374  BRACHIAL  ANEURISM. 

clavicle  and  a  portion  of  the  sternum  when  operating  on  the  first  portion  of 
the  right  subclavian,  and  also  favors  Souchon's  plan  of  using  two  or  three 
non-contiguous  absorbable  ligatures,  with  the  ordinary  surgeon's  knot,  and 
drawn  tight  enough  to  occlude  the  A'essel  and  check  jjulsation  in  the  aneu- 
rism, but  not  to  rupture  the  arterial  coats.  Ligation  of  the  innominate  has 
been  practised  in  a  number  of  cases  with  successful  results,  but  is  a  very 
formidable  operation.  When  undertaken  it  is  generally  advised  to  tie  the 
carotid  and  the  vertebral  at  the  same  time.  Distal  ligature  has  never  suc- 
ceeded alone.  Amputation  at  the  shoulder-joint  with  distal  ligature  of  the 
subclavian,  is  not  very  satisfactory,  but  may  be  demanded.  Mace  wen  has 
cured  one  case  of  subclavian  aneurism  by  needling.  In  the  third  portion 
proximal  compression  should  first  be  tried.  Ligation  to  the  proximal  side 
in  the  second  or  third  portion  is  the  preferable  operation.  Excision,  direct 
comi)ression,  and  manipulation  have  been  successful  in  isolated  cases. 

Axillary  Aneurism.— A  history  of  traumatism  frequently  precedes 
the  development  of  axillary  aneurism,  such  as  attempts  at  the  reduction  of 
old  dislocations  of  the  humerus,  and  wounds  and  injuries  of  the  axilla.  The 
development  is  rapid,  corresponding  to  the  lack  of  support  afforded  by  the 
tissues  of  the  axillary  space.  It  may  grow  upward,  raising  the  shoulder, 
dislocating  the  clavicle,  and  appearing  in  the  supraclavicular  triangle ; 
inward,  eroding  the  ribs,  or  outward,  abducting  the  arm,  eroding  the 
humerus,  and  perhaps  bursting  into  the  shoulder-joint.  It  is  very  liable  to 
inflammation.  Characteristic  pulse-  and  pressure-changes  are  present,  as  is 
neuralgia  of  the  branches  of  the  brachial  plexus.  It  has  been  mistaken  for, 
and  must  be  diagnosed  from,  abscess  in  the  axilla. 

Treatment. — Medical  treatment  may  be  tried  if  operation  is  impossible, 
but  is  not  apt  to  be  successful.  Compression  of  the  subclavian  over  the 
first  rib  should  be  tried  first,  and,  as  it  is  painful,  anaesthesia  may  be  neces- 
sary. If  it  fails,  ligation  of  the  third  portion  of  the  subclavian  should  be 
employed.  Excision  may  be  practised  when  the  aneurism  is  small  and 
springs  from  the  third  jjortion  and  presses  on  the  nerves.  Eeid's  method 
and  flexion  have  also  been  recommended.  Suppuration  will  call  for  the  old 
operation  or  amputation,  the  latter  being  also  necessary  in  cases  comj)licated 
by  uncontrollable  hemorrhage  and  gangrene. 

Brachial  Aneurism. — This  is  very  rare,  with  the  exception  of  the 
traumatic  form  at  the  elbow  following  venesection.  It  occurred  but  once  in 
Crisp's  group  of  five  hundred  and  fifty-one  cases  of  aneurism.  At  the  elbow 
it  has  a  tendency  to  grow  upward  along  the  line  of  the  vessel.  Pain  from 
pressure  on  the  neighboring  median  nerve  is  a  prominent  symptom. 

Treatment. — Compression  is  a  satisfactory  method  of  treatment,  except 
for  the  liability  of  j)ressing  on  the  branches  of  the  brachial  plexus.  Proxi- 
mal ligation  of  the  brachial  artery  is  to  be  preferred  except  in  aneurisms 
high  up,  but,  owing  to  the  free  anastomosis,  it  may  fail.  Excision  is  suit- 
able for  traumatic  cases,  and  may  be  practised  in  other  forms,  especially 
when  there  is  pressure  on  the  nerves. 

Radial  and  Ulnar  Aneurisms. — In  these  aneurisms  compression  of 
the  brachial  artery  by  flexion  at  the  elbow  is  advisable.  If  this  fails,  the 
artery  should  be  ligated  when  the  aneurism  is  deeply  seated,  or  the  sac 


ANEURISM  OF  THE  ABDOMINAL   AORTA. 


375 


Fig.  281. 


Eiosiou  of  "s  eitebr'^  bj  aneuiism  of  the 
abdominal  aorta 


excised  when  it  is  superficial.     Aneurisms  of  the  palmar  arch  should  be 
treated  by  proximal  and  distal  ligature  and  excision  of  the  sac. 

Aneurism  of  the  Abdominal  Aorta.— The  most  common  site  of  its 
development  is  near  the  coeliac  axis.  It  is  usually  sacculated,  and  generally 
takes  a  forward  direction.  It  is  associated 
with  pain  in  the  back,  perhaps  shooting 
around  the  abdominal  wall,  and  gastric  symp- 
toms, particularly  vomiting,  and  jaundice  also 
may  be  present.  When  it  grows  backward  it 
erodes  the  vertebra,  and  may  open  the  spinal 
canal  and  cause  death  by  compression  or  in- 
flammation of  the  cord.  (Fig.  281.)  Eetar- 
dation  of  the  femoral  pulse  is  often  present. 
Eupture  takes  jjlace  retroperitoneally,  into 
the  pleura,  or  into  the  peritoneum,  or  the 
intestine,  particularly  the  duodenum.  Death 
also  follows  infarction  of  the  superior  mesen- 
teric artery,  or  obliteration  of  the  lumen  of 
the  aorta  by  clots.  It  must  be  diagnosed  from 
overlying  tumors  and  from  the  pulsating  or 
throbbing  aorta  found  in  neurasthenic  females. 
The  presence  of  a  distinct  pulsating  tumor  is 
necessary  to  a  diagnosis.  When  an  aneurism 
is  felt  below  the  umbilicus  it  iisually  sijriugs 

from  one  of  the  iliac  vessels.     Dissecting  aneurism  is  sometimes  present  in 
the  abdominal  aorta. 

Treatment. — Medical  treatment  should  be  carefully  tried,  although  it 
will  often  fail.  Ligation  of  the  abdominal  aorta  has  been  uniformly  fatal. 
It  has  been  practised  thirteen  times.  Keen's  case  survived  the  operation 
longest,  dying  after  forty-eight  days  from  cutting  through  of  the  ligature 
and  secondary  hemorrhage.  This  is  the  great  obstacle  to  success,  the  expan- 
sile pulsation  being  so  great  as  to  rupture  the  vessel  where  it  is  suddenly 
constricted  by  the  ligature.  Murray  cuied  a  case  by  rapid  compression,  and 
it  has  since  been  successful  in  the  hands  of  others.  If  the  disease  is  low  enough 
to  permit  it,  this  procedure  may  be  successful,  although  it  is  attended  with 
danger  of  injury  to  the  sac,  the  viscera,  and  the  peritoneum.  To  obviate 
this  danger.  Keen  has  suggested  oijening  the  abdomen  and  temporarily 
occluding  the  aorta  by  a  special  clamp  which  he  has  devised  for  the  purj^ose. 
Macewen  practised  needling  in  a  case  of  abdominal  aneurism  with  excellent 
results,  the  patient  being  well  after  two  and  a  half  years'  hard  labor.  In  this 
procedure  it  is  important  to  ascertain  first  whether  any  of  the  viscera  lie 
between  the  sac  and  the  abdominal  wall.  Wire  has  been  introduced  in  the 
treatment  of  this  aneurism,  with  unfavorable  results.  Galvanism  in  connec- 
tion with  the  introduction  of  wire  has  also  been  practised,  the  aneurism  first 
being  exposed  bj'  laparotomy. 

Iliac  Aneurism. — The  external  iliac  artery  is  the  one  most  frequently 
affected.  This  aneurism  may  reach  a  considerable  size  in  the  pelvis  before 
being  diagnosed.     There  is  often  change  in  the  pulse  of  the  corresponding 


376  GLUTEAL,  SCIATIC,  AND  PUDIC  ANEURISMS. 

leg,  sometimes  oedema,  or  even  gangrene.  It  is  frequently  of  rapid  growth. 
It  should  be  carefully  diagnosed  from  aortic  aneurism,  tumor,  abscess  of 
spinal  origin,  and  pulsating  sarcoma  springing  from  the  pelvic  bones.  A 
close  study  of  the  history,  the  location,  the  character  of  pulsation,  and  the 
condition  of  the  pulse  and  circulation  in  the  corresponding  limb  are  the 
main  points  to  be  relied  upon  in  making  the  diagnosis. 

Treatment. — Eapid  compression  applied  to  the  iliac  arteries  or  the 
abdominal  aorta  has  been  practised  ■with  success.  Ligation  of  the  common 
or  external  iliac  furnishes  fairly  favorable  results,  and  may  be  practised 
extraperitoneally  or  transperitoneally,  the  latter  operation  being  preferred 
by  some  operators  on  account  of  the  very  extensive  incision  and  dissection 
necessary  to  the  extraperitoneal  route.  Excision  of  the  sac  after  applying 
Ijroximal  and  distal  ligatm-es  has  given  good  results. 

Renal  Aneurism. — Thirteen  cases  of  this  affection  have  been  collected 
by  Keen.  Some  of  them  were  of  considerable  size.  They  are  often  trau- 
matic, the  larger  ones  presenting  as  tumors,  usually  growing  rapidly  and 
with  smooth,  elastic  surface.  Hsematuria  is  an  important  symptom,  and 
fatal  hemorrhage  from  rupture  into  the  pelvis  of  the  kidney  a  common 
termination.  Diagnosis  must  exclude  renal  calculus,  renal  hsemoj)hilia, 
rupture  of  the  kiduey,  and  tumor.  The  treatment  indicated  is  nephrectomy, 
care  being  taken  to  avoid  hemorrhage  in  ligating  the  pedicle.  Oases  so 
treated  recovered. 

Gluteal,  Sciatic,  and  Pudic  Aneurisms. — The  gluteal,  sciatic, 
and  pudic  arteries  are  sometimes  the  seats  of  aneurism,  the  first  being  the 
vessel  most  frequently  involved.  Most  of  the  cases  are  traumatic  in  origin, 
and  owing  to  theii'  deep  situations  are  not  easily  recognized,  especially  as 
they  may  be  partially  intrapelvic.  They  generally  rupture  before  reaching 
a  very  large  size.  The  symptoms  are  swelling  in  the  buttock,  accompanied 
by  pain,  referred  along  the  great  sciatic  nerve,  and  interference  with  move- 
ments of  the  hip,  with  the  ordinary  signs  of  aneurism.  Diagnosis  must 
exclude  abscess  and  malignant  tumor,  and  may  demand  the  use  of  the 
exploring  needle.  Intrapelvic  involvement  may  be  sometimes  recognized 
by  rectal  or  vaginal  examination. 

Treatment. — Spontaneous  aneurism  may  be  treated  by  proximal  liga- 
tion, the  old  operation,  or  excision.  If  it  cannot  be  ascertained,  as  is 
frequently  the  case,  whether  there  is  extension  into  the  pelvis,  ligation  of 
the  internal  iliac  is  indicated  ;  for  traumatic  aneurism  the  old  operation  is 
to  be  preferred.  The  aorta  or  common  iliac  may  be  controlled  by  pressure 
through  the  abdominal  wall  during  the  operation.  Macewen's  operation, 
galvano-puncture,  and  j)articularly  the  injection  of  perchloride  of  iron,  have 
been  practised,  as  there  is  little  danger  in  this  situation  from  embolism. 

Femoral  Aneurism. — This  may  develop  in  the  course  of  the  common 
or  the  superficial  femoral,  or  the  profunda,  although  it  is  very  rare  in  the 
last  mentioned.  It  is  usually  sacculated,  and  is  most  frequently  seen  in 
Scarpa's  triangle,  where  it  assumes  a  globular  shai^e.  (Pig.  282.)  In  Hun- 
ter's canal  it  has  a  flattened  shape,  from  the  limits  in  which  it  is  confined 
by  the  surrounding  muscles  and  fascioe.  There  are  the  usual  changes  in  the 
pulse  below,  except  when  the  profunda  is  the  seat  of  the  disease.     It  may 


POPLITEAL  ANEURISM. 


377 


be  associated  with  oedema  from  venous  pressure,  with  paiu  from  the  near 
relationship  of  the  long  saijhenous  nerve,  and  with  erosion  of  the  pelvis 
and  inflammation  of  the  hip-joint. 

Death  may  be  caused  by  rupture  Fig.  282. 

or  gangrene,  which  latter  accident 
is  less  common  than  in  popliteal 
aneurism,  owing  to  the  freer  anas- 
tomosis. 

Treatment. — Aneurism  of  the 
common  femoral,  which  appears 
in  the  inguinal  region,  admits  of 
the  same  treatment  as  in  case  of 
the  external  iliac.  Compressio]i 
of  the  external  iliac  or  the  com- 
mon femoral,  if  there  is  room 
above  the  sac,  may  first  be  tried. 

Ligation  of  the  common  femoral  was  formerly  considered  a  very  dangerous 
procedure,  owing  to  the  number  of  branches  given  off  near  the  ligature  and 
the  consequent  liability  to  secondary  hemorrhage  ;  gangrene  was  also  feared. 
With  asepsis  this  operation  has  given  much  better  results.  If  there  is  no 
room  to  tie  the  common  femoral,  the  external  iliac  may  be  ligated,  either 
extraperitoneally  or  transijeritoneally.  If  ligation  fails,  excision  of  the  sac 
should  be  practised. 

Aneurism  of  the  Superficial  Femoral. — In  aneurism  of  this  vessel 
proximal  comi^i-ession  yields  excellent  results,  and  should  first  be  given  a 
trial  when  feasible ;  other'^'ise  ligation  of  the  superficial  femoral  when  it  can 
be  done,  or,  if  not,  of  the  common  femoral  or  external  iliac,  is  the  best 
treatment.  Macewen  has  reijorted  a  cure  by  needling.  Excision  will  be 
found  useful,  as  it  has  proved  successful  in  a  number  of  cases  in  which  it 
has  been  tried.     Eeid's  method  is  also  applicable  here. 

Aneurism  of  the  profunda  should  be  treated  by  compression  of  the 
common  femoral,  and,  if  this  fails,  ligation  of  the  same  vessel  or  of  the 
external  iliac. 

Popliteal  Aneurism. — The  popliteal  artery  is  the  most  common  seat 
of  aneurism  next  to  the  arch  of  the  aorta.  It  is  predisposed  to  by  the 
stretching  and  traumatism  to  which  the  artery  is  exposed  during  movements 
of  the  knee,  by  the  fact  of  its  bifurcating  at  the  lower  margin  of  the  space, 
and  by  the  lack  of  supporting  tissue  around  it.  It  may  be  bilateral.  It  is 
usually  sacculated,  appearing  as  a  tumor  in  the  popliteal  space,  causing  pain 
by  pressure  on  the  internal  popliteal  nerve,  and  sometimes  paralysis  in  the 
distribution  of  this  nerve.  Owing  to  the  very  close  relationship  of  the 
artery  and  the  vein  in  this  space,  oedema  and  gangrene  are  common.  When 
it  takes  a  forward  direction  it  erodes  the  femur,  excites  a  synovitis  of  the 
knee-joint,  and  may  perforate  the  posterior  ligament,  rupturing  into  the 
joint  itself.  It  may  extend  upward  into  Hunter's  canal  or  downward  into 
the  calf.     Rupture  may  also  take  place  subcutaneously  or  externally. 

Treatment. — Compression  may  be  employed  either  digitally  or  instru- 
meutally  to  the  common  or  superficial  femoral.     Ligation  is  often  successful. 


378  TIBIAL  AND   PLANTAR  ANEURISMS. 

and  tlie  superficial  femoral  at  tlie  apex  of  Scarjja's  triangle  is  the  point  at 
which  to  occlude  the  vessel,  although  it  may  also  be  practised  in  Hunter's 
canal,  or  even  in  the  upper  portion  of  the  popliteal  space.  Eeid's  method 
and  flexion  probably  yield  their  best  results  in  this  situation,  and,  although 
uncertain,  are  not  dangerous.  Finally,  excision  has  been  practised  a  num- 
ber of  times  and  very  successfully.  Bolton  gives  a  mortality  of  five  and 
two-tenths  per  cent,  from  this  operation. 

Tibial  and  Plantar  Aneurisms, — Aneurisms  of  the  tibial  arteries 
are  generally  traumatic  in  origin  and  arise  from  j)unctured  or  gunshot 
wounds,  but  may  arise  spontaneously.  Kinlocli  has  collected  twenty-two 
cases  of  spontaneous  aneurism  of  the  posterior  tibial  artery.  The  treatment 
of  aneurism  of  the  tibial  arteries  consists  in  the  use  of  distal  compression  of 
the  femoral  artery,  and  if  this  fails  to  ijroduce  a  cure  the  aneurism  should 
be  exposed  by  incision  and  opened,  and,  after  the  application  of  ligatures  to 
the  vessels  upon  either  side  of  the  sac,  it  should  be  excised.  Aneurism 
of  the  dorsalis  pedis  or  plantar  artery  should  be  treated  by  ligature  of 
the  vessel  upon  each  side,  and  excision  of  the  sac. 


CHAPTER    XXI. 

LIGATION  OF  AKTERIES. 
By  Heney  R.  Wharto^-,  M.D. 

The  ligation  of  an  artery  in  its  continuity  is  an  operation  which  demands 
skill  and  exact  anatomical  knowledge  in  the  operator,  and  may  be  required 
for  the  control  of  hemorrhage,  the  cure  of  aneurism,  and  occasionally  to 
arrest  the  growth  of  malignant  tumors  by  diminishing  their  blood-supf>ly. 

The  instruments  required  for  this  operation  are  scalpels,  dissecting  for- 
ceps, a  grooved  director,  a  dry  dissector,  retractors,  and  an  aneurism  needle 
or  probe.  The  best  material  for  ligatures  is  carefully  pre^jared  chromicized 
catgut,  kangaroo  tendon,  or  sterilized  silk. 

In  the  application  of  a  ligature  to  an  artery  in  its  continuity  the  surgeon 
should  make  his  incision  in  the  line  which  corresponds  to  the  general  course 
of  the  vessel,  and,  when  possible,  a  portion  of  the  vessel  should  be  selected 
for  the  application  of  the  ligature  half  an  inch  or  an  inch  below  any  large 
collateral  branch.  The  surgeon  steadies  the  skin  with  two  fingers  and  makes 
an  incision  of  the  required  length  through  the  skin  with  a  scalpel ;  the 
superficial  fascia  being  exposed,  it  is  picked  up  on  a  dii-ector  and  divided  to 
an  equal  length  with  the  incision  in  the  skin  ;  if  any  large  superficial  veins 
come  into  view,  these  should  be  displaced.  When  the  deep  fascia  has  been 
exposed  it  should  be  nicked  and  divided  upon  a  director.  After  dividing 
the  deep  fascia  the  surgeon  should  seek  for  the  intermuscular  space  which 
leads  down  to  the  vessel,  or  the  muscles,  nerves,  or  tendons  which  are  the 
guides  to  the  vessel.  At  this  poiut  valuable  information  may  be  gained  by 
observing  the  small  arterial  branches  which  come  up  from  the  main  vessel 
through  the  intermuscular  spaces,  which  will  often  serve  as  guides  to  the 
position  of  the  vessel.  The  surgeon  should  next  work  down  in  this  space, 
separating  the  tissues  with  a  director,  AUis'  s  dry  dissector,  the  handle  of  a 
knife,  or  the  finger,  until  the  sheath  of  the  vessel  is  exposed.  The  artery 
may  generally  be  recognized  by  its  pulsation,  yet  sometimes  it  is  so  feeble 
that  it  does  not  serve  to  identify  the  vessel  ;  arteries  have  frequently  been 
confounded  with  tendons,  veins,  and  nerves.  Arteries  present  a  jjinkish- 
buff  color  and  are  compressible,  while  tendons  are  pearly  white  in  color  and 
are  much  denser  in  consistence ;  the  deep  blue  color  and  thin  walls  of  veins 
usually  distinguish  them  without  difficulty  from  arteries.  When  the  sheath 
of  the  artery  has  been  exposed,  it  should  be  picked  uj)  with  forceps  and 
nicked  with  the  point  of  a  knife  applied  flatwise ;  the  incision  into  the 
sheath  should  be  only  of  suificient  size  to  allow  the  aneurism  needle  to 
l^ass  through  it  around  the  vessel ;  as  the  walls  of  the  vessels  receive  their 
nutrition  from  the  vessels  of  the  sheath,  extensive  separation  or  dissection 
of  the  sheath  should  always  be  avoided.  Only  the  main  arterial  trunks 
possess  a  distinct  sheath,  which  is  replaced  in  the  smaller  arteries  by  a  layer 

379 


380  LIGATION   OF  THE  INNOMINATE  ARTEEY. 

of  loose  cellular  tissue.  The  wall  of  the  artery  being  exposed  by  a  small 
incision  in  the  sheath,  an  aneurism  needle  (Fig.  283)  threaded  with  a  liga- 
ture is  passed  around  the  vessel,  and,  tlie  ligature  being  grasped  with  for- 
ceps, the  needle  is  withdrawn;  or  the  needle  may  be  passed  around  the 
vessel,  and  after  being  threaded  with  a  ligature  withdrawn,  bringing  the 
ligature  after  it.    In  passing  the  needle  care  should  always  be  taken  to  direct 

it  away  from  important  struc- 
-'^'^'-  "®^-  tures,  such  as  veins  and  nerves, 

which  are  in  proximity  to  the 
artery,  as  the  injury  of  a  vein 
under  such  circumstances,  or 
the  inclusion  of  a  nerve  in  the 
ligature,  might  give  rise  to 
serious  consequences.  Before 
Aneurism  needle.  tying  the  ligature  the  surgeon 

should  satisfy  himself  that  the 
ligature  when  tied  will  control  the  circulation  in  the  vessel  below  its  point 
of  application.  This  may  be  done  by  placing  the  tip  of  the  finger  upon 
the  vessel  and  drawing  upon  the  ends  of  the  ligature,  so  as  to  occlude  it 
between  the  ligature  and  the  finger.  Having  satisfied  himself  as  to  this 
point,  the  ligature  should  be  securely  tied  with  the  reef-knot,  or  the  sur- 
geon's knot  and  reef-knot  combined,  and  the  ends  cut  short.  Some  sur- 
geons in  ligating  arteries  apply  two  ligatures  and  divide  the  vessel  between 
the  ligatures.  The  wound  may  be  closed  without  drainage  by  the  applica- 
tion of  a  few  sutures. 

As  it  is  a  matter  of  the  first  importance  that  primary  union  be  obtained 
in  wounds  made  for  the  ligation  of  arteries  in  their  continuity,  since  if  infec- 
tion of  the  wound  occurs  sloughing  of  the  vessel  may  occur  and  secondary 
hemorrhage  result,  the  surgeon  should  therefore  be  most  careful  that  every 
detail  is  observed  which  will  make  and  preserve  the  wound  aseptic. 

LIGATION   OF   SPECIAL   ARTERIES. 

Ligation  of  the  Innominate  Artery. — The  innominate  artery  is 
the  largest  branch  given  off  from  the  arch  of  the  aorta,  and  is  about  an  inch 
and  a  half  in  length  ;  it  lies  immediately  behind  the  sterno- clavicular  articu- 
lation, where  it  divides  into  the  right  carotid  and  right  subclavian  arteries. 
By  extending  the  neck  the  innominate  artery  can  be  drawn  up  and  rendered 
more  sui^erficial. 

A  V-shaped  incision  is  made,  each  branch  of  which  is  two  and  a  half 
or  three  inches  in  length.  One  incision  lies  over  the  anterior  edge  of  the 
sterno-cleido-mastoid  muscle,  the  other  is  parallel  to  and  a  little  above  the 
clavicle  (Fig.  284,  g) ;  the  incisions  are  carried  down  to  the  superficial 
fascia,  and  the  flap  is  dissected  up.  If  the  anterior  jugular  vein  is  met 
with,  it  should  be  displaced  or  ligated.  The  sternal  and  a  portion  of 
the  clavicular  attachments  of  the  sterno-cleido-mastoid  muscle  are  next 
divided  uj)ou  a  director ;  the  sterno-thyroid  and  sternohyoid  muscles  and 
the  middle  cervical  fascia  are  next  exposed,  covered  by  the  thyroid  veins. 
These  are  pressed  aside,  and  the  outer  fibres  of  the  sterno-hyoid  and  sterno- 


LIGATION  OF  THE   COMMON   CAROTID   ARTERY. 


381 


f 


Lines  of  incision  for  ligation  of — g,  innominate 
artery ;  li,  common  carotid  artery ;  i,  superior  tliy- 
roid  and  vertebral  arteries  ;  j,  lingual ;  /,  subclavian 
axillary  artery  below  the  clavicle. 


thyroid  muscles  are  divided,  the  thyroid  veins  being  disiilaced,  and  upon 
tearing  through  the  fascia  with  a  director  the  common  carotid  is  exposed 
and  traced  down  to  the  innominate  artery.  The  difficult  part  of  the  opera- 
tion is  the  isolation  of  the  artery,  which  is  accomplished  by  pressing  the 
innominate  vein  against  the  sternum 

with   the  finger   and   separating   the  Fig.  284. 

artery  from  its  sheath  about  half  an 
inch  below  its  bifurcation.  The  aneu- 
rism needle  should  be  passed  around 
the  vessel  from  the  outer  side,  to  avoid 
the  right  innominate  vein,  the  pneu- 
mogastric  nerve,  and  the  pleura. 

Ligation  of  the  Common 
Carotid  Artery,— The  right  primi- 
tive carotid  artery  has  its  origin  from 
the  innominate,  and  the  left  from  the 
arch  of  the  aorta.  The  carotid  artery 
on  the  right  side  is  shorter  than  the 
one  on  the  left ;  the  left  carotid  passes 
obliquely  from  its  origin  into  the  neck 
in  front  of  the  trachea,  oesophagus, 
and  thoracic  duct,  the  left  innomi- 
nate vein,  the  thymus  giaud,  and  the 
sterno-thyroid  and  steruo-hyoid  mus-  artery; 
cles  being  in  front ;    on  the  right  of 

the  vessel  lies  the  innominate  artery,  and  on  the  left  the  left  subclavian  artery 
and  pneumogastric  nerve.  The  surgical  anatomj?  of  the  carotid  arteries 
after  they  have  entered  the  neck  is  identical.  A  line  drawn  from  the  sterno- 
clavicular articulation  to  a  point  midway  between  the  angle  of  the  jaw  and 
the  mastoid  process  of  the  temporal  bone  represents  the  general  course  of  the 
vessel.  The  point  of  election  for  the  ligation  of  the  common  carotid  artery 
is  just  above  the  omo-hyoid  muscle,  about  three-quarters  of  an  inch  below 
the  bifurcation  of  the  vessel. 

The  patient  should  be  placed  in  the  recumbent  position,  the  shoulders 
raised  and  thrown  back,  the  head  supported  upon  a  pillow  and  turned 
somewhat  to  the  opposite  side.  The  incision  should  be  three  inches  in 
length,  along  the  anterior  border  of  the  sterno-cleido-mastoid  muscle,  the 
centre  corresponding  with  the  cricoid  cartilage.  (Fig.  284,  A.)  The  skin, 
superficial  fascia,  platysma  myoides,  and  deep  fascia  are  next  divided  upon 
the  director,  when  the  anterior  edge  of  the  sterno-cleido-mastoid  muscle 
is  exi^osed ;  the  intersi^ace  between  this  mu.scle  and  the  sterno-hyoid  and 
sterno-thyroid  muscles  is  exposed  and  the  latter  muscles  displaced  inward, 
when  the  artery  will  be  found  with  the  jugular  vein  external  to  it,  and  the 
descendens  uoni  nerve  lying  upon  the  sheath.  The  sheath  of  the  vessels  is 
next  picked  up  and  opened,  and  the  artery  is  carefully  separated  from  it 
with  a  director ;  the  artery  lies  internally,  the  internal  jugular  vein  exter- 
nally and  somewhat  more  superficially,  and  the  pneumogastric  nerve  lies 
between  the  two  and  is  more  deeply  placed.     (Fig.  287.)     The  sympathetic 


382 


LIGATION   OF  THE  EXTERNAL   CAROTID  ARTERY. 


Collateral  circulation  after  ligation  of  the  common 
carotid  artery.     (Agnew.) 


nerve  is  behind  the  vessel  external  to  the  sheath.     The  needle  should  be 

passed  from  without  inward. 

Collateral  Circulation. — When  the  common   carotid    artery   is  tied,   the 

circulation  is  maintained  by  anastomosis  between  the  inferior  thyroid  arteries 

from  the  thyroid  axis  and  the  suj)e- 
FiG.  285.  rior  thyroid  arteries  from  the  exter- 

nal carotid,  and  also  between  the  as- 
cending branches  of  the  transversalis 
colli  from  the  thyroid  axis  and  the 
princeps  cervicis  from  the  occipital. 
(Fig.  285.)  There  is  also  free  com- 
munication between  the  internal  and 
the  external  carotid,  both  outside  of 
and  within  the  skull. 

Ligation  of  the  External 
Carotid  Artery.— This  artery  ex- 
tends fiom  the  upper  border  of  the 
thyroid  cartilage  upward  and  back- 
ward to  the  deep  sulcus  behind  the 
angle  of  the  jaw  opposite  the  parotid 
gland,  into  which  it  passes.  The 
l^atient  should  be  placed  in  the  same  position  as  for  the  ligation  of  the 
common  carotid  artery.  An  incision  should  be  made  over  the  inner  edge 
of  the  sterno-cleido-mastoid  muscle  from  the  angle  of  the  jaw  to  a  point 
corresponding  to  the  middle  of  the  thyroid  cartilage  (Fig.  286,  c) ;  having 
divided  the  skin,  platysma,  and  cellular  tissue,  the  external  jugular  vein 
is  drawn  aside  when  encountered  ;  the  deep  fascia  being  opened,  the  facial 
and  lingual  veins  will  be  exposed,  and  should  be  drawn  to  one  side,  or 
if  this  is  impossible  they  should  be  ligated  and  divided  between  the  liga- 
tures. The  artery  is  next  exposed,  covered  by  the  hypoglossal  nerve  and  the 
sterno-hyoid  and  digastric  muscles ;  the  vessel  should  be  carefully  isolated 
from  the  internal  carotid  artery  and  the  internal  jugular  vein,  both  of  which 
lie  along  its  outer  side.  The  needle  should  be  passed  from  without  inward. 
Ligation  of  the  Internal  Carotid  Artery.— This  artery  is  seldom 
tied  excej)t  in  case  of  a  wound  of  the  vessel,  and  even  in  such  a  case  it  is 
probably  better,  from  the  great  uncertainty  attending  the  true  source  of  the 
bleeding,  to  ligate  the  common  carotid  artery.  It  is  ligated  by  making  an 
incision  similar  to  that  for  the  exposure  of  the  carotid  artery,  and  the  vessel 
will  be  found  external  to  the  external  carotid  artery  in  relation  with  the 
superior  thyroid,  lingual,  and  facial  veins  and  hypoglossal  nerve  ;  in  passing 
the  needle  the  i)oint  should  be  directed  away  from  the  internal  jugular  vein, 
— that  is,  from  without  inward. 

Ligation  of  the  Superior  Thyroid  Artery. — This  artery  has  its 
origin  from  the  external  carotid  artery  about  one-fourth  of  an  inch  below 
the  great  horn  of  the  hyoid  bone.  An  incision  three  inches  in  length  is 
made  along  the  anterior  border  of  the  sterno-cleido-mastoid  muscle,  starting 
a  little  lower  than  that  for  the  external  carotid  artery.  (Fig.  284,  i.)  The 
skin,  superficial  fascia,  platysma,  and  deep  fascia  being  divided,  the  cellular 


LIGATION   OF  THE  FACIAL  ARTERY. 


383 


tissue  iu  the  sulcus  between  tlie  upper  portion  of  the  larynx  and  the  great 
vessels  of  the  neck  should  be  broken  uj)  with  a  director,  and  the  vessel 
exposed.  The  needle  should  be  passed  around  the  vessel  from  above  down- 
ward with  its  point  directed  towards  the  thyroid  body,  to  avoid  injury  to 
the  carotid. 

Ligation  of  the  Lingual  Artery.— The  lingual  artery  arises  from 
the  carotid  about  an  inch  above  the  sui^erior  thyroid,  nearly  opposite  the 
great  horn  of  the  hyoid  bone.  The  head  should  be  turned  a  little  to  the 
opposite  side  and  well  extended,  so  as  to  increase  the  space  between  the 
hyoid  bone  and  the  base  of  the  jaw.  A  curved  incision,  two  inches  in 
length,  with  its  concavity  directed  ujjward,  should  be  made  from  the  anterior 
edge  of  the  sterno-cleido-mastoid  muscle  half  an  inch  above  the  hyoid  bone 
to  a  point  within  one  inch  of  the  median  line  of  the  neck.  (Fig.  284, ,/. )  The 
skin  and  platysma  being  divided,  and  superficial  veins  being  displaced,  the 
deep  fascia  should  next  be  opened  upon  a  director.  At  this  jjoint  the  sub- 
maxillary gland  will  be  exposed  ;  this  should  be  displaced  upward  with  the 
handle  of  the  knife  or  the  finger,  and  after  dividing  the  capsule  of  the  gland 
there  will  be  exposed  the  shining  aponeurosis  which  holds  the  digasti-ic 
tendon  to  the  hyoid  bone.  The  hypoglossal  nerve  will  also  be  exposed  a 
few  lines  above  the  cornu  of  the  bone,  run- 
ning across  the  hyoglossus  muscle  forward  ^^^-  ^^'^■ 
and  upward  towards  the  middle  of  the  jaw. 
The  fibres  of  the  hyoglossus  muscle  should 
be  divided  for  a  short  distance  midway 
between  the  hypoglossal  nerve  and  the  hyoid 
bone,  and  the  artery  will  be  exposed.  The 
needle  should  be  passed  around  the  vessel 
from  above  downward,  to  avoid  the  nerve. 

Ligation  of  the  Facial  Artery. — 
The  facial  artery  arises  from  the  external 
carotid  a  short  distance  above  the  lingual 
artery.  It  is  ligated  at  the  point  where  it 
crosses  the  lower  jaw,  in  front  of  the  mas- 
seter  muscle,  and  is  here  exposed  by  an  in- 
cision one  inch  in  length  over  the  inferior 
maxillary  bone.  (Pig.  286,  d.)  The  skin, 
subcutaneous  fascia,  platysma,  and  deep 
fascia  having  been  divided,  the  vessel  will 

be  exposed,  and,  after  having  separated  it  from  the  vein  on  its  outer  side, 
the  needle  should  be  passed  between  the  vein  and  the  artery. 

Ligation  of  the  Occipital  Artery. — This  artery  arises  from  the 
external  carotid  artery  opposite  the  facial.  The  cervical  portion  of  the 
occiijital  artery  is  seldom  ligated  excei^t  for  wounds  of  that  vessel.  The 
occipital  portion  of  the  artery  is  the  one  usually  ligated,  and  is  exposed  by 
a  horizontal  incision  two  inches  iu  length,  starting  ft'om  a  jjoint  half  an 
inch  below  and  in  front  of  the  apex  of  the  mastoid  process,  and  carried 
obliquely  backward  parallel  to  the  border  of  this  process.  (Fig.  286,  &.) 
The  skin  and  fascia  being  divided,  the  insertion  of  the  sterno-cleido-mastoid 


Lines  of  incision  for — a,  temporal  artery ; 
6,  occipital  artery ;  c,  external  carotid  ar- 
tery ;  d,  facial  artery. 


384 


LIGATION   OF  THE  SUBCLAVIAN  ARTERY. 


Fig.  287. 


muscle  should  be  exposed,  "which  is  also  divided,  and  the  aponeurosis  of 
the  splenius  is  next  exposed.  This  should  be  opened  and  the  digastric 
groove  felt  for,  and  when  the  belly  of  the  digastric  muscle  is  exposed  the 
artery  is  brought  into  view  by  separating  the  cellular  tissue  in  the  anterior 
angle  of  the  wound  with  a  director. 

Ligation  of  the  Temporal  Artery. — The  temporal  artery  is  the 
continuation  of  the  external  carotid  artery,  and  crosses  the  zygoma  posterior 
to  the  condyle  of  the  lower  jaw  and  a  quarter  of  an  inch  in  fi-ont  of  the 
tragus  of  the  ear.  It  is  exposed  by  a  vertical  incision  one  inch  in  length 
a  little  in  front  of  the  tragus  of  the  ear.  (Fig.  286,  a.)  The  skin  and  dense 
subcutaneous  cellular  tissue  being  divided,  the  artery  should  be  exposed. 
The  temporal  vein  accompanies  the  artery  and  lies  nearer  to  the  ear,  and  in 
some  cases  the  auriculo-temporal  nerve  is  also  in  close  relation  to  the  artery. 
The  needle  should  be  passed  from  behind  forward. 

Ligation  of  the  Subclavian  Artery.— This  artery  arises  from  the 
innominate  artery  on  the  right  side  and  from  the  arch  of  the  aorta  on  the 

left  side.  The  A^essel  extends  from  the 
sterno- clavicular  articulation  to  the 
lower  border  of  the  first  rib.  The  ves- 
sel is  crossed  by  the  scalenus  anticus 
muscle,  and  is  thereby  divided  into 
three  surgical  regions :  the  first  part 
from  its  origin  to  the  scalenus  anticus 
muscle ;  the  second  part  beneath  or 
covered  by  this  muscle  ;  and  the  thh-d 
portion  from  the  external  margin  of 
the  scalenus  anticus  muscle  to  the  first 
rib.  The  vessel  is  rarely  subjected  to 
operation  in  either  the  first  or  the 
second  part,  but  is  frequently  tied  in 
the  third  part.  The  left  subclavian 
artery  in  its  first  portion  is  larger  and 
more  vertical  in  its  direction  than 
the  right  subclavian,  and  is  situated 
more  posteriorly ;  on  account  of  the 
difficulty  in  exposing  this  portion,  and  the  possibility  of  injuring  the  thoracic 
duct,  the  ligation  in  its  first  portion  is  seldom  attempted.  The  incision  for  the 
first  portion  of  the  subclavian  artery  is  the  same  as  that  for  the  innominate 
(Fig.  284,  g),  and  the  ligature  is  passed  from  the  outer  side,  the  pneumo- 
gastric  and  ijhrenic  nerves  being  pressed  inward  towards  the  carotid  artery. 
The  incision  for  the  second  portion  of  the  subclavian  artery  begins  an 
inch  external  to  the  sterno- clavicular  articulation,  half  an  inch  above  and 
parallel  to  the  clavicle,  and  is  three  or  four  inches  in  length.  The  steps  of 
the  operation  are  the  same  as  for  the  ligation  of  the  third  portion  of  the 
vessel,  and  when  the  scalenus  anticus  muscle  has  been  exposed  it  is  divided 
upon  a  director  ;  care  should  be  taken  to  avoid  injury  of  the  phrenic  nerve, 
which  lies  upon  the  anterior  aspect  of  the  muscle. 

The  point  of  election  for  the  ligation  of  the  subclavian  artery  is  the  third 


Ligation  of  left  common  carotid  artery  and  sub- 
clavian artery. 


LIGATION   OF  THE   VERTEBRAL   ARTERY. 


385 


portion.  The  shoulders  should  be  elevated  by  a  pillow,  the  head  turned 
towards  the  opposite  side,  and  the  shoulder  corresponding  to  the  side  upou 
which  the  artery  is  to  be  ligated  drawn  downward.  The  skin  should  nest 
be  drawn  downward  over  the  clavicle,  and  an  incision  three  or  four  inches 
in  length,  beginning  an  inch  external  to  the  sterno-clavicular  articulation, 
made  over  the  clavicle,  and  the  tissues  divided  down  to  the  bone.  (Fig. 
284,  /. )  When  this  incision  has  been  made  the  integument  is  relaxed,  and 
its  elasticity  Avill  draw  the  incision  about  half  an  inch  above  the  clavicle. 
The  superficial  structures  having  been  divided,  the  external  jugular  vein 
must  be  drawn  to  one  side,  or,  if  this  is  imj)ossible,  it  should  be  divided 
between  ligatures.  The  deep  fascia  is  next  divided  upon  a  director.  The 
posterior  belly  of  the  omo-hyoid  muscle  is  found  and  drawn  upward  and 
outward.  The  outer  border  of  the  scalenus  anticus  is  uext  felt  for  and 
followed  downward  to  the  tubercle  of  the  first  rib.  The  artery  lies  against 
this,  between  it  and  the  lowest  bundle  of  the  brachial  plexus.  The  sub- 
clavian vein  lies  in  front  of  this  muscle,  but  upon  a  lower  plane.  (Fig.  287.) 
The  artery  is  carefully  denuded  with  a  director,  to  avoid  injury  of  the 
subclavian  vein  or  the  pleura,  and  the  needle  should  be  passed  from  below, 
care  being  taken  not  to  include  the 

lowest  bundle  of  the  brachial  plexus  -^''^^-  -'''^• 

in  the  ligature.  The  surgeon  should 
also  examine  carefully  to  see  that  the 
phrenic  nerve,  which  occasionally 
passes  into  the  chest  over  the  third 
portion  of  the  subclavian  artery,  is  not 
included  in  the  ligature. 

Collateral  Oirculation. — When  the  ar- 
tery is  ligated  in  its  second  or  third 
portion,  the  circulation  of  the  upper 
extremity  is  maintained  by  the  blood 
passing  through  the  suprascapular  and 
transversalis  colli  arteries,  which  run  across  the  neck  and  anastomose  with 
vessels  from  the  axillary  artery,  the  subscapular  and  the  dorsalis  scapulae, 
while  the  main  trunk  of  the  subscapular  joins  the  descending  branches 
from  the  posterior  scapulai-,  which  is  also  derived  from  the  thyroid  axis. 
(Fig.  288. ) 

Ligation  of  the  Vertebral  Artery. — The  vertebral  artery  arises 
from  the  subclavian  artery  and  enters  the  vertebral  foramen  of  the  sixth  cer- 
vical vertebra.  An  incision  from  three  to  three  and  a  half  inches  in  length, 
parallel  with  the  anterior  edge  of  the  sterno-cleido-mastoid  muscle,  ending  an 
inch  above  the  clavicle,  should  be  made.  (Fig.  284,  i. )  The  anterior  edge 
of  the  sterno-cleido-mastoid  being  exposed,  the  middle  cervical  fascia  is 
divided ;  the  carotid  artery  and  the  jugular  vein  are  exposed  and  drawn 
inward.  The  gap  between  the  longus  colli  and  scalenus  anticus  muscles 
is  next  felt  for,  about  an  inch  below  the  carotid  tubercle  ;  the  fascia  covering 
it  is  torn  through  and  the  muscles  are  separated,  when  the  vertebral  vein 
comes  into  view.  This  vein  being  held  aside,  the  vertebral  artery  should 
then  be  exposed  and  the  ligature  passed  around  it. 

25 


Collateral  circulation  after  ligation  of  the  sub- 
clavian artery,     (Agnew.) 


386  LIGATION   OF  THE   AXILLARY   ARTERY. 

Ligation  of  the  Inferior  Thyroid  Artery. — The  incision  for 
exposure  of  the  inferior  thyroid  artery  is  the  same  as  that  for  the  vertebral 
artery.  (Fig.  284,  i.)  The  anterior  edge  of  the  steruo-cleido-mastoid  muscle 
having  been  exposed,  it  is  drawn  outward  ;  the  middle  cervical  fascia  is  next 
divided,  and  the  carotid  artery  and  internal  jugular  vein  are  drawn  outward 
with  a  retractor.  The  head  being  slightly  flexed,  the  surgeon  feels  for  the 
carotid  tubercle  and  then  separates  the  cellular  tissue  with  a  director,  when 
the  artery  should  be  found  below  the  carotid  tubercle.  The  needle  should 
be  passed  between  the  artery  and  the  vein. 

Ligation  of  the  Internal  Mammary  Artery.— This  artery  is  a 
branch  of  the  first  part  of  the  subclavian  artery.  It  may  be  ligated  by 
making  a  vertical  incision  two  and  a  half  inches  in  length,  commencing  at 
the  lower  border  of  the  clavicle,  and  carried  parallel  with  and  three  lines 
external  to  the  sternum.  The  skin  and  superficial  fascia  being  divided,  the 
fibres  of  the  pectoralis  major  are  exposed ;  these  should  be  divided,  as  well 
as  the  external  intercostal  aponeurosis  and  the  muscular  fibres  of  the  internal 
intercostal  muscle ;  the  fasciculi  of  the  latter  muscle  should  be  raised  and 
divided  upon  a  director,  when  the  vessel  will  be  exposed.  The  internal 
mammary  artery  is  not  often  ligated  below  the  fourth  intercostal  space. 

Ligation  of  the  Axillary  Artery. — The  axillary  artery  extends 
from  the  middle  of  the  clavicle  to  the  insertion  of  the  teres  major  into  the 
humerus;  the  axillary  vein  lies  upon  the  inner  side  and  in  front  of  the 
artery.  The  artery  may  be  ligated  either  in  its  upper  portion  just  below 
the  clavicle,  or  in  its  lower  jjortion  in  the  axilla. 

Ligation  of  the  Axillary  Artery  below  the  Clavicle. — The  arm 
being  drawn  off  from  the  side,  in  order  to  render  apparent  the  fissure  between 
the  two  portions  of  the  pectoralis  major  muscle,  an  oblique  incision  is  made 
over  this  depression,  three  inches  in  length,  commencing  half  an  inch  from 
the  sterno-clavicular  articulation.  (Fig.  284,  e.)  Having  divided  the  skin 
and  fascia,  the  intermuscular  space  which  leads  upward  towards  the  clavicle 
should  be  opened  and  its  edges  separated  with  a  director.  The  fibres  of  the 
pectoralis  major  being  separated,  the  costo-coracoid  membrane  is  torn 
through,  care  being  taken  not  to  injure  the  cephalic  vein  at  the  outer 
portion  of  the  wound ;  the  pectoralis  minor  is  next  seen,  and,  after 
separating  the  cellular  tissue  with  a  director,  the  axillary  vein  is  exposed 
crossing  from  the  upper  edge  of  the  muscle  to  the  clavicle  ;  the  vein  almost 
completely  covers  the  artery,  which  is  exposed  by  drawing  the  vein  inward. 
The  needle  is  passed  around  the  artery  from  within  outward. 

Ligation  of  the  Axillary  Artery  in  the  AxiUa. — The  arm  being- 
drawn  off  from  the  side,  an  incision  two  and  a  half  inches  long;  starting  at 
the  upijer  point  of  the  axilla  and  carried  down  the  arm  at  the  edge  of  the 
coraco-brachialis  muscle,  is  made.  The  skin  and  superficial  fascia  having 
been  incised,  the  deep  fascia  is  picked  up  upon  a  director  and  divided,  when 
the  coraco-brachialis  muscle  will  be  exposed  ;  this  should  be  held  aside  by 
a  retractor,  and  there  should  first  be  exposed  the  median  nerve,  next  the 
musculo-cutaneous  nerve,  and  then  the  axillary  artery  with  the  axillary  vein 
on  the  inner  side ;  the  ulnar  and  internal  cutaneous  nerves  also  lie  to  the 
inner  side  of  the  artery.     The  needle  should  be  passed  between  the  artery 


LIGATION  OF  THE   BRACHIAL  ARTERY. 


387 


Ligation  of  the  brachial  artery  at  the  middle  third  and 
at  the  hend  of  the  elbow. 


and  the  vein  and  its  point  conducted  towards  the  coraco-brachialis  muscle, 
care  being  taken  to  avoid  the  median  and  musculocutaneous  nerves. 

Ligation  of  the  Brachial  Artery.— The  brachial  artery  extends 
from  the  tendon  of  the  teres  major  muscle  along  the  inner  edge  of  the  coraco- 
brachialis  and  biceps  muscles 
to  about  half  an  inch  below  the 
bend  of  the  elbow.  The  artery 
may  be  tied  in  its  upper  or  middle 
third  or  at  the  bend  of  the  elbow. 
Ligation  of  the  Brachial 
Artery  in  the  Middle  of  the 
Arm. — An  incision  three  inches 
long  is  made  on  a  line  correspond- 
ing to  the  inner  edge  of  the  biceps 

muscle  (Fig.  289) ;  the  skin  and  cellular  tissue  are  divided,  care  being  taken 
not  to  injure  the  basilic  vein,  which  should  be  drawn  posteriorly  ;  the  deep 
fascia  is  next  cut  through  and  the  fibres  of  the  biceps  muscle  are  exposed  ; 
this  muscle  should  be  drawn  forward,  and  the  sheath  of  the  vessel  enclosing 
the  artery  and  veins  is  exposed.  The  median  nerve  is 
Fig.  290.  pressed  aside,  and,  the  sheath  having  been  opened,  the 

artery  is  separated  from  its  veins,  and  the  needle  is  passed 
from  the  median  nerve  around  the  vessel.  The  occasional 
high  division  of  the  vessel  should  be  borne  in  mind. 

Ligation  of  the  Brachial  Artery  at  the  Bend  of 
the  Elbow. — An  incision  should  be  made  along  the  inner 
edge  of  the  tendon  of  the  biceps  muscle,  two  inches  in 
length.  (Fig.  289.)  The  skin  and  superficial  fascia  having 
been  opened,  the  bicipital  aponeurosis  is  exposed ;  this 
being  divided,  the  artery  will  be  found  immediately  below, 
the  median  nerve  being  some  distance  to  the  inner  side. 
After  isolating  the  veins,  the  needle  should  be  passed 
around  the  vessel  from  within  outward. 
Collateral    circuia-  Collateral  Circulation. — After  ligation  of  the  brachial 

tion  after  ligation  of   artcrj^  the  Circulation  of  the  parts  below  is  maintained 

the  brachial  artery  in     ,i         "^   i     ,,  .  -,   .    j.      .  j?        i  j_i 

its  lower  third.    (Ag-   ttirough  the  supcrior  and  inferior  profunda,  ortheanasto- 

new.)  motica  magna,  which  anastomoses  with  recurrent  branches 

from  the  radial,  ulnar,  and  interosseous  arteries.   (Fig.  290. ) 

Ligation  of  the  Radial  Artery. — The  radial  artery  extends  in  a 
straight  line  from  a  point  half  an  inch  below  the  centre  of  the  fold  of  the 
elbow  to  the  inner  side  of  the  styloid  process  of  the  radius.  The  artery  may 
be  tied  at  its  upper,  middle,  or  lower  third. 

Ligation  of  the  Radial  Artery  at  the  Upper  Third  of  the  Fore- 
arm.— An  incision  two  and  a  half  inches  in  length,  on  a  line  drawn  from 
the  middle  of  the  bend  of  the  elbow  to  the  ulnar  side  of  the  styloid  process 
of  the  radius,  is  made  ;  it  should  begin  one  and  a  half  inches  below  the  bend 
of  the  elbow.  (Fig.  291.)  The  skin  and  superficial  fascia  are  divided,  the 
superficial  veins  being  avoided,  and  the  deep  fascia  is  exposed.  When  the 
edge  of  the  supinator  longus  muscle  is  recognized  its  aponeurosis  is  divided 


LIGATION  OF    THE  ULNAR  ARTERY. 


Fig.  291. 


along  its  ulnar  side  and  the  fibres  of  tlie  pronator  radii  teres  muscle  are 
exposed ;  the  vessel  lies  in  the  interspace  between  these  muscles,  surrounded 
by  adiijose  tissue,  and  after  being  exposed  the  veins 
should  be  isolated  and  the  needle  passed  from  without 
inward.  The  radial  nerve  lies  so  far  external  to  the  artery 
that  it  is  not  often  exposed  in  this  operation. 

Ligation  of  the  Radial  Artery  at  the  Middle 
Third  of  the  Forearm. — An  incision  two  inches  in 
length,  following  the  same  line  as  that  for  the  ligation  of 
the  upper  third  of  the  artery,  should  be  made,  and  having 
divided  the  skin  and  the  sux^erficial  and  deep  fascite,  the 
artery  is  found  in  the  interspace  between  the  flexor  carpi 
radialis  on  the  inner  side  and  the  supinator  longus  on  the 
outer  side.  The  radial  nerve  is  in  close  relation  to  the 
vessel  on  the  radial  side,  and  the  needle  should  be  passed 
around  the  artery  from  without  inward. 

Ligation  of  the  Radial  Artery  at  the  Lower 
Third  of  the  Forearm. — An  incision  two  inches  in 
length,  following  the  same  line  as  that  for  the  ligation  of 
the  upper  third  of  the  artery,  is  made  one  inch  above 
the  wrist.  (Fig.  291.)  The  skin,  superficial  fascia,  and 
deep  fascia  having  been  divided,  the  artery  will  be  found 
between  the  tendon  of  the  flexor  cariji  radialis  on  the 
inner  side  and  the  tendon  of  the  supinator  longus  on  the 
outer  side  ;  the  veins  being  separated,  the  needle  may  be 
passed  in  either  direction. 
Ligation  of  the  Ulnar  Artery. — The  ulnar  artery  descends  along 
the  inner  side  of  the  forearm  between  the  flexor  carpi  ulnaris  muscle  ou  the 
inside  and  the  flexor  sublimis  digitorum  on  the  outside.  The  artery  rests 
upon  the  flexor  profundus  digitorum  muscle,  and  has  the  ulnar  nerve  to  the 
inner  side.  The  artery  is  tied  at  the  junction  of  the  upj)er  and  middle  thirds 
of  the  forearm  and  at  the  lower  third. 

Ligation  of  the  Ulnar  Artery  at  the  Junction  of  the  Upper 
and  Middle  Thirds  of  the  Forearm.^Au  incision  three  inches  in 
length  should  be  made,  starting  four  inches  below  the  internal  condyle  of 
the  humerus,  on  a  line  passing  from  this  point  to  the  outer  boi-der  of  the 
pisiform  bone.  Having  divided  the  skin  and  the  superficial  and  deep  fascise. 
the  interspace  between  the  flexor  cai-pi  ulnaris  and  the  flexor  sublimis  digi- 
torum muscles  will  be  exposed.  Entering  this  space  and  raising  the  flexor 
sublimis  digitorum  and  working  transversely  across  the  arm,  the  artery  will 
be  found  resting  upon  the  deep  flexor,  with  the  ulnar  nerve  to  the  ulnar  side. 
The  needle  should  be  passed  from  the  nerve  around  the  artery. 

Ligation  of  the  Ulnar  Artery  in  the  Lower  Third  of  the 
Forearm. — An  incision  two  inches  in  length  should  be  made  a  little  to  the 
radial  side  of  the  tendon  of  the  flexor  carpi  ulnaris,  ending  an  inch  above 
the  wrist.  The  skin,  superficial  fascia,  and  deep  fascia  being  divided,  the 
artery  will  be  exposed,  with  its  accomj)anying  veins,  between  the  tendons  of 
the  flexor  carpi  ulnaris  and  the  flexor  sublimis  digitorum,  the  ulnar  nerve 


Ligation  of  the  radial 
artery  at  the  upper  and 
lower  thirds  and  of  the 
ulnar  artery  at  the  lower 
third. 


LIGATION   OF  THE  OOMIMON  ILIAC  ARTERY.  389 

being  to  the  ulnar  side  of  the  vessel.     (Fig-  291.)    The  needle  should  be 
passed  fiom  within  outward,  to  avoid  the  nerve. 

Ligation  of  the  Superficial  Palmar  Arch.— Ligation  of  the 
palmar  arch  is  usually  required  to  control  hemorrhage  from  wounds  of  the 
arch,  and  both  ends  of  the  divided  arch  should  be  secured  by  ligatures. 
The  skin,  the  palmaris  brevis  muscle,  and  the  palmar  fascia  cover  the  vessels, 
and  beneath  them  lie  the  divisions  of  the  median  and  uluar  nerves,  as  well  as 
the  tendons  of  the  flexor  muscles  of  the  fingers.  The  Esmarch  bandage 
should  be  applied,  so  as  to  control  hemorrhage  and  afford  the  operator  a 
satisfactory  view  of  the  parts. 

Ligation  of  the  Deep  Palmar  Arch. — The  deep  palmar  arch  is 
formed  by  the  radial  artery  and  a  branch  from  the  ulnar  artery,  and  lies 
upon  the  interosseous  muscles.  It  is  covered  by  the  flexor  tendons  of  the 
fingers  and  the  short  flexor  of  the  thumb.  The  wound  should  be  enlarged, 
and  both  ends  of  the  divided  arch  should  be  secured,  care  being  taken  to 
avoid  injury  to  the  deep  structures  of  the  palm. 

Ligation  of  an  Intercostal  Artery. — Ligation  of  an  intercostal 
ai'tery  may  be  required  in  penetrating  or  non-penetrating  wounds  of  the 
chest.  The  intercostal  artery  runs  in  a  groove  along  the  lower  border  of  the 
rib,  where  it  may  be  secured  by  separating  it  from  the  rib,  or  it  may  be 
necessary  to  excise  a  portion  of  the  rib  before  it  can  be  satisfactorily  exposed. 

Ligation  of  the  Abdominal  Aorta. — The  abdominal  aorta  may  be 
exposed  by  an  incision  in  the  linea  alba  from  a  point  three  inches  above 
the  umbilicus  to  a  point  three  inches  below  it.  The  superficial  structures 
having  been  divided,  the  peritoneum  is  opened,  the  intestines  are  pressed 
aside,  and  the  aorta  is  exposed,  covered  by  the  peritoneum  with  the  filaments 
of  the  sympathetic  nerve  resting  upon  it,  and  with  the  vena  cava  to  the  right 
side.  The  peritoneum  being  torn  through  with  a  director,  the  needle  should 
be  passed  from  right  to  left  around  the  vessel. 
After  securing  the  ligature  the  ends  should  be 
cut  short  and  the  external  wound  closed  as  an 
ordinary  laparotomy  wound. 

Ligation  of  the  Common  Iliac  Ar- 
tery.— The  common  iliac  arteries  are  about  two 
inches  in  length  ;  the  right  vessel,  in  consecxuence 
of  its  having  to  pass  over  the  body  of  the  fifth 
lumbar  vertebra,  is  longer  than  the  left.  The 
right  iliac  artery  is  covered  in  front  by  the  peri- 
toneum and  the  ileum,  and  at  its  termination  by 
the  ureter  ;  the  primitive  iliac  veins  are  ijlaced 
behind,  and  on  its  outer  side  are  the  inferior 
vena  cava  and  the  right  iliac  vein.  The  left  iliac 
artery  is  covered  anteriorly  by  the  peritoneum  ^'=''^"°"  °'  '''^J^^;"  "^'"'^^  ^"^ 
and  the  rectum  and  the  superior  hemorrhoidal 

artery,  and  at  its  termination  by  the  ureter  ;  the  left  commou  iliac  vein  is  on 
the  inner  side  and  also  behind  the  artery.     (Fig.  292.) 

The  incision  for  the  common  iliac  artery  is  from  four  to  six  inches  in 
length,  beginning  half  an  inch  above  the  middle  of  Poupart's  ligament,  and 


390 


LIGATION   OF  THE   EXTERNAL   ILIAC   AETEEY. 


Fig.  293. 


Incisions  for  ligation  of  the  iliac  arte- 
ries :  a  and  6,  common  iliac  :  c,  external  or 
internal  iliac. 


is  carried  outward  and  curved  upward  after  passing  the  anterior  superior 
spine  of  the  ilium.  (Fig.  293,  6.)  The  skin,  superiicial  fascia,  and  aponeu- 
rosis of  the  external  oblique  muscle  being  divided,  the  fibres  of  the  internal 
oblique  and  transversalis  muscles  are  raised  upon  a  director  and  divided, 

and  the  transversalis  fascia  is  exposed.  This 
is  opened  at  the  lower  part  of  the  wound, 
and  the  finger  is  introduced  and  the  jterito- 
neum  pressed  back.  The  ojjeuing  in  the 
trans^^ersalis  fascia  is  next  enlarged,  and  the 
peritoneum  is  carefully  drawn  inward  and 
upward  with  the  fingers  towards  the  inner 
edge  of  the  wound.  The  surgeon  next  feels 
for  the  external  iliac  artery,  and  passes  the 
finger  along  this  until  the  common  iliac  ar- 
tery is  reached.  The  loose  cellular  tissue 
in  which  it  is  embedded  is  separated,  and 
the  needle  is  passed  from  within  outward 
to  avoid  the  common  iliac  vein,  which  on 
the  left  side  lies  on  the  inner  side  of  the 
artery  and  on  the  right  side  lies  behind  the 
artery.  The  ureter  generally  remains  at- 
tached to  the  peritoneum  ;  if  not,  it  is  seen 
crossing  the  bifurcation  of  the  common  iliac 
artery  with  the  genito-crural  nerve,  and  care  should  be  taken  to  avoid  injury 
to  these  structures  in  passing  the  needle. 

Transperitoneal  Method. — The  com-  yig.  294. 

mon,  external,  or  internal  iliac  artery  may 
also  be  exposed  through  an  abdominal  in- 
cision thi'ee  inches  in  length  in  the  linea 
alba  over  the  artery,  opening  the  peritoneal 
cavity.  (Pig.  293,  a.)  The  vessel  being- 
exposed  and  ligated,  the  ends  of  the  liga- 
ture are  cut  short,  and  the  external  wound 
is  closed.  In  this  method  of  ligation  the 
Trendelenberg  position  will  be  found  most 
useful.  This  method  of  ligating  the  iliac 
arteries  has  recently  been  employed  in  a 
number  of  cases  with  good  results,  and  pos- 
sesses the  advantage  that  the  exposure  of 
the  vessels  is  very  free  and  there  is  little 
danger  of  injury  to  the  veins.  This  pro- 
cedure has  been  practised  to  expose  and 
comjiress  the  iliac  arteries  as  a  preliminary 
step  in  amputation  at  the  hip-joint. 

Ligation  of  the  External  Iliac  Artery.— This  artery  extends  from 
the  sacro-iliac  junction,  along  the  inner  margin  of  the  psoas  muscle,  to  Pou- 
part's  ligament.  At  its  upper  part  the  external  iliac  vein  is  situated  behind, 
and  below  it  is  to  the  inner  side  of  the  vessel.     The  vessel  is  exposed  by  an 


Ligation  of  the  external  iliac  and  femoral 
arteries. 


LIGATION   OF  THE  GLUTEAL  ARTERY. 


391 


incision  three  or  four  inches  in  length,  half  an  inch  above  Poupart's  ligament, 
made  at  first  parallel  to  it,  and  then  curved  ujiward.  (Fig.  293,  c. )  Having 
divided  the  tissues  of  the  abdominal  wall,  the  peritoneum  is  exposed,  and 
should  be  pushed  upward  and  inward.  (Fig.  294. )  The  external  iliac  artery 
lies  at  the  inner  border  of  the  psoas  muscle,  and  the  vein  is  on  its  inner  side  ; 
the  anterior  crural  nerve  covered  by  the  iliac  fascia  is  on  the  outer  side  ;  the 
geuito-crural  nerve  passes  obliquely  across  the  artery.  The  needle  should 
be  passed  from  within  outward. 

Ligation  of  the  Internal  Iliac  Artery.— This  artery  leaves  the 
common  iliac  artery  at  the  sacro-iliac  junction.  The  psoas  magnus  muscle  is 
on  the  outer  side  of  the  vessel.  The  internal  iliac  vein  and  the  lumbo-sacral 
nerve  lie  behind,  and  the  peritoneum  and  u^reter  are  in  front  of  the  artery. 
The  incision  is  the  same  as  for  the  external  iliac  artery.  The  peritoneum 
being  exposed,  it  is  pushed  upward  and  inward,  and  the  internal  iliac  artery 
is  exposed.  The  vessel  is  carefully  isolated  from  the  vein  which  lies  behind 
and  on  the  inner  side,  and  the  needle  is  passed  from  within  outward. 

Collateral  Circulation. — After  ligation  of  the  iliac  arteries  the  blood  finds 
its  way  to  the  limb  below  by  the  ilio-lumbar  and  obturator  branches  from 
the  internal  iliac,  anastomosing  with  the  lumbar  arteries  from  the  aorta 
and  with  the  internal  circumflex  from  the  profunda  femoris.  The  circum- 
flex iliac  also  communicates  with  the  lumbar  arteries. 

Ligation  of  the  Gluteal  Artery. — The  gluteal  artery  emerges  from 
the  pelvis  by  the  great  sacro-sciatic  foramen,  above  the  pyriformis  muscle. 
(Fig.  295. )     An  incision  three  or  four  inches 

in  length  should  be  made,  extending  from  Eig.  295. 

the  x^osterior  superior  spinous  process  of  the 
ilium  to  a  point  midway  between  the  tuber 
ischii  and  the  great  trochanter.  The  skin 
and  fascia  having  been  divided,  the  fibres 
of  the  gluteus  maximiis  muscle  are  separated 
and  held  apart  and  the  deep  fascia  is  divided, 
and  tl\e  artery  should  then  be  sought  for 
above  the  pyriformis  muscle  at  the  upper 
border  of  the  great  sacro-sciatic  notch  ;  it 
is  accompanied  by  a  nerve  and  by  veins. 

Ligation  of  the  Sciatic  and  the 
Internal  Pudic  Artery. — These  arteries 
are  exposed  by  an  incision  three  or  four 
inches  in  length,  a  little  lower  than  that  em- 
ployed for  the  exposure  of  the  gluteal  artery. 
The  skin,  superficial  fascia,  deep  fascia,  and 
fibres  of  the  gluteus  maximus  having  been 
divided,  the  vessels  should  be  exposed  as 
they  leave  the  great  sciatic  notch  at  the 

lower  edge  of  the  pyriformis  muscle.  The  internal  pudic  artery  re-enters 
the  pelvis  through  the  lesser  sciatic  notch,  lying  on  the  inner  side  of  the 
sciatic  artery  during  its  passage  over  the  spine  of  the  ischium.  The  needle 
should  be  passed  so  as  to  avoid  injury  of  the  veins. 


Relations  of  the  gluteal,  sciatic,  and  pudic 
arteries.    (Agnew.) 


392  LIGATION   OF  THE  FEMOKAL  ARTERY. 

Ligation  of  the  Femoral  Artery. — The  femoral  artery  occupies 
tile  inner  and  anterior  portion  of  the  thigh  ;  it  is  crossed  by  the  sartorius 
muscle,  and  is  thus  divided  into  two  unequal  portions.  The  portion  above 
the  sartorius  muscle  occupies  Scarjja's  triangle.  After  leaving  Scarpa's 
triangle  the  artery  enters  an  aponeurotic  canal  formed  between  the  adductor 
niagnus  and  vastus  interuus  muscles  (Hunter's  canal),  after  which  it  per- 
forates the  adductor  and  enters  the  popliteal  space.  The  femoral  vein  is  at 
first  to  the  inner  side  of  the  artery,  then  passes  behind  the  artery,  and  near 
the  apex  of  Scarpa's  triangle  is  to  its  outer  side.  The  anterior  crural  nerve 
is  situated  some  distance  to  the  outer  side  of  the  artery.  In  Hunter's  canal 
the  artery  is  covered  by  the  long  saphenous  vein,  and  is  in  close  relation  to 
the  internal  saphenous  nerve.  The  course  of  the  artery  in  the  thigh  may  be 
indicated  by  a  line  drawn  from  a  point  midway  between  the  anterior  superior 
spinous  process  of  the  ilium  and  the  symjihysis  pubis  to  the  tuberosity  of  the 
internal  condyle  of  the  femur.  The  artery  may  be  tied  just  below  Poupart's 
ligament,  at  the  apex  of  Scarpa's  triangle,  or  in  Hunter's  canal. 

Ligation  of  the  Femoral  Artery  below  Poupart's  Ligament. — 
An  incision  should  be  made,  beginning  midway  between  the  anterior  superior 
spinous  process  of  the  ilium  and  the  symj)hysis  pubis,  one-fourth  of  an  inch 
above  Poupart's  ligament,  and  extending  two  inches  downward.  The  skin 
and  superficial  fascia  having  been  divided,  the  deep  fascia  is  exposed  and 
opened,  when  the  sheath  of  the  vessel  is  brought  into  view.  The  sheath 
being  opened,  the  artery  should  be  isolated  from  the  femoral  vein,  which 
lies  to  the  inner  side.  The  anterior  crural  nerve  lies  to  the  outer  side.  The 
needle  should  be  passed  from  within  outward. 

Ligation  of  the  Femoral  Artery  at  the  Apex  of  Scarpa's 
Triangle. — This  is  considered  the  point  of  election  for  the  ligation  of  the 

femoral  artery  from  the  fact  that  it  is  farthest 

Fig.  296.  removed  from  the  main  collateral  branch, 

/,»  iii\      the  profunda  femoris  artery.    An  incision 


/ 


should  be  made  three  inches  in  length,  the 
centre  of  which  should  be  a  little  above  the 
f)oint  where  the  sartorius  muscle  crosses  a 
line  drawn  from  the  middle  of  Poupart's 
ligament  to  the  inner  condyle  of  the  femur. 
The  skin,  superficial  fascia,  and  deep  fascia 
having  been  divided,  the  edge  of  the  sar- 
torius muscle  will  be  seen,  which  is  drawn 
outward  and  the  sheath  of  the  vessel  is 

Ligation  of  the  femoral  artery  in  Scarpa's  ,         ,  t        mi  -      t 

triangle.  cxposcd  aud  Opened.     The  vein  lies  on  the 

inner  side  of  and  somewhat  behind  the 
artery,  and  the  long  saphenous  nerve  is  on  the  outer  side.  (Pig.  296.)  The 
needle  should  be  passed  from  within  outward. 

Ligation  of  the  Femoral  Artery  in  Hunter's  Canal. — An  incision 
three  inches  in  length  should  be  made  along  the  tendou  of  the  adductor 
maguus,  the  centre  of  which  is  at  the  junction  of  the  lower  and  middle 
thirds  of  the  thigh.  (Pig.  297.)  The  skin,  superficial  fascia,  and  deep 
fascia  having  been  divided,  the  sartorius  muscle  is  exposed,   and  care 


LIGATION   OF  THE  ANTERIOR  TIBIAL  ARTERY. 


393 


should  be  taken  not  to  injure  the  internal  saphenous  vein.     The  sartorius 
muscle  should  be  drawn  downward,  exposing  the  aponeurosis,  which  forms 

Fig.  297. 


Fig, 


Ligation  of  the  femoral  artery  in  Hunter's  canal. 

the  anterior  wall  of  the  vascular  canal ;  this  should  be  opened  upon  a 
director,  and  the  artery  uncovered  and  separated  from  the  vein,  which  lies 
upon  the  outer  side.     The  needle  should  be  passed  from  without  inward. 

Collateral  Circulation.  When  the  femoral  arterj^  is  tied  below  the  origin 
of  the  profunda  the  blood  finds  its  way  to  the  limb  below  by  anastomoses 
between  the  ijerforating  branches  of  the  profunda  and  the  anastomotica 
magna,  with  the  articular  arteries  from  the  popliteal  and  the  reciirrent 
branch  from  the  anterior  tibial. 

Ligation  of  the  Popliteal  Artery. — The  popliteal  artery  extends 
from  the  opening  in  the  adductor  magnus  muscle  to  the  lower  border  of  the 
popliteus  muscle.  An  incision  three  or  four  inches  in 
length  should  be  made  along  the  external  border  of  the 
semimembranosus  muscle.  The  skin  and  superficial  fascia 
having  been  divided,  the  deei?  fascia  is  opened,  care  being 
taken  not  to  injure  the  saphenous  vein.  The  edges  of  the 
wound  being  held  apart,  the  adipose  tissue  is  broken  up 
with  a  director,  and  the  internal  popliteal  nerve  will  be 
first  exj)osed,  and  next  the  vein  ;  both  of  these  structures 
are  external  to  the  artery.  The  artery  is  isolated  and  the 
needle  is  passed  from  without  inward.     (Fig.  298. ) 

Ligation  of  the  Anterior  Tibial  Artery. — 
The  anterior  tibial  artery  begins  at  the  lower  border  of 
the  popliteus  muscle.  The  artery  may  be  tied  in  the 
upper,  middle,  or  lower  third  of  the  leg.  The  general 
dii'ection  of  the  artery  corresponds  to  a  line  drawn  from 
the  middle  of  the  space  between  the  head  of  the  fibula  and 
the  tubercle  of  the  tibia  and  the  middle  of  the  anterior  intermalleolar  space. 

Ligation  of  the  Anterior  Tibial  Artery  in  the  Upper  Third 
of  the  Leg. — An  incision  from  two  and  a  half  to  three  inches  in  length 
should  be  made  one  and  a  quarter  inches  external  to  the  spine  of  the  tibia. 
(Pig.  299.)  The  skin  and  superficial  fascia  having  been  divided,  the  deep 
fascia  should  be  opened  on  a  line  corresponding  with  the  intermuscular 
space  between  the  tibialis  anticus  and  extensor  longus  digitorum  muscles ; 


■Ik 


Ligation  of  the  i>opli- 
teal  artery. 


394  LIGATION   OF  THE  POSTERIOR  TIBIAL  ARTERY. 

by  separating  tliese  muscles  and  working  down  in  this  interspace  the 
artery  is  exposed,  with  a  vein  on  either  side  of  it,  and  the  anterior  tibial 
nerve  externally.     The  needle  should  be  passed  from  without  inward. 


Ligation  of  tlie  anterior  tibial  artery.     (Agnew.) 

Ligation  of  the  Anterior  Tibial  Artery  at  its  Middle  Third.— 
An  incision  three  inches  in  length  should  be  made  in  the  same  line  as  that 
for  the  upper  portion  of  the  vessel.  The  skin,  superficial  fascia,  and  deep 
fascia  being  divided,  the  interspace  between  the  tibialis  auticus  and  extensor 
longus  digitorum  muscles  is  opened,  and  a  third  muscle  comes  into  view, 
the  extensor  proprius  pollicis ;  the  artery  lies  between  the  extensor  proprius 
poUicis  and  the  tibialis  anticus,  and  the  anterior  tibial  nerve  is  to  the  outer 
side.     The  needle  should  be  passed  from  without  inward. 

Ligation  of  the  Anterior  Tibial  Artery  in  its  Lower  Third. — 
The  artery  is  exj)osed  by  an  incision  two  inches  in  length  on  the  line  of  the 
artery,  beginning  three  inches  above  the  ankle-joint.  The  skin,  superficial 
fascia,  and  deep  fascia  having  been  divided,  the  tendon  of  the  extensor 
proprius  pollicis  muscle,  the  second  tendon  from  the  tibia,  should  be  sought 
for.  The  artery  is  found  between  the  extensor  proprius  pollicis  tendon  and 
the  tendon  of  the  extensor  longus  digitorum,  the  anterior  tibial  nerve  being 
to  the  outer  side.     The  needle  should  be  passed  from  without  inward. 

Ligation  of  the  Dorsalis  Pedis  Artery.-  An  incision  one  inch 
in  length  should  be  made  on  a  line  drawn  from  the  middle  of  the  anterior 
intermalleolar  space  to  a  point  midway  between  the  extremities  of  the  first 
two  metatarsal  bones,  or  an  incision  may  be  made  along  the  outer  border  of 
the  extensor  proprius  pollicis.  The  skin  and  the  superficial  and  deep  fascise 
having  been  divided,  the  artery  will  be  found  lying  inside  of  the  inner 
tendon  of  the  short  extensor  of  the  toes ;  the  nerve  is  to  the  outer  side. 
The  needle  should  be  passed  from  without  inward. 

Ligation  of  the  Posterior  Tibial  Artery.— The  posterior  tibial 
artery  begins  at  the  lower  border  of  the  poijliteus  muscle  and  passes  down 
the  back  part  of  the  leg,  crossing  as  it  descends  to  the  tibial  side.  The 
course  of  the  artery  is  indicated  by  a  line  drawn  from  the  middle  of  the 
popliteal  space  to  a  point  midway  between  the  tendo  Achillis  and  the 
internal  malleolus  of  the  tibia.  The  artery  may  be  ligated  in  its  upper, 
middle,  or  lower  third. 


LIGATION   OF  THE  POSTERIOR  TIBIAL  ARTERY. 


395 


Ligation  of  the  Posterior  Tibial  Artery  at  its  Upper  Third. — 
An  incision  three  and  a  half  inclies  in  length  should  be  made  half  an  inch 
from  the  inner  edge  of  the  tibia,  beginning  two  inches  below  the  head  of  the 
bone.  (Fig.  300.)  The  skin  and  superficial  fascia  being  divided,  care  being 
taken  to  avoid  large  superficial  veins,  the  deep  fascia  is  opened,  and  the 
origin  of  the  soleus  muscle  is  detached  from  the  tibia ;  upon  raising  it,  its 
under  surface  will  present  a  white,  shining  sheet  of  tendinous  material, 
beneath  which  will  be  seen  a  layer  of  fascia  covering  the  tibialis  posticus 
muscle.  If  search  be  made  towards  the  middle  of  the  leg,  the  artery  will 
be  found  covered  by  the  intermuscular  fascia,  the  nerve  being  to  the  outer 
side.  The  needle  should  be  passed  from  without  inward  after  the  veins 
have  been  separated  from  the  artery. 

Ligation  of  the  Posterior  Tibial  Artery  at  its  Middle  Third. — 
An  incision  two  and  a  half  inches  in  length  should  be  made  parallel  with 
the  inner  edge  of  the  tibia  and  half  an  inch  from  its  border.  The  skin  and 
the  superficial  and  deep  fascite  should  be  divided,  and  the  inner  edge  of  the 
soleus  muscle  will  be  exj)osed ;  displace  this  outward,  and  the  artery  with 
its  veins  will  be  exposed,  also  the  posterior  tibial  nerve  to  the  outer  side. 
The  needle  should  be  passed  from  without  inward. 

Ligation  of  the  Posterior  Tibial  Artery  behind  the  Inner  Mal- 
leolus.— A  curved  incision  two  inches  in  length  should  be  made  midway 
between  the  tendo  Achillis  and  the  internal  malleolus.    (Fig.  300. )    Having 


Fig.  300. 


Ligation  of  the  posterior  tibial  artery  at  its  lower  third.    (Agnew.) 

divided  the  skin  and  superficial  fascia,  the  deep  fascia  should  be  lifted  upon 
a  director  and  freely  opened,  when  the  artery  will  be  exposed,  with  the 
tendons  of  the  tibialis  posticus  and  flexor  lougus  digitorum  muscles  on  the 
inner  side  and  the  posterior  tibial  nerve  and  tendon  of  the  flexor  longus 
pollicis  muscle  on  the  outer  side.  The  veins  should  be  separated  from  the 
artery,  and  the  needle  passed  from  without  inward. 


CHAPTER    XXII. 

SURGERY   OP  THE  NERVES. 
By  Heney  E.  Wharton,  M.D. 


IsTeueitis  consists  in  an  inflammation  of  the  connective  tissu.e  of  nerves, 
and  may  occur  from  wounds  or  other  injuries  of  nerves,  from  exposure  to 
cold,  or  arise  from  constitutional  diseases,  such  as  rheumatism,  gout,  syphi- 
lis, typhoid  fever,  or  from  the  toxic  action  of  certain  drugs,  such  as  lead, 
mercury,  arsenic,  and  alcohol.  The  affection  may  exist  as  an  acute  or  as  a 
chronic  neuritis. 

Acute  Neuritis. — This  affection  is  characterized  by  pain,  extending 
downward  in  the  course  of  the  distribution  of  the  nerve,  which  is  constant, 
is  worse  at  night,  and  is  aggravated  by  x'>i'essure  or  motion  of  the  part ; 
there  are  also  a  certain  amount  of  febrile  disturbance,  numbness  and  ting- 
ling in  the  area  supplied  by  sensory  filaments,  and  marked  hypersesthesia, 
which,  if  the  affection  exists  for  any  considerable  time,  may  be  followed  by 
anaesthesia.  Spasmodic  muscular  jerking  ia  the  early  stages  of  the  affection, 
if  motor  filameuts  are  involved,  may  be  followed  by  paralysis  and  muscular 
wasting.  Acute  neuritis  often  begins  with  inflammation  of  the  sheath  or 
perineurium,  which  is  followed  by  oedema  of  the  sheath,  with  marked  increase 
in  the  connective-tissue  elements  of  the  nerve  and  softening  of  the  nerve- 
tubules  from  granular  and  fatty  changes,  as  well  as  from  inflammatory 
exudates.  Acute  neuritis  may  result  from  exposure  to  cold,  or  from  contu- 
sions or  wounds  of  nerves ;  the  affection  is  not  infrequent  after  punctured 
wounds,  and  the  contusion  or  laceration  of  nerves  following  fractures  and 
dislocations,  and  strains  or  ruptures  of  fibrous  tissue,  fascia,  and  muscles. 
Acute  neuritis  is  most  likely  to  be  confounded  with  neuralgia,  but  may  be 
differentiated  from  the  latter  affection  by  the  fact  that  the  pain  is  continuous 
in  neuritis  and  may  be  elicited  by  pressure  upon  the  nerve,  and  that  it  is 
later  followed  by  sensory,  motor,  or  trophic  changes. 

Treatment. — In  the  treatment  of  thts  affection  heat  or  cold  may  be 
applied,  as  is  most  comfortable  to  the  patient ;  anodyne  applications  may 
also  be  employed.  The  part  should  be  put  at  rest,  a  splint  being  applied  to 
the  part  when  it  is  possible.  If  the  pain  is  intense,  hypodermic  injections 
of  morphine  and  atropine  should  be  used.  In  the  subacute  stage  of  the 
affection  counterirritation  and  the  use  of  the  galvanic  current  are  often 
followed  by  satisfactory  results. 

Chronic  Neuritis. — This  condition  may  follow  acute  neuritis  or  may 
develop  slowly  from  long-continued  irritation  of  nerves  froju  local  or  consti- 
tutional causes.  In  this  affection  there  is  marked  sclerosis  of  the  connective 
tissue  of  the  endoneurium,  with  pressure  on  the  nerve-tubules,  which  pro- 
396 


NEURALGIA.  397 

duces  degeneration  and  atrophy  of  the  same.  Chronic  neuritis  may  exist 
as  an  ascending  or  a  descending  neuritis ;  the  former,  however,  is  more 
common.  This  form  of  neuritis  is  apt  to  be  confounded  with  neuralgia,  but 
tlie  develoi^ment  of  sensory,  motor,  and  trophic  disturbances  will  often 
show  the  true  nature  of  the  affection. 

Treatment. — Pain,  if  prominent,  should  be  relieved  by  the  hypodermic 
use  of  morphine,  atropine,  or  chloroform ;  counterirritation  by  the  use  of 
blisters,  or  the  actual  cautery,  may  be  emx:)loyed  with  benefit.  The  faradic 
or  constant  galvanic  current  shoiild  be  employed  in  cases  in  which  there  are 
paralysis  and  muscular  wasting.  The  patient  should  be  well  fed,  and  care 
taken  that  he  secures  sleep.  Strychnine  can  often  be  used  with  advantage, 
and  in  rheumatic  or  syphilitic  cases,  or  gouty  cases,  treatment  appropriate 
to  these  affections  should  be  instituted  ;  in  some  cases  nerve-stretching  may 
be  resorted  to  with  success.  B'erves  irritated  by  scars  or  projecting  points 
of  bone  should  be  dissected  free  of  them.  Eecovery  is  slow,  and  is  often 
imj)erfect. 

Neuralgia. — N"euralgia  is  an  affection  of  the  nerves,  characterized  by 
acute  paroxysmal  pain,  which  is  referred  to  the  areas  of  their  distribution, 
and  often  without  discoverable  organic  lesions.  Irritation  of  peripheral 
nerves  may  be  a  cause  of  reflex  neuralgia.  The  inclusion  of  a  nerve  in  a 
mass  of  callus  or  in  scar  tissue  may  give  rise  to  neuralgia  in  the  distribution 
of  the  nerve.  It  may  be  excited  by  some  source  of  local  irritation :  a 
carious  tooth  will  often  give  rise  to  severe  neuralgia,  which  will  manifest 
itself  at  a  jpoint  distant  from  the  source  of  irritation  ;  stone  in  the  kidney 
may  give  rise  to  neuralgia  of  the  testicle.  The  pain  in  neuralgia  may  follow 
accurately  the  course  of  distribution  of  a  nerve,  or  it  may  be  experienced 
over  a  considerable  amount  of  surface,  and  is  almost  always  unilateral.  . 
Neuralgic  pain  may  be  diagnosed  from  inflammatory  pain  by  the  absence 
of  fever  and  by  the  fact  that  the  former  is  relieved  by  pressure,  while  the 
latter  is  aggravated  by  it. 

Epileptiform  Neuralgia. — This  variety  of  neuralgia  usually  attacks 
the  face,  and  may  occur  in  any  of  the  branches  of  the  fifth  i)air  of  nerves, 
is  accomx^anied  by  intense  pain,  and  in  some  cases  by  muscular  sj)asm. 
The  attacks  are  intermittent,  and  the  paroxysms  of  pain  may  last  from  a  few 
seconds  to  a  minute.  The  mucous  membrane  of  the  lips,  gums,  and  nostrils 
may  be  the  seat  of  pain  as  well  as  the  skin.  The  paroxysms  may  be  brought 
on  by  exposure  to  a  draught  of  cold  air  or  by  movement  of  the  facial  muscles. 
The  patient  often  exercises  great  caution  in  the  movement  of  the  jaws  or 
lijis  in  eating  and  talking,  from  the  fi-equency  with  which  these  movements 
bring  on  a  paroxysm  of  jaain. 

Treatment. — The  treatment  of  neuralgia  in  the  majority  of  cases 
belongs  to  the  domain  of  medicine,  and  consists  in  the  use  of  anodynes  and 
counterirritants,  and  the  employment  of  massage  and  the  galvanic  current, 
together  with  the  use  of  constitutional  remedies,  such  as  iron,  arsenic, 
quinine,  strychnine,  iihenacetine,  and  antipyrin.  Where,  however,  medici- 
nal treatment  fails  to  give  I'clief,  various  operative  procedures  may  be  prac- 
tised upon  the  nerves,  such  as  neurectasy  or  nerve-Stretching,  neurotomy, 
or  neiu-ectomy.     (See  page  404.)    The  treatment  of  neuralgia  due  to  the 


398 


CONTUSION  OF  NERVES. 


Fig. 


i;*< 


inclusion  of  a  nerve  in  a  mass  of  callus  or  a  cicatrix  consists  in  freeing 
tlie  nerve  from  the  compressing  tissue  by  dissecting  out  the  cicatrix  or 
chiselling  away  the  callus.  Neuralgia  due  to  bulbous  enlargement  of  nerves 
in  stumps  after  amputation  is  treated  by  excision  of  the  bulbous  ends  of 
the  nerves.  Operations  for  the  relief  of  neuralgia  when  none  of  the  pre- 
viously mentioned  conditions  are  present  are  seldom  followed  by  permanent 
relief,  but  occasionally  such  a  fortunate  result  follows ;  in  the  majority  of 
cases,  however,  temporary  relief  is  obtained.  In  epileptiform  and  intract- 
able facial  neuralgias  operative  treatment  alone  is  capable  of  giving  relief. 
Ifeurotomy,  neurectomy,  and  nerve-stretching  (neurectasy)  act  by  intermitt- 
ing the  transmission  of  stimuli  along  the  nerve-trunks  or  branches  and 
putting  at  rest  an  over-stimulated  nerve-centre. 

INJURIES   OP   NERVES. 

Injuries  of  nerves  are  more  common  in  the  upper  extremity  than  in  the 
lower,  from  the  fact  that  they  are  anatomically  more  exposed.  IsTerves  may 
be  contused  or  compressed,  or  maj'  be  incised  or  lacerated. 
Contusion  of  Nerves. — K^erves  in  exposed  posi- 
tions may  suffer  from  contusion,  such  as  the  musculo- 
spiral  nerve  in  the  arm,  the  ulnar  at  the  elbow,  and  the 
brachial  plexus  in  the  neck.  Slight  contusions  of  nerves 
are  usually  followed  to  a  greater  degree  by  loss  of  motion 
than  by  loss  of  sensation.  In  severe  contusions  there  may 
be  complete  destruction  of  the  nerve-fibres  at  the  point  of 
injury,  and  this  may  be  followed  by  loss  of  function  as 
marked  as  that  following  complete  section  of  nerves.  We 
have  recently  had  under  our  care  a  case  of  contusion  of 
the  external  popliteal  nerve  following  an  outward  dislo- 
cation of  the  knee,  in  which  the  loss  of  power  in  parts 
supj)lied  by  the  nerve  was  complete.  (Fig.  301.)  In  this 
case,  upon  exposure  of  the  nerve  at  the  seat  of  injuiy 
some  months  afterwards  it  was  found  that  about  an  inch 
of  the  nerve  was  converted  into  a  fibrous  cord  ;  resection 
and  suture  were  practised,  with  a  satisfactory  result.  If 
after  contusion  of  a  nerve  there  is  loss  of  muscular  power, 
but  it  is  still  capable  of  conveying  sensory  impulses,  the 
prognosis  is  good  ;  but  if  after  a  few  months  there  is  loss 
of  both  motor  and  sensory  power,  the  prognosis  is  bad. 

Treatment. — In  cases  of  slight  contusion  of  nerves  no 
special  treatment  is  indicated  :  the  part  should  be  kept  at 
rest,  and  anodyne  lotions  applied,  and  usually  in  a  short 
time  the  motor  and  sensory  functions  will  be  restored.  In 
Paralysis  following  cases  where  there  is  little  disturbance  of  the  sensory  func- 
tion, with  marked  impairment  of  the  motor  function,  rest 
and  the  use  of  massage  and  galvanism  will  usually  be  fol- 
lowed by  improvement  in  a  few  weeks.  In  cases  where  there  is  comxjlete 
loss  of  power,  both  motor  and  sensory,  following  contusion  of  a  nerve,  and 
improvement  does  not  occur  after  a  month  or  two  under  the  employment  of 


contusion  of  the  exter- 
nal popliteal  nerve. 


COMPRESSION  OF  NERVES.  399 

massage  and  galvanism,  it  may  be  necessary  to  expose  the  nerve  at  the  point 
of  injury,  excise  the  injured  ijortion,  and  unite  the  ends  of  the  nerve  by 
sutures. 

Compression  of  Nerves. — Compression  may  affect  nerve-trunks  or 
nerve-lilaments,  and  may  be  rapid  or  slow  in  its  action.  Rapid  compression 
may  occur  from  traumatisms,  and  has  many  points  in  common  with  contusion  ; 
it  is  accompanied  by  an  effusion  of  blood  between  the  fibres  of  the  nerve. 
It  may  result  from  compression  of  a  nerve 

between  an  external  object  and  a  neighbor-  ^"^'-  ''''^^ 

ing  bone.  Pressui-e  on  nerves  from  the  d is-  r- 
placed  bones  in  fractures  or  dislocations 
may  give  rise  to  marked  symx^toms.  The 
musculo-spiral  nerve  is  not  infrequently 
affected  in  fractures  of  the  humerus.  (Fig. 
302.)  Paralysis  of  the  parts  supplied  by 
this  nerve  has  occurred  from  the  use  of 
Esmarch's  tube  applied  tightly  to  control 
hemorrhage.  Pain  and  loss  of  motor  func- 
tion in  the  sciatic  nerve  are  also  occasion- 
ally observed  in  cases  of  growths  or  abscess  Wnst-drop  following  involvement  of  the 

.1  1     •  -Ti         1       •         jT  ii  „  J?     musculo-spiral   nerve    in    fracture    of    the 

m  the  pelvis.     Paralysis  of  the  nerves  of   ]-,unjg,.us 
the  arm  from  j)ressure  often  occurs  during. 

heavy  sleep,  especially  a  drunkard's  sleep.  Slow  compression  may  result 
from  long-continued  pressure  upon  nerves,  as  is  seen  in  paralysis  of  the  arm 
from  pressure  on  the  brachial  plexus  by  crutches,  from  callus  or  cicatricial 
tissue,  and  from  tumors  or  aneurisms.  Compression  of  terminal  filaments  of 
nerves  usually  results  from  their  involvement  in  cicatrices  or  malignant 
growths  of  the  skin. 

Symptoms. — These  vary  with  the  nerve  involved,  whether  it  be  a  sen- 
sory, motor,  or  mixed  one.  If  a  sensory  nerve  be  involved,  the  symptoms 
are  neuralgic  pain,  numbness,  hyperaesthesia,  and  more  or  less  anaesthesia. 
In  motor  nerves,  muscular  weakness,  tremor,  and  paralysis  are  the  marked 
symptoms.  In  a  mixed  nerve,  sensory  distm-bances  are  first  developed, 
and  these  are  followed  later  by  motor  paralysis.  If  the  compression  is  not 
relieved,  trophic  changes,  such  as  muscular  wasting,  bullae,  and  ulceration 
of  the  skin  are  observed  in  the  parts  suj)X3lied  by  the  nerve. 

Treatment. — This  consists  first  in  removing  the  cause,  and  usually 
after  this  has  been  accomplished  recovery  of  function  occurs.  In  cases 
of  rapid  com^jression,  where  marked  disorganization  of  the  nerve  has  not 
occurred,  recovery  usually  follows  in  a  few  weeks,  but  it  may  require  months. 
The  use  of  the  galvanic  current  to  improve  the  nutrition  of  the  nerve- 
trunk,  combined  with  the  faradic  cui'rent  and  massage,  is  often  advan- 
tageous. If  the  symj)toms  be  due  to  a  growth  which  can  be  removed, 
this  should  be  accomxilished  without  injury  to  the  nerve ;  if  the  nerve  can- 
not be  freed  from  the  tumor,  it  should  be  resected  and  the  ends  united  by 
sutures.  If  the  nerve  is  involved  in  a  scar,  it  should  be  dissected  out  and 
the  scar  tissue  removed,  and  when  the  compression  is  due  to  calhis  this 
should  be  carefully  cut  away  so  as  to  free  the  nerve.     In  cases  of  i^aralysis 


400  WOUNDS  OF  NERVES. 

from  the  use  of  crutches,  these  should  be  abandoned  for  a  time,  and  after 
the  removal  of  the  cause,  massage  and  galvanism  should  be  employed. 

Dislocation  of  Nerves. — Dislocation  of  a  ner^  e,  aside  from  its  occur- 
rence in  connection  with  fractures  or  dislocations,  is  rarely  seen.  The 
peroneal  nerve  is  sometimes  dislocated  in  fractures  of  the  tibia.  The  ulnar 
nerve  at  the  elbow  is  occasionally  dislocated  by  direct  injury  or  forced 
extension  of  the  forearm.  A  number  of  cases  of  dislocation  of  this  nerve 
have  been  reported,  and  we  have  had  recently  under  our  care  a  case  of  dislo- 
cation of  the  ulnar  nerve  from  direct  violence.  The  symptoms  of  this  injury 
are  usually  numbness  and  tingling  iu  the  parts  supplied  by  the  ulnar  nerA^e, 
and  the  jaatient  often  feels  something  slip  near  the  inner  condyle  of  the 
humerus  upon  extension  and  flexion  of  the  arm.  Upon  examinatiou  the 
surgeon  can  feel  a  cord  iu  front  of  the  inner  condyle  when  the  arm  is  flexed, 
which  slips  back  into  its  groove  when  the  arm  is  extended.  Iu  some  cases 
the  symj)toms  following  this  injury  gradually  disappear,  the  nerve  accustom- 
ing itself  to  its  changed  position ;  iu  others,  more  or  less  pain,  numbness, 
and  disability  persist. 

Treatment. — This,  in  the  case  of  the  ulnar  nerve,  consists  in  replacing 
the  nerve  and  holdiug  it  in  place  by  a  compress  and  bandage,  at  the  same 
time  fixing  the  motion  of  the  elbow-joint  by  means  of  a  splint.  If  this 
treatment  fails  to  prevent  recurrence  of  the  dislocation,  it  is  better  to  expose 
the  nerve  by  an  incision,  and,  after  making  a  bed  for  it  behind  the  inner 
condyle  of  the  humerus,  to  fix  it  in  its  normal  position  by  two  or  three 
chromicized  catgut  sutures  passed  through  the  inner  margin  of  the  triceps 
tendon  and  somewhat  loosely  around  the  nerve ;  sutures  should  also  be 
applied  to  unite  the  divided  margin  of  the  fascial  expansion  of  the  triceps 
tendon  superficial  to  the  nerve. 

Wounds  of  Nerves. — These  may  be  either  incised,  lacerated,  or 
punctured.  Incised  wounds  of  nerves  are  produced  by  sharp  cutting  instru- 
ments, such  as  knives,  or  by  fragments  of  glass ;  accidental  division  of  nerves 
is  most  frequent  from  glass  wounds  caused  bj^  thrusting  the  hand  or  foot 
through  a  pane  of  glass  or  from  the  breaking  of  glass  vessels.  Lacerated 
wounds  of  nerves  may  occur  in  connection  with  extensive  laceration  of 
other  parts,  as  is  frequently  seen  in  machinery  and  railroad  accidents,  in 
fractures  or  dislocations,  or  in  gunshot  wounds.  Punctured  wounds  of 
nerves  generally  result  from  needles,  pins,  or  nails,  and  are  not  usually 
followed  by  complete  loss  of  function,  but  may  give  rise  to  neuralgia  or 
neuritis. 

Symptoms. — The  immediate  symptoms  following  the  division  or  exten- 
si^e  laceration  of  a  mixed  nerve  are  not  always  distinctive  ;  the  pain  may 
be  slight  or  may  be  severe.  The  muscles  supplied  by  the  divided  nerve  are 
immediately  paralyzed,  and  remain  iu  this  condition  so  long  as  the  nerve 
remains  ununited.  (Fig.  303.)  At  the  end  of  three  or  four  days  they  refuse 
to  respond  to  a  strong  faradic  current.  Later,  the  muscular  tissue  wastes 
and  degenerates,  so  that  at  the  end  of  two  or  three  months,  very  little 
remains.  Eeactiou  to  the  galvanic  current  disappears  more  slowly,  and  may 
not  be  entirely  lost  for  several  months.  While  galvanic  irritability  is  present 
the  reactions  of  degeneration  may  be  obtained,  which  are  as  follows.     In  a 


fT';^ 


TREATMENT  OF  DIVIDED  NERVES.  401 

healthy  muscle  the  cathodal  closure  couti-action  is  greater  than  the  anodal 
closure  contractiou  ;  but  after  division  of  a  nerve,  when  the  muscle  is  under- 
going degeneration,  there  is  rapid  loss  of  irritability  in  the  affected  nerve  to 
the  galvanic  or  the  faradic  ciu-rent,  and  the  muscles  supplied  by  the  nerve 
rapidly  lose  their  irritability  when  excited  with  the  faradic  current,  but 
show  for  several  days  increased  irrita- 
bility to  the  galvanic  current.    Instead  Fig.  303. 
of  the  short,  quick  contraction  of  the  j^^^^^^ 
normal  muscle  we  obtain  a  slow,  de-                         MK^^^^^^slk 
liberate   contraction  in  the  diseased 
muscle,  with  gradual  increase  in  the 
anodal  closure  contractiou,  so  that  in 
a  short  time  it  becomes  equal  to  or 
greater  than  the  cathodal. 

The  changes  following  division  of 
a  nerve  containing  sensory  fibres  are 
as  follows.  The  patient  is  usually  at 
once  conscious  of  a  numbness  in  the 
parts  supplied  by  the  divided  nerve, 

the  anaesthesia  of  the  skin  being  most  Paralysis  of  the  oceipUo-frontalis  on  the  left 

,      ,       T  ....         T    .  side  from  wound  of  the  anterior  temporal  branch 

marked.    In  severe  injuries,  involving    of  the  facial  nerve. 
other  tissues  as  well  as  the  nerves, 

sensory  disturbances  are  often  masked  by  the  pain  and  shock  of  the  injury. 
In  other  cases  there  is  no  marked  loss  of  sensibility  in  the  parts  suijplied  by 
the  divided  nerve,  which  condition  can  be  accounted  for  only  by  anastomosis 
with  neighboring  nerves.  Sensation  may  be  lost  immediately  after  the 
injury,  but  may  soon  return,  the  return  of  sensation  being  always  more 
prompt  than  that  of  motion. 

In  addition,  certain  trophic  changes  occur  in  the  tissues  from  which  the 
nerve-supply  is  cut  off,  which  may  be  manifested  in  the  skin  by  a  glossy 
appearance  and  the  development  of  herpes  or  ulcers  or  superficial  gangrene 
in  the  anaesthetic  area.  The  nails  may  become  thickened  and  curved,  and 
present  ridges  upon  their  surface.  The  hair  is  often  shed  fi-om  the  anaes- 
thetic area,  or  becomes  brittle.  The  joints  may  also  become  inflamed  and 
swollen,  presenting  much  the  appearance  of  rheumatic  arthritis,  and  fibrous 
ankylosis  may  result,  causing  marked  impairment  of  function. 

When  no  union  of  a  divided  nerve  occurs,  collateral  innervation  may 
take  place,  analogous  somewhat  to  the  collateral  circulation  which  occurs 
after  division  and  occlusion  of  blood-vessels,  which  exj)lains  the  cases  of 
apparent  immediate  regeneration  after  suture  of  nerves. 

Eepair  of  injured  nerves  is  considered  on  page  83. 

Treatment  of  Divided  Nerves. — Eecently  divided  nerves  should  be 
approximated  by  sutures  ;  great  care  should  be  exercised  to  render  the 
wound  aseptic,  so  that  healing  may  be  obtained  without  suppm-ation.  If 
the  ends  of  the  divided  nerve  are  much  torn  or  lacerated,  they  should  be 
trimmed  off  or  freshened  so  as  to  obtain  good  surfaces  for  approximation. 
If  the  amount  of  lacerated  tissue  which  has  to  be  removed  is  considerable, 
it  may  be  necessary  to  stretch  both  ends  of  the  nerve  before  they  can  be 

26 


402  SECONDARY  S'UTURE  OF  NERVES. 

brouglit  into  apposition.  There  may  also  be  a  considerable  amount  of  retrac- 
tion of  the  ends  of  the  nerve,  so  that  it  will  often  be  necessary  to  enlarge 
the  wound  before  they  can  be  found.  The  material  used  for  sutures  should 
be  fine  silk  or  chromicized  catgut.  The  sutures  should  be  passed  through 
the  nerve  and  its  sheath  about  an  eighth  of  an  inch  from  its  cut  extremity. 
As  few  sutures  as  possible  should  be  used,  two  irsually  being  sufficient,  and 
the  sutures  should  be  tied  just  tight  enough  to  bring  the  divided  ends  of  the 
nerve  together.  The  sheath  may  also  be  united  with  sutures.  An  ordinary 
sewing-needle  is  better  than  the  bayonet-pointed  surgical  needle,  as  it  does 
not  injure  the  fibres  in  its  passage.  After  applying  the  sutures  the  wound 
should  be  closed  and  dressed,  and  the  part  fixed  in  the  best  position  to  secure 
relaxation  of  the  nerve.  Eestoration  of  function  is  usually  slow  ;  even  after 
immediate  union  of  divided  nerves  a  certain  amount  of  impairment  of  motion 
or  sensation  may  be  permanent.  After  union  has  occurred,  the  restoration 
of  function  may  be  hastened  by  the  use  of  galvanism  and  massage. 

Secondary  Suture  of  Nerves. — Many  cases  of  divided  nerves  do  not 
come  under  the  observation  of  the  surgeon  for  weeks  or  months  after  the 
injury,  at  which  time  degenerative  changes  have  taken  place  in  them,  and 
the  ends  are  usually  included  in  a  mass  of  cicatricial  tissue.  The  results 
of  secondary  suture  have  been  so  satisfactory  that  it  is  always  well  to  make 
an  attempt  to  approximate  the  ends  of  the  nerve.  In  performing  secondary 
suturing  a  free  incision  should  be  made  over  the  line  of  the  nerve,  and  it 
should  be  exposed  above  and  below  the  point  of  division.  It  should  then 
be  traced  upward  and  downward  into  the  cicatricial  tissue ;  the  latter 
should  be  freely  removed,  and  a  fresh  section  made  of  each  end  of  the 
nerve.  The  bulbous  enlargement  upon  the  peripheral  end  should  be 
removed,  as  it  consists  largely  of  fibrous  tissue,  or  the  upper  portion  only 
should  be  left.  If  there  is  much  separation  between  the  freshened  ends  it 
will  be  found  necessary  to  stretch  the  nerve  freely  or  practise  some  of  the 
plastic  oj)erations  upon  the  nerves  which  are  described  later,  and  by  so 
doing  the  ends  can  usuallj^  be  brought  into  contact.  Two  or  three  sutures 
of  fine  silk  or  chromicized  catgut  should  next  be  jpassed  through  the  ends  of 
the  nerve  and  secured,  and  the  wound  then  closed  and  dressed.  Eestoration 
of  function  after  secondary  suture  is  very  slow  ;  marked  improvement  may 
not  be  manifested  for  months,  or  even  years. 

Punctured  Wounds  of  Nerves. — The  treatment  of  punctured  wounds 
of  mixed  nerves  which  are  followed  by  severe  pain,  muscular  spasm,  or 
hyperfesthesia  of  the  skin,  probably  due  to  a  netiritis,  consists  in  putting 
the  part  at  complete  rest  by  the  use  of  splints,  the  local  use  of  anodyne 
applications,  and  couuterirritation  by  means  of  blisters  or  cautery.  If 
after  the  use  of  these  remedies,  the  symptoms  persist,  the  nerve  should  be 
exposed  at  the  seat  of  injury  and  nerve-stretching  should  be  practised. 

Partial  Division  of  Nerves. — It  is  probable  that  partial  division  of 
nerves  is  much  more  common  than  is  generally  suspected  in  subcutaneous 
wounds,  and  that  the  slight  disturbance  that  occurs  in  such  cases  is  due 
to  the  fact  that  the  uncut  fibres  prevent  retraction  of  the  severed  por- 
tions of  the  nerve,  and  iinion  of  the  divided  portions  takes  place  in  a  short 
time. 


NEURORRHAPHY.  403 

Treatment. — If  a  partially  divided  nerve  is  exposed  in  a  wound,  the 
severed  portions  should  be  approximated  by  sutures.  Secondary  suturing 
of  partially  divided  nerves  may  be  undertaken  if  the  disturbances  of  sen- 
sation and  motion  following  the  injury  are  marked,  and  this  procedure  is 
accomplished  by  exposing  the  nerve  at  the  seat  of  injury  and  removing  the 
cicatricial  tissue  surrounding  it,  and  if  little  nerve-tissue  is  found  to  be 
present  the  nerve  should  be  resected  and  the  ends  united  by  sutures.  If 
only  a  small  portion  of  the  nerve  is  involved  in  the  cicatrix,  this  may  be 
dissected  out  and  a  few  sutures  applied  to  the  portion  of  the  nerve  which 
has  been  loosed  from  the  cicati-ix. 

Neuromata. — Neuromata  are  tumore  growing  ujaon  or  between  the 
fasciculi  of  a  nerve ;  they  are  usually  fibrous  or  fibrocellular  growths 
attached  to  the  sheath  of  the  nerve,  and  are  known  as  false  neuromata. 
(See  pages  279  and  288.) 

The  painful  subcutaneous  tubercle,  which  is  a  small  fibroma  developed  upon 
a  cutaneous  branch  of  a  sensory  nerve,  is  considered  by  some  writers  as  a 
form  of  neuroma.     Sarcomata  and  cysts  may  also  develop  in  nerves. 

Treatment. — The  tumor  should  be  dissected  from  the  nerve,  if  possible, 
without  injury  to  the  nerve-fibres  ;  this  can  be  done  in  many  cases  of  false 
neuromata.  If,  however,  the  tumor  cannot  be  removed  without  dividing  or 
excising  a  portion  of  the  nerve,  this  should  be  done,  and  the  divided  ends  of 
the  nerve  should  be  united  to  bring  about  speedy  restoration  of  function.  If 
the  amount  of  the  nerve-trunk  removed  is  so  extensive  that  the  ends  cannot 
be  united  by  sutures,  even  after  stretching  the  ends  of  the  nerve,  attemj^ts 
should  be  made  to  unite  them  by  neuroplasty,  or  nerve -grafting,  or  threads 
of  chromicized  catgut  should  be  passed  through  the  ends  of  the  nerve  and 
tied, — suture  a  distance, — and  upon  this  framework,  even  if  the  gap  is  exten- 
sive, the  reparative  material  from  the  ends  of  the  nerve  may  be  deposited, 
and  union  of  the  divided  ends  ultimately  effected. 

Plexiform  neuromata,  if  not  too  extensive,  or  if  upon  parts  where  their 
presence  causes  great  disfigurement,  should  be  removed  by  dissection. 

OPERATIONS   UPON   NERVES. 

Nerve-Suture,  or  Neurorrhaphy.— The  primary  or  secondary 
approximation  of  divided  nerves  by  the  application  of  sutures  has  been 
described  under  wounds  of  nerves.  In  exposing  wounded  nerves  for 
suturing  the  use  of  Bsmarch's  bandage  is  most  satisfactory,  as  its  employ- 
ment enables  the  operator  to  recognize  the  nerve  and  adjacent  tissues. 
Nerve-sutures  should  be  of  some  mateiial  which  can  be  thoroughly  sterilized 
and  is  callable  of  absorption  or  of  becoming  encysted  in  the  tissues. 

Nerve-Grafting. — Where  it  has  been  necessary  to  remove  a  consider- 
able portion  of  a  nerve,  as,  for  instance,  iu  the  removal  of  a  tumor  or  a 
neuroma,  or  where  a  portion  of  a  nerve  has  been  removed  in  an  accidental 
injury,  if  it  is  foimd  that  the  gap  between  the  ends  of  the  nerve  is  too  great, 
even  after  stretching  the  ends,  to  permit  of  approximation  with  sutures, 
lengthening  of  the  nerve  may  be  done,  a  flap  or  flaps  being  turned  from  one 
or  both  ends  of  the  divided  nerve  and  united  by  sutures  (neuroplasty). 
(Pig.  304.)     The  gap  may  also  be  filled  by  a  graft  of  nerve- tissue  ;  a  section 


404  NERVE-STRETCHING. 

of  nerve  from  a  recently  amputated  limb,  if  it  can  be  obtained,  or,  if  not,  a 
piece  of  nerve  from  a  freshly  killed  animal,  is  cut  of  sufficient  lenath  to  fill 


Neuroplasty.     ( Willard. ) 

the  gap,  and  is  sutured  to  the  nerve  at  each  end  by  clu-omicized  catgut 
sutures.     (Fig.  305.)    It  is  probable  that  nerve-grafts  simply  act  as  a  frame- 

FiG.  305. 


Nerve-grafting.     (Willard. 

work  for  the  deposit  of  new  tissue,  but  some  experimenters  assert  that  the 
grafts  ijroduce  embryonic  nerve-fibres  capable  of  assisting  in  reunion. 

Nerve  Implantation. — This  procedure  has  recently  been  practised, 
and  consists  in  making  a  lateral  implantation  of  the  cut  end  of  one  nerve  into 
an  adjacent  nerve  ;  this  is  accomplished  by  opening  the  sheath  of  the  nerve 
by  an  incision  and  inserting  the  cut  end  of  the  nerve  into  this  opening  and 
securing  it  by  sutures.  Both  the  upper  and  lower  ends  of  a  nerve  may  be 
implanted  into  a  neighboring  nerve  in  this  manner. 

Neurectasy,  or  Nerve-Stretching.— ISTerve-stretching  or  elongation 
is  a  procedure  in  which  the  nerve  is  exposed  and  stretched  in  both  directions. 
It  has  been  shown  by  the  experiments  of  Vogt  that  a  nerve  is  capable  of 
an  elongation  of  one-twentieth  of  its  length,  the  greatest  elongation  occur- 
ring at  its  spinal  extremity.  The  amount  of  force  that  can  be  applied  to 
an  undivided  nerve  without  producing  rupture  is  a  matter  of  importance  in 
the  operation  of  nerve-stretching.  The  force  required  to  rupture  the  sciatic 
nerve  is  fi'om  one  hundred  to  one  hundred  and  sixty  pounds ;  the  median, 
nmsculo-spiral,  and  ulnar  nerves  will  resist  a  strain  of  from  fifty  to  eighty 
pounds ;  the  facial  nerve  will  stand  a  strain  of  from  seven  to  twelve  pounds. 
Traction  upon  the  nerve  from  the  spinal  cord  towards  the  periphery  is  said 
to  have  more  effect  upon  the  sensory  fibres,  while  traction  upon  the  nerve 
from  the  periphery  towards  the  spine  is  said  especially  to  affect  the  motor 
fibres.  The  changes  produced  in  the  nerve  by  stretching  are  detachment 
of  the  sheath  from  the  nerve,  rupture  of  the  blood-vessels  of  the  sheath,  and 
dilatation  of  the  vessels  of  the  substance  of  the  nerve ;  laceration  of  the 
nerve-tubules  is  in  proj)ortion  to  the  violence  employed.  Degeneration  of 
the  nerve-fibres  occurs,  which  in  time  is  followed  by  the  formation  of  new 
nerve-fibres  and  complete  regeneration  of  the  nerve.  There  is  probably 
a  distinct  impression  j)roduced  upon  the  spinal  cord  by  nerve-stretching, 
as  experiments  upon  animals  show  verj^  decided  lesions  of  the  cord, 
such  as  hemorrhages  and  inflammatory  exudations,  as  the  result  of  this 
procedui-e. 

The  physiological  effect  of  nerve-stretching  is  shown  by  decreased  con- 
ducting power,  numbness  or  complete  antesthesia,  diminution  or  loss  of 
muscular  power,  and  in  some  cases  trojphic  changes. 


NEURECTOMY.  405 

Operation. — The  uerve  should  be  exposed  by  iiicisiou  and  isolated,  and 
if  it  be  a  small  one,  as  the  facial,  an  aneurism  needle  should  be  passed 
under  it  and  it  should  be  stretched  in  both  directions  ;  if  a  large  nerve,  such 
as  the  sciatic  or  median,  a  finger  should  be  placed  under  it,  and  it  should 
be  stretched  in  both  directions,  care  being  taken  to  beep  the  force  applied 
well  within  the  limit  of  the  breaking  strain.  The  bloodless  method  of  nerve- 
stretching  is  applied  only  to  the  sciatic  nerve,  which  may  be  stretched  by 
placing  the  patient  upon  his  back,  with  the  leg  extended  at  the  kuee,  and 
flexing  the  thigh  forcibly  ni^on  the  pelvis,  forced  flexion  being  continued 
for  ten  or  fifteen  minutes.  The  patient  should  be  anaesthetized  before  the 
manipulation  is  practised. 

Application. — In  nerve-stretching  it  is  probable  that  the  tearing  or 
stretching  of  the  tubules  extends  far  beyond  the  immediate  seat  of  ojDera- 
tion,  affecting  even  distant  branches,  and  this  is  possibly  the  reason  why  this 
operation  is  more  satisfactory  in  certain  cases  than  neurotomy  or  neurectomy. 
Nerve-stretching  may  be  employed  with  advantage  in  cases  of  neuralgia  and 
chronic  neuritis.  In  neuralgia  following  injuries  of  nerves,  when  the  nerves 
are  compressed  by  scar-tissue  or  j)resent  inflammatory  thickening,  the  results 
following  this  procedure  are  often  most  satisfactory.  In  such  cases  the  nerve 
should  be  separated  from  the  scar-tissue  and  thoroughly  stretched.  ISTerve- 
stretching  has  been  employed  in  cases  of  paralysis,  epilepsy,  and  tetanus,  and 
for  the  relief  of  the  lightning  pains  of  tabes  dorsalis,  but  apparently  without 
permanent  benefit.  In  dealing  with  mixed  nerves,  nerve-stretching  should 
be  preferred  to  neurotomy  or  neurectomy  in  certain  cases,  as  the  former 
ojjeration  is  followed  by  only  temporary  loss  of  motion  and  sensation, 
while  the  latter  produces  not  only  anaesthesia,  but  also  piermanent  muscular 
paralysis. 

Neurotoniy. — I^eurotomj^,  or  nerve-section,  is  the  intentional  division 
of  a  nerve,  and  is  a  procedure  which  is  practised  for  the  relief  of  pain 
or  spasm.  In  performing  this  operation  the  nerve  is  exijosed  at  a  conve- 
nient position  and  is  divided  with  the  knife  or  scissors.  Owing  to  the 
fact  that  union  of  the  divided  nerve  soon  takes  place,  which  is  often  fol- 
lowed by  a  return  of  the  troublesome  symptoms,  this  operation  is  not 
now  much  employed  and  has  largely  been  superseded  by  the  operation  of 
neurectomy. 

Neurectomy. — This  consists  in  the  exposure  and  resection  of  a  con- 
siderable portion  of  a  uerve,  so  that  a  wide  gap  exists  between  its  ends. 
Neurectomy  is  frequently  employed  in  cases  of  neuralgia  and  muscular  spasm 
with  satisfactory  results.  As  union  of  the  ends  of  the  divided  nerve  some- 
times takes  place,  even  though  a  considerable  portion  has  been  removed,  as 
is  evidenced  by  the  return  of  the  symijtoms,  the  ends  are  often  turned  back, 
or  portions  of  muscles  or  fascia  are  interposed  to  prevent  their  reunion. 

Nerve- Avulsion  (Thiersch). — In  this  operation  traction  on  the 
trunk  of  a  iieripheral  ner^■e  is  emploj'ed  to  tear  it  at  its  central  origin.  The 
nerve  being  carefully  separated  from  the  surrounding  connective  tissue,  the 
forceps,  which  resemble  Lister  s  forceps,  having  one  concave  and  one  convex 
blade,  are  fastened  at  right  angles  to  the  nerve,  and  the  nerve  is  twisted. 
The  torsion  must  be  done  slowly,  a  half-turn  every  second.     In  this  manner 


406 


SUPERIOR  MAXILLARY  NERVE. 


Fig.  306. 


not  only  the  main  peripheral  trunk  but  all  its  branches  are  twisted  into  one 
common  cord,  until  it  becomes  more  or  less  fixed  in  some  bony  canal  or  at 
its  ganglion  ;  then,  as  the  axis  cylinder  is  broken  by  twisting,  gentle  traction 
is  sufficient  to  sever  the  surrounding  sheath.  Where  it  is  impossible  to  reach 
the  peripheral  portion,  the  nerve  may  be  divided  in  its  middle,  and  the 
central  end  twisted ;  the  peripheral  end  should  then  be  pulled  out  of  the 
wound  as  far  as  possible  and  cut  off,  in  order  to  prevent  reunion. 

The  operations  of  nerve-stretching,  neurotomy,  neurectomy,  and  nerve- 
avulsion  are  often  j)ractised  on  the  following  nerves  : 

The  Supra-orbital  Nerve. — This  nerve  emerges  from  the  supra-orbital 
foramen  or  notch  at  the  junction  of  the  middle  and  inner  thirds  of  the  eye- 
brow. It  may  be  exposed  by  an  incision  about 
three-fourths  of  an  inch  in  length,  made  parallel 
with  the  eyebrow  aud  just  beneath  it  (Fig.  306) ; 
the  scar  resulting  will  be  hidden  by  the  folds  of 
the  skin.  The  supratrochlear  nerve  lies  half  an 
inch  to  the  inner  side  of  the  supra-orbital  notch, 
and  may  be  exi^osed  by  a  like  incision. 

The  Superior  Maxillary  Division  of  the 
Fifth  Nerve. — This  nerve  may  be  exposed  by 
a  curved  incision  one  and  a  half  inches  long, 
just  below  the  lower  border  of  the  orbit.  The 
Ijositiou  of  the  foramen  of  exit  is  one-fourth  of 
an  inch  below  the  orbit,  on  a  line  drawn  from 
the  supra-orbital  notch  to  the  canine  tooth  of 
the  same  side.  The  nerve  lies  deeper  than 
would  be  expected,  by  reason  of  the  concavity  of  the  surface  of  the  superior 
maxillary  bone  and  because  it  is  covered  by  the  elevator  muscles  of  the 
upper  lip.  The  nerve  being  exposed,  it  is  seized  with  haemostatic  forceps, 
or  a  ligature  is  tied  around  it  to  be  used  for  the  purpose  of  traction  upon  it. 
(Fig.  306.)  A  portion  of  the  edge  of  the  orbit  just  over  the  foramen  is  cut 
away  with  a  chisel,  the  tissues  of  the  orbit  are  pushed  upward  with  a 
retractor,  the  thin  bony  wall  between  the  orbital  cavity  and  the  nerve-canal 
is  broken  through  with  a  director  or  elevator,  and  the  nerve  is  exposed.  It  • 
is  then  grasped  with  forceps  and  cut  off  with  blunt  scissors  as  far  back  as 
possible.  The  terminal  filaments  should  next  be  torn  loose  from  the  skin 
and  muscles  by  traction  upon  the  distal  end  of  the  nerve  with  forceps.  The 
infra-orbital  artery,  which  accompanies  the  nerve,  is  sometimes  injured, 
and  gives  rise  to  free  hemorrhage,  which  can  be  controlled  by  packing  the 
cavity  with  a  strip  of  sterilized  gauze. 

Removal  of  Meckel's  Gi-anglion. — The  incision  for  the  removal  of  this 
ganglion  should  be  a  curved  one,  extending  from  canthus  to  canthus,  about 
a  fourth  of  an  inch  below  the  orbit.  If  more  room  is  required,  it  may  be 
supplemented  by  a  straight  incision  made  at  right  angles  to  the  first.  The 
infra- orbital  nerve  is  found,  and  a  ligature  attached  to  it.  The  anterior  wall 
of  the  antrum  is  perforated  with  a  three-quarter-inch  trephine  or  a  gouge, 
including  the  infra-orbital  foramen.  The  posterior  wall  of  the  antrum  is 
next  perforated  with  a  half-inch  trephine  or  a  gouge.     In  removing  the 


Exposure  of  the  supra-orbital  and 
superior  maxillary  division  of  the 
fifth  nerve. 


INFERIOR  DENTAL  NERVE. 


407 


Fig.  307. 


section  of  bone  from  the  posterior  wall  great  care  should  be  taken  to  avoid 
injury  of  the  internal  maxillary  artery,  which  lies  just  behind  the  opening  in 
the  bone.  The  nerve  is  next  divided  in  advance  of  the  foramen,  and  after 
breaking  down  the  wall  of  the  bony  canal  it  is  traced  back  to  the  spheno- 
maxillary fossa  and  to  the  foramen  rotundum,  and  the  nerve  and  ganglion  just 
below  the  foramen  are  cut  away  with  blunt-pointed  curved  scissors.  Hemor- 
rhage is  controlled  by  packing  the  wound  with  strij)s  of  sterilized  gauze. 

For  operations  upon  the  Gasseriau  ganglion,  see  Surgery  of  the  Head. 

Inferior  Dental  Nerve. — This  nerve  is  exj)osed  by  a  horizontal  incision 
two  inches  in  length  behind  the  angle  and  along  the  border  of  the  lower 
jaw,  which  is  less  likely  to  divide  branches  of  the  seventh  nerve  than  a 
vertical  incision.  The  incision  is  carried  down  to  the  bone,  the  soft  parts 
are  pushed  upward  on  the  vertical  ramus,  the  posterior  portion  of  the 
masseter  m^^scle  is  pushed  forward,  and  when  the  angle  of  the  jaw  is  fully 
exposed  a  half-inch  trephine  is  applied  an  inch  and  a  quarter  above  the 
angle.  When  the  disk  of  bone  has  been  removed  the  nerve  is  exposed  in 
the  canal  (Fig.  307),  is  lifted  with  an  aneu- 
rism needle,  and  may  be  stretched  or  re- 
sected. If  the  inferior  dental  artery  is 
wounded,  free  bleeding  occurs,  which  may 
be  controlled  by  ligatures,  by  plugging  the 
canal  with  a  piece  of  catgut,  or  by  ijacking 
with  gauze. 

The  inferior  dental  nerve  may  also  be 
exposed  through  the  mouth.  The  mouth 
being  held  open  with  a  gag  on  the  opposite 
side,  an  incision  should  be  made  along  the 
anterior  border  of  the  lower  jaw,  extending 
from  the  last  upper  molar  to  the  correspond- 
ing tooth  in  the  lower  jaw.  After  division 
of  the  mucous  membrane  the  finger  should 
be  inserted  between  the  internal  pterygoid 

muscle  and  the  ramus  of  the  jaw,  to  separate  the  muscle  and  feel  for  the 
sharp  projection  of  bone  which  marks  the  orifice  of  the  inferior  dental  canal. 
An  aneurism  needle  should  then  be  passed  forward  from  the  inner  aspect 
of  the  jaw,  and  the  nerve  should  be  hooked  upon  this  and  drawn  forward. 
In  resecting  the  nerve  care  should  be  taken  not  to  injure  the  inferior  dental 
artery. 

The  Lingual  Nerve. — This  nerve  maybe  exposed  by  passing  a  ligature 
through  the  tongue  and  pulling  it  forcibly  towards  the  oijposite  side  to  make 
the  nerve  tense ;  the  nerve  can  then  be  felt  as  a  firm  cord  beneath  the 
mucous  membrane  of  the  floor  of  the  mouth  between  the  jaw  and  the  tongue. 
An  incision  is  made  through  the  mucous  membrane  at  this  point,  and  the 
nerve  is  raised  upon  an  aneurism  needle  and  resected  or  stretched.  Eesec- 
tion  of  this  nerve  is  resorted  to  in  cases  of  neuralgia  or  malignant  disease 
of  the  tongue  for  the  relief  of  pain. 

The  Facial  Nerve. — This  nerve  may  be  exposed  at  its  point  of  exit 
from  the  stylo-mastoid  foramen  by  an  incision  behind  the  ear  carried  from 


Exposure  of  the  inferior  dental  nerve. 


408  THE  GEEAT  SCIATIC  NERVE. 

the  level  of  the  external  auditory  meatus  downward  and  forward  to  the  angle 
of  the  jaw.  After  dividing  the  stin  and  fascia  the  aponeurosis  of  the  sterno- 
mastoid  is  exposed  and  retracted  ;  the  posterior  border  of  the  parotid  gland 
is  also  exposed,  and  should  be  drawn  forward.  The  prevertebral  muscles 
and  their  fascia  are  next  exposed,  and  the  nerve  lies  in  front  of  these.  It 
should  be  lifted  upon  an  aneurism  needle,  cleared  of  surrounding  tissues, 
and  resected.  To  locate  the  nerve  it  may  sometimes  be  necessary  to  use  a 
fine-pointed  electrode,  with  a  sponge  electrode  upon  the  cheek. 

The  Spinal  Accessory  Nerve.  This  nerve  is  exposed  by  an  incision 
the  centre  of  which  is  opposite  the  hyoid  bone,  and  which  is  made  parallel 
to  the  anterior  margin  of  the  sterno- mastoid  muscle.  This  muscle  should  be 
strongly  retracted,  when  the  nerve  will  be  found  crossing  the  carotid  artery 
and  internal  jugular  vein,  penetrating  the  muscle  from  its  under  sm-face. 
The  nerve  when  exposed  is  lifted  upon  an  aneurism  needle  and  resected. 
Eesection  of  this  nerve  is  often  resorted  to  in  cases  of  spasmodic  wry-neck. 

The  Cervical  Plexus. — The  nerves  of  the  cervical  plexus  may  be 
exjiosed  by  an  incision  parallel  with  the  posterior  border  of  the  sterno- 
cleido-mastoid  muscle  near  its  middle. 

The  Brachial  Plexus. — The  nerves  of  this  plexus  may  be  exposed  iu 
the  neck  or  in  the  axilla.  The  cords  of  the  brachial  plexus  may  be  exposed 
iu  the  neck  by  an  incision  parallel  with  and  just  above  the  clavicle,  similar 
to  that  for  ligation  of  the  subcla\'ian  artery.  To  expose  it  in  the  axilla  an 
incision  is  made  similar  to  that  employed  in  ligation  of  the  axillary  artery. 

The  Median  Nerve. — This  nerve  is  exposed  in  the  upper  arm  by  an 
incision  two  inches  iu  length  parallel  to  the  inner  border  of  the  biceps 
muscle  near  its  middle  ;  the  nerve  crosses  in  front  of  the  artery  from  without 
inward.  The  median  nerve  may  also  be  exposed  at  the  bend  of  the  elbow, 
or  in  the  forearm  by  an  incision  two  inches  in  length  at  the  inner  side  of 
the  pal  maris  longus  tendon  just  above  the  wrist. 

The  Musculo-Spiral  Nerve. — This  nerve  may  be  exposed  at  the 
middle  or  lower  third  of  the  arm.  It  is  reached  with  the  greatest  ease  in 
the  latter  situation  by  an  incision  two  inches  in  length  on  a  line  drawn 
from  the  external  condyle  to  the  insertion  of  the  deltoid  muscle.  After 
dividing  the  skin  and  fascia  the  nerve  can  be  felt  with  the  finger  upon  the 
humerus  in  the  groove  between  the  brachialis  anticus  and  supinator  longus 
muscles. 

The  Ulnar  Nerve. — The  ulnar  nerve  may  be  exposed  in  the  middle  of 
the  arm,  just  above  the  elbow,  or  in  the  forearm.  In  the  middle  of  the  arm 
it  may  be  exposed  by  an  incision  similar  to  that  for  exposure  of  the  median 
nerve,  and  is  to  be  sought  for  to  the  inner  side  of  that  nerve.  It  is  exposed 
with  the  greatest  ease  behind  the  elbow,  where  it  can  be  felt  in  a  groove 
between  the  inner  condyle  and  the  olecranon  jirocess.  In  the  lower  part 
of  the  forearm  it  may  be  exposed  by  an  incision  along  the  radial  border  of 
the  flexor  carpi  ulnaris  muscle. 

The  Radial  Nerve. — This  nerve  may  be  exposed  by  an  incision  similar 
to  that  employed  in  ligation  of  the  radial  artery  in  the  forearm  down  to  a 
point  about  three  inches  above  the  wrist,  where  it  passes  under  the  tendon 
of  the  supinator  longus  muscle  to  the  baCk  of  the  hand. 


THE  ANTERIOR   AND  POSTERIOR  TIBIAL  NERVES. 


409 


Fig.  308. 


The  Great  Sciatic  Nerve. — This  nerve  is  exposed  by  an  incision  three 
or  four  inches  in  length,  beginning  just  below  the  gluteo-femoral  crease  on  a 
line  from  the  middle  of  the  popliteal  space  to  a 
point  a  little  to  the  inner  side  of  the  middle  of 
a  line  drawn  from  the  great  trochanter  to  the 
tuber  ischii.  After  dividing  the  skin  and  fascia 
the  gluteus  maximus  muscle  should  be  drawn 
outward  and  upward,  and  the  biceps  muscle 
drawn  inward,  when  the  nerve  will.be  brougiit 
-into  view.     (Fig.  308.) 

The  Internal  Pophteal  Nerve. — This  nerve 
lies  under  the  deep  fascia  in  the  middle  of  the 
popliteal  space,  and  may  be  exposed  by  a  longi- 
tudinal incision  in  this  position. 

The  External  Popliteal  Nerve.— This  nerve  is  exposed  by  an  incision 
two  inches  in  length  on  the  inner  side  of  the  tendon  of  the  biceps,  a  short 
distance  above  its  insertion  into  the  head  of  the  fibula. 

The  Anterior  and  Posterior  Tibial  Nerves.— These  nerves  may  be 
exposed  at  any  point  in  the  leg  or  at  the  ankle  by  incisions  similar  to  those 
employed  in  ligation  of  the  anterior  and  posterior  tibial  arteries. 


Exposure  of  sciatic  nerve. 


CHAPTEE    XXIII. 

SURGERY  OF  MUSCLES,   TENDONS,  FASCIA,   AND  BURS^. 
By  Henry  E.  Wharton,  M.D. 

INJURIES   OF   MUSCLES. 

Muscles. — Muscles  may  present  incised,  lacerated,  and  contused  wouuds ; 
the  latter  varieties  are  often  subcutaneous.  Laceration  of  muscular  tissue 
may  result  from  the  application  of  external  force,  or  from  the  sudden,  for- 
cible, and  improperly  opposed  contraction  of  a  muscle.  When  the  latter 
accident  occurs,  the  patient  usually  exi^eriences  a  sudden  sharp  pain,  with  a 
sense  of  giving  way  in  the  region  of  injury,  and  in  attempting  to  move  the 
part  finds  that  there  is  disability  to  a  greater  or  less  extent.  Extensive 
gaping  may  result  from  incised  and  lacerated  wounds  of  the  muscles,  the 
amount  of  separation  depending  upon  the  direction  and  completeness  of  the 
division  of  the  muscular  fibres ;  transverse  wounds  of  muscles  present  this 
symptom  in  a  more  marked  degree  than  longitudinal  wounds.  Eupture  of 
the  sterno-cleido-mastoid  muscle  during  birth  is  probably  only  a  partial 
rupture,  giving  rise  to  the  condition  known  as  congenital  tumor  of  the  sterno- 
mastoid,  and  may  cause  a  form  of  wry-neck. 

In  operations  the  division  of  muscles  should  be  avoided  as  far  as  possible  ; 
they  may  be  freed  from  the  sheath  to  assist  retraction,  or  split  longitudinally. 

Eupture  of  the  rectus  abdominis  muscle  has  occurred  in  parturition,  and  of 
the  adductors  of  the  thigh  in  spasmodic  efforts,  and  of  the  flexors  of  the  fore- 
arm and  the  tricejys  in  violent  muscular  efforts.  The  psoas  muscle  has  also 
been  torn,  and  the  iliacus  muscle  torn  from  its  attachment  to  the  ilium  by 
falls  upon  the  pelvis. 

Strains  and  sprains  of  muscles  are  frequent  injuries,  and  may  consist  in 
simjjle  stretching  of  the  fibres  of  the  muscle,  or  in  laceration  of  some  of  the 
muscular  fibres  ;  both  of  these  injuries  are  capable  of  producing  more  or  less 
loss  of  function  in  the  injured  muscle.  Eepair  of  muscular  tissue  takes  place 
entirely  by  the  formation  of  fibrous  tissue  at  the  seat  of  injury. 

Treatment. — Incised  and  lacerated  wounds  of  muscles  should  be  treated 
by  the  introduction  of  buried  sutures,  catgut  or  silk,  between  the  ends  of 
the  divided  muscle,  to  bring  them  in  apposition.  The  sutures  should  be 
introduced  some  distance  from  the  ends  of  the  muscle  and  tied  loosely ; 
mattress  sutures  are  least  likely  to  cut  out.  When  a  considerable  portion  of 
the  muscle  has  been  lost  and  it  is  impossible  to  approximate  the  ends,  a 
number  of  strong  chromicized  catgut  sutures  may  be  introduced  to  act  as  a 
framework  for  the  deposit  of  reparative  material, — suture  a  distance ;  muscle- 
grafting  is  useless  because,  even  if  the  graft  retains  its  vitality,  it  is 
eventually  converted  into  fibrous  tissue,  but  muscle-transplantation  may  be 
employed.  In  all  wounds  of  muscles  the  i^arts  should  be  put  completely  at 
rest  by  the  application  of  splints,  straps,  and  bandages. 
410 


DISEASES  OF  MUSCLES.  411 

Subcutaneous  icounds  of  muscles,  if  not  involving  the  whole  thickness  of 
the  muscles,  do  not  require  the  application  of  sutures,  but  if  the  muscles 
are  completely  torn  across,  which  may  be  recognized  by  the  gap  which  can 
be  felt  between  the  ends,  they  should  be  exposed  by  incision  and  the  ends 
united  by  buried  sutures.  Strains  and  sprahis  of  muscles  are  best  treated  by 
strapping,  the  straps  of  adhesive  plaster  being  firmly  applied,  and  additional 
support  and  fixation  being  given  by  splints  and  bandages. 

Hernia  of  Muscles. — This  condition  consists  in  a  protrusion  of  a  por- 
tion of  a  muscle  through  a  gap  in  the  deep  fascia  overlying  it,  and  generally 
results  from  wounds  in  which  healing  of  the  wound  in  this  fascia  has  not 
taken  place.  The  protrusion  of  the  muscular  tissue  is  usually  marked  upon 
contraction  of  the  muscle,  and  is  often  accompanied  by  some  impairment  of 
muscular  power.  Treatment. — If  the  muscular  protrusion  is  of  small 
extent,  no  disability  results  and  no  treatment  is  required.  In  recent  cases, 
however,  when  there  exists  a  certain  amount  of  disability,  the  application 
of  a  compress  and  bandage  or  of  an  elastic  bandage  for  a  time  will  often 
effect  a  cure.  Where  the  latter  methods  fail  to  give  relief,  it  is  better  to  cut 
down  upon  the  hernia  and  expose  the  gap  in  the  deep  fascia  ;  the  edges  of 
the  fascia  should  be  freshened,  and  brought  iato  apposition  by  sutures  of 
silk  or  chromicized  catgut. 

DISEASES   OE   MUSCLES. 

Myalgia. — This  disease,  which  is  characterized  by  a  painful  condition 
of  a  voluntary  muscle,  may  result  from  traumatic  causes,  such  as  strains  or 
twists  or  slight  lacerations,  giving  rise  to  inflammation  of  the  muscular 
tissue,  or  may  arise  from  acute  infectious  diseases,  from  syphilis,  or  from ' 
the  toxic  action  of  certain  drugs,  such  as  lead,  mercury,  or  alcohol,  and  may 
be  neuralgic  in  character.  Treatment.— This  consists  in  putting  the 
affected  muscle  at  rest  by  the  use  of  strapping  or  the  application  of  splints, 
and  the  employment  of  heat  and  anodyne  lotions,  or  the  hypodermic  use  of 
morphine  and  atropine.     Massage  may  also  be  employed  with  advantage. 

Myositis. — This  affection  consists  in  an  inflammation  of  the  voluntary 
muscles,  and  may  arise  from  traumatism  or  overuse  of  a  muscle,  from  dia- 
thetic conditions,  such  as  gout  and  rheumatism,  from  secondary  syphilis,  or 
gummatous  infiltration,  from  infection  followed  by  diffused  suppuration,  or 
from  the  presence  of  the  embryos  of  the  trichina  spiralis  in  the  muscular 
fibres.  We  saw  recently  a  lad  who  presented  a  marked  inflammation  of  the 
biceps  muscle,  the  muscle  being  tender  and  swollen,  with  loss  of  function ; 
the  condition  had  developed  after  a  day's  work  in  a  blacksmith-shop,  when 
he  had  constantly  used  a  heavy  sledge-hammer.  Treatment. — The  treat- 
ment of  myositis  due  to  traumatism  and  overuse  of  the  muscle  consists  in 
putting  the  muscle  at  rest  by  the  use  of  splints  and  bandages,  or  strapping, 
and  in  the  application  of  anodyne  lotions.  Myositis  arising  from  rheuma- 
tism and  syphilis  will  be  relieved  by  treatment  appropriate  to  those  affec- 
tions. Infective  myositis  with  suppuration  should  be  treated  by  incisions 
into  the  inflamed  muscle,  to  secure  free  drainage,  and  the  application  of  an 
antiseptic  dressing.  The  muscular  invasion  of  trichiniasis  requires  both 
constitutional  and  local  treatment. 


412 


INJURIES   AND   DISEASES   OF  THE  FASCIiE. 


Ossification  of  Muscles. — Ossification  of  a  portion  of  the  belly  of  a 
muscle,  or  more  frequently  of  its  point  of  insertion  into  a  bone,  is  occasion- 
ally observed  as  the  result  of  long-continued  irritation,  and  often  in  rheuma- 
toid arthritis.  The  development  of  bone  plates  in  the  adductor  muscles  of 
the  thigh,  known  as  rider'' s  hone,  is  not  infrequent  in  those  who  ride  on  horse- 
back constantly.  We  have  observed  a  case  in  the  brachialis  anticus  muscle 
of  a  young  man  consequent  uijon  repeated  blows  of  the  fist. 

Myositis  ossificans  is  a  rare  affection,  in  which  there  is  a  wide-spread 
ossification  of  the  muscles  following  a  general  muscular  inflammation.  The 
cause  of  this  affection  is  unknown.  The  course  is  slow,  and  is  uuaifected 
by  treatment ;  death  usually  results  from  exhaustion  or  involvement  of  the 
respiratory  muscles. 

Atrophy  of  Muscles. — Atrophy  of  muscular  tissue  may  arise  from 
disuse,  from  nerve  injury,  from  disease  of  the  joints  or  of  the  spine,  or 
from  contusion,  as  is  often  seen  after  contu- 
Fi«- 309.  sions  of  the  shoulder.     (Fig.  309.)    Muscular 

atrophy  is  a  prominent  sym^jtom  in  i)rogres- 
sive  muscular  ati'ophy  and  infantile  paralysis. 
Hypertrophy  of  Muscles.— A  mus- 
cle may  increase  in  size  from  actual  increase 
in  the  number  and  size  of  the  muscular  fibres 
through  unusual  action  of  the  muscle,  or  from 
increase  in  the  connective  tissue,  lymphatics, 
or  blood-vessels  of  the  muscle. 

Contracture  of  Muscles. — This  affec- 
tion, which  consists  in  a  jjermanent  shorten- 
ing of  a  muscle, — that  is,  the  aijproximation 
of  its  point  of  origin  and  its  point  of  inser- 
tion,— may  result  from  many  causes,  such  as 
inflammation,  loss  of  substance,  diseases  of 
contiguous  joints,  paralysis  of  opj)Osing  mus- 
cles, cicatricial  contraction,  diseases  of  the 
central  nervous  system,  hysteria,  and  chorea.  Eicord  has  described  a  form 
of  contracture  in  muscles,  particularly  in  the  biceps,  which  results  from 
syphilis.  The  treatment  of  contracture  of  muscles  is  considered  in  the  article 
upon  Orthopfedic  Surgery. 

Tumors  of  Muscle. — Muscular  tissue  may  be  the  seat  of  carcinoma- 
tous, sarcomatous,  syphilitic,  fibrous,  cystic,  vascular,  cartilaginous,  or 
osseous  growths.  The  treatment  of  these  affections  depends  largely  upon 
their  nature;  non-malignant  growths  can  often  be  removed  by  dissection ; 
malignant  growths  involving  muscles  of  the  extremities  call  for  excision  of 
the  growth,  or  in  many  cases  for  amputation  of  the  limb. 


Atrophy  of  the  muscles  of  the  left  shoul- 
der following  contusion. 


INJURIES  AND  DISEASES  OF  FASCIAE. 

Wounds  of  Fasciae. — The  various  fasciae  of  the  body  which  invest 
and  compress  the  muscles  and  separate  them  from  one  another  are  often 
exposed  to  injury.  Wounds  of  fascite  are  of  especial  interest  to  the  surgeon, 
from  the  fact  that  they  open  up  certain  planes  of  tissue  in  which  infection 


RUPTURE  OF  TENDONS.  413 

or  suppuration  maj'  occur  and  cause  wide-spread  destruction  of  the  tissues. 
Wounds  of  the  deep  fascia  are  apt  to  be  followed  by  hernia  of  the  subjacent 
muscles.  The  inelasticity  of  the  fascia  in  inflammation  of  subjacent  struc- 
tures causes  marked  tension,  which  is  apt  to  be  followed  by  great  pain  and 
also  sepsis  and  sloughing.  Wounds  of  fasciae  also  gape  widely  and  are  often 
followed  by  a  weak  scar. 

Treatment. — The  treatment  of  an  open  wound  of  the  deep  fascia  consists 
in  approximating  the  edges  of  the  fascia  with  sutures  ;  if  destruction  of  a 
portion  of  the  fasciie  has  occurred,  from  its  inelastic  character  it  is  not  pos- 
sible to  bring  the  edges  into  contact.  Subcutaneous  wounds  of  the  deep 
fascia  unaccompanied  by  hernia  of  the  muscles  should  be  treated  by  rest, 
position,  and  fixation  of  the  parts  by  strapping  and  splints. 

Contraction  of  Fasciae. — As  the  result  of  inflammation  following 
traumatism,  or  of  certain  diathetic  conditions,  such  as  gout  or  rheumatism, 
shortening  of  fasciae  may  occur,  giving  rise  to  marked  deformities ;  the 
deformities  arising  from  contraction  of  the  fascia  lata,  the  popliteal  fascia, 
and  the  palmar  fascia  are  familiar  to  every  surgeon.  The  treatment  of  these 
conditions  will  be  considered  under  Orthopaedic  Surgery. 

INJURIES  AND  DISEASES  OP  TENDONS. 

Rupture  of  Tendons. — Complete  or  partial  rupture  of  tendons  may 
occur  from  sudden  violent  effort,  i^roducing  unusual  muscular  contraction, 
or  may  result  from  slight  sti'ains,  as  seen  in  cases  of  rheumatoid  arthiritis. 
Improper  co-ordination,  according  to  Pagenstecker,  is  an  important  element 
in  their  prodiiction.  When  such  an  accident  occurs,  the  patient  experiences 
a  sense  of  something  giving  way  and  sharp  pain  at  the  seat  of  injury,  which 
is  followed  by  loss  of  muscular  power  and  later  by  swelling  and  ecchy- 
mosis.  The  tendons  in  which  this  accident  is  most  likely  to  occur  are 
those  of  the  plantaris,  the  quadriceps  extensor  femoris,  the  long  head  of  the 
biceps,  the  Ugamentum  patella;,  and  the  tendo  Achillis.  Avulsion  of  tendons 
may  result  from  machinery  accidents :  the  fingers  or  toes  being  caught  in 
machinery,  the  tendons  are  torn  out,  often  with  a  portion  of  the  attached 
muscles. 

Treatment. — In  case  of  a  ruptured  tendon  it  is  possible  to  have  repair 
take  place,  if  the  gaj)  between  the  ends  is  not  too  extensive,  by  putting  the 
parts  at  rest  and  in  such  a  position  as  to  favor  the  apposition  of  the  ends  of 
the  tendon.  The  time  reciuired,  however,  is  considerable,  and  the  functional 
result  may  be  imperfect.  In  view  of  these  facts,  it  is  wiser  to  treat  cases  of 
ruptured  tendon  by  exposing  the  ends  by  incision  and  aj)proximating  them 
with  silk  or  chromicized  catgut  sutures,  and  after  dressing  the  wound  ax)ply- 
ing  a  plaster-of-Paris  bandage  to  fix  the  part  and  hold  it  in  such  a  position 
as  will  secure  the  greatest  relaxation  of  the  injured  tendon. 

Rupture  of  the  Plantaris. — The  tendon  of  this  muscle  is  often  torn 
bj'  sudden  violent  motion,  in  wrestling,  lawn  tennis,  etc.,  and  the  part 
becomes  tender  and  swollen  and  later  ecchymosed.  Treatment. — The 
limb  should  be  put  at  rest  and  the  part  supported  by  strapping  for  a  few 
days ;  after  this  massage  and  passive  motion  should  be  practised,  and  the 
disability  will  usually  be  relieved  in  two  or  three  weeks. 


414 


EUPTrEE   OF  THE  TENDO  ACHILLIS. 


Rupture  of  the  Quadriceps  Extensor  Femoris. — This  injury 
results  from  violent  action  of  the  muscles  when  the  knee  is  slightly  bent, 
and  may  consist  in  a  rupture  of  the  quadriceps  just  above  the  fjatella  or  in 
a  tearing  away  of  the  insertion  of  the  tendon  from  the  patella,  stripping  off 
a  portion  of  the  jjeriosteum  and  fibrous  cajisule  with  occasionally  some 
particles  of  the  bone.  The  patient  experiences  sadden  pain  and  cannot 
stand  upon  or  extend  the  leg,  and  there  is  a  marked  transverse  gaj)  in  the 
tissues  above  the  patella.  Treatment. — A  compress  and  bandage  may 
be  applied  and  the  limb  fixed  in  the  extended  position  by  a  plaster-of-Paris 
bandage  applied  to  the  leg  and  thigh,  but  if  the  rupture  has  been  complete 
great  disability  is  apt  to  result,  so  that  it  is  better  to  expose  the  seat  of 
injury  by  incision  and  suture  together  the  ends  of  the  ruptured  tendon.  In 
cases  of  tearing  away  of  the  insertion  of  the  tendon  of  the  quadriceps  exten- 
sor femoris  or  ligamentum  patellae  from  the  patella,  to  secure  a  satisfactory 
result  it  is  often  necessary  to  expose  the  separated  tendon,  and  after  drilling 
the  patella  at  a  number  of  points  to  pass  kangaroo  tendon  or  silk  sutures 
through  the  iDcrforations  in  the  bone  and  through  the  end  df  the  tendon  to 
fix  its  insertion  in  the  normal  position. 

Rupture  of  the  Ligamentum  Patellae. — This  accident,  which  results 
from  the  same  causes  which  j^roduce  li'acture  of  the  patella,  is  occasionally 
met  with.  The  symptoms  are  sudden  sharp  jsain  where  the  ru^jture  occurs, 
swelling,  inability  to  extend  the  leg,  with  upward  displacement  of  the  patella 
and  a  marked  gap  below  the  patella.  Treatment. — As  the  disability  is 
likely  to  be  permanent,  the  ends  of  the  tendon 
should  be  exposed  by  incision  and  secured 
together  by  silk  or  chromicized  catgut  sutures 
and  the  limb  fixed  in  the  extended  position  by 
a  j)laster-of- Paris  bandage. 

Rupture  of  the  Tendo  Achillis.— This 
may  result  from  sudden  violent  muscular  effort ; 
sharp  pain  is  a  prominent  symptom  and  is  de- 
scribed by  the  French  term  coiq)  de  fouet,  and 
there  is  also  swelling  and  loss  of  function.  The 
loss  of  function  is  very  marked,  and  examina- 
tion will  reveal  a  decided  gap  between  the  torn 
ends  of  the  tendon.  Treatment. — This  con- 
sists in  exi^osing  the  ruptvu-ed  ends  of  the  tendon 
by  incision  and  securing  them  together  by 
sutures.  The  foot  should  be  extended  and  the 
knee  flexed,  and  the  limb  maintained  in  this 
position  for  two  or  three  weeks  by  a  suitable 
splint  or  a  plaster-of-Paris  bandage. 

Rupture  of  the  Long  Head  of  the 
Biceps.  — This  tendon  usually  ruptures  near  its 
insertion  as  the  result  of  muscular  effort ;  rheu- 
matoid arthritis  predisposes  to  the  accident.  The  patient  feels  something 
give  way  in  the  arm  and  he  cannot  flex  it ;  there  is  also  sharp  pain  and 
swelling,  and  the  characteristic  deformity  is  present.     (Fig.  310.)     Treat- 


FiG.  310. 


Rupture  of  long  head  of  biceps  muscle. 
(After  Treves.) 


AVOUNDS   OF  TENDONS.  415 

ment. — The  arm  should  be  bandaged  from  the  fingers  to  the  shoulder  and 
carried  in  a  sling,  and  in  a  few  weeks  passive  motion  and  massage  should 
be  practised.  The  end  of  the  tendon  forms  adhesion  in  its  new  position 
and  a  fair  functional  result  may  be  obtained. 

Occasionally  the  tendon  of  insertion  of  the  hiceps  is  ruptured  or  is  torn 
from  its  attachment  to  the  tubercle  of  the  radius,  which  is  recognized  by  a 
transverse  gap  in  the  tissues  above  the  elbow.  In  this  condition  the  ends 
of  the  tendon  should  be  exposed  by  incision  and  sutured,  and  the  arm  should 
be  fixed  for  some  weeks  in  the  ijosition  of  acute  flexion,  and  afterwards 
passive  motion  and  massage  should  be  employed. 

Wounds  of  Tendons. — Wounds  of  tendons  may  be  punctured, 
incised,  or  lacerated,  and  may  be  subcutaneous  or  open.  The  subcutaneous 
variety  of  incised  wounds  is  frequently  produced  in  the  ordinary  operation 
of  tenotomy,  and  the  favorable  course  wliich  these  wounds  run  is  known  to 
every  surgeon.  Punctured  wounds  of  tendons,  unless  septic  matter  is  intro- 
duced by  means  of  the  puncturing  instrument,  are  usually  followed  by  little 
trouble.  Open  wounds  of  the  sheaths  of  tendons  are  serious  injuries,  both 
as  regards  inflammatory  complications  which  may  arise  if  the  wou.nd  becomes 
septic,  and  the  loss  of  function  which  results  if  union  of  the  divided  ends 
of  the  tendon  is  not  secured.  These  wounds  are  often  seen  in  connection 
with  incised  wounds  of  the  skin,  fascia,  and  muscles,  and  result  from  injury 
by  sharp-edged  instruments,  such  as  knives  or  scythes,  or  from  broken  glass. 
These  woiinds  of  tendons  are  usually  seen  about  the  hands  and  feet. 

Treatment. — The  divided  ends  of  the  tendon  should  be  exjjosed,  and 
fastened  together  by  the  introduction  of  one  or  two  sutures  of  silk  or  catgut. 
Difficulty  is  sometimes  experienced  in  locating  the  proximal  end  of  the 
tendon,  it  often  being  so  much  retracted  that  it  becomes  necessary  to  enlarge 
the  wound  to  expose  it.  It  is  well  also  to  suture  the  divided  sheath  of  the 
tendon  with  a  few  sutures  of  tine  silk  or  catgut.  The  wound  should  be 
carefully  dressed,  and  the  part  placed  in  the  position  of  relaxation  and  put 
at  rest  by  the  application  of  a  sijlinfc  or  plaster-of- Paris  bandage.  Lacerated 
wounds  of  tendons  should  be  treated  in  the  same  manner.  Here  it  may  be 
necessary  to  trim  away  some  of  the  lacerated  tissue  to  obtain  a  good  surface 
for  apposition. 

Secondary  Suture  of  Tendons. — It  sometimes  happens  that  the 
division  of  a  tendon  escapes  notice  at  the  primary  dressing  of  a  wound,  and 
after  healing  has  occurred  it  is  found  that  there  is  a  certain  amount  of  loss 
of  function,  which  points  to  the  division  and  non-union  of  the  tendon.  In 
such  a  case  the  ends  of  the  divided  tendon  should  be  exposed  by  an  incision  ; 
and  there  is  here  often  considerable  difSculty  in  finding  the  proximal  end, 
which  is  generally  greatly  retracted.  When  exposed,  the  ends  of  the  tendon 
should  be  freshened  and  brought  into  apposition  by  two  or  three  sutures  of 
catgut  or  silk  passed  through  them  some  distance  from  their  edges,  so  that 
they  will  not  be  likely  to  cut  out  before  union  occurs.  If  it  is  found  impos- 
sible after  stretching  the  proximal  end  of  the  tendon  and  its  attached  muscle 
to  bring  it  into  contact  with  the  distal  end,  sutures  may  be  introduced  between 
the  ends,  even  if  a  gap  of  some  size  exists,  these  sutures  serving  as  a  frame- 
work for  the  deposit  of  I'eparative  material ;  or  some  operation  for  length- 


416 


TENOSYNOVITIS. 


Fig.  311. 


Fig.  312. 


\1 


ening  the  tendon  may  be  undertaken.     Secondary  suturing  of  tendons  is 
often  followed  by  the  most  satisfactory  results. 

Lengthening  of  Tendons. — This  operation  may  be  practised  to 
increase  the  length  of  contracted  tendons  and  muscles,  or  to  lengthen  a 
tendon  so  as  to  bring  the  divided  ends  together  in  the  secondary  suturing. 
It  is  accomplished  by  introducing  a  knife  and  making  an  incision  partly 
through  the  tendon,  then  splitting  the  tendon 
for  a  short  distance  and  cutting  through  it, 
aud  sutm'ing  the  ends.  (Fig.  311.)  In  case 
of  marked  retraction  of  the  proximal  end  of 
a  tendon,  a  iiap  may  be  turned  down  from  the 
proximal  end  aud  sutured  to  the  distal  end, — 
Czerny's  method.     (Pig.  312.) 

Dislocation  of  Tendons.— Tendons  are 
occasionally,  as  the  result  of  extreme  violence, 
thrown  out  of  their  normal  iDOsitions.  This 
condition  is  sometimes  observed  in  the  tendon 
of  the  long  head  of  the  biceps,  which  may  be 
thrown  out  of  the  bicipital  groove.  Disloca- 
tion is  most  common  in  the  tendons  in  relation 
with  the  ankle-joint.  Extreme  inversion  of 
the  foot  throws  out  the  tendons  behind  the 
internal  malleolus,  and  extreme  eversion  dis- 
places the  tendons  behind  the  external  mal- 
leolus ;  therefore  after  reduction  of  tendons 
near  the  internal  malleolus  place  the  foot  in 
eversion,  and  for  those  of  the  external  malleolus  place  the  foot  in  inversion. 
In  the  treatment  of  a  displaced  tendon,  the  use  of  a  compress  and  bandage 
applied  after  the  tendon  has  been  replaced,  and  fixation  of  the  part  for  a 
time,  will  often  secure  it  in  its  normal  position.  If,  however,  this  fails  to 
control  the  tendency  to  displacement,  the  tendon  should  be  exjjosed  by  an 
incision  and  sutured  in  its  normal  position,  being  held  by  a  flap  of  peri- 
osteum or  fibrous  tissue  sutured  across  it. 

Tenosynovitis  or  Thecitis. — Inflammation  of  the  synovial  sheaths 
of  tendons  may  occur  in  the  following  forms  :  1,  nonsuppurative;  2,  suppu- 
rative ;  3,  tuberculous ;  4,  syphiUtio ;  5,  gonorrliceal ;  and  may  exist  as  an  acute 
or  a  chronic  affection. 

Non-Suppurative  Tenosynovitis. — This  affection,  sometimes  de- 
scribed as  serofibrinous  tenosynovitis,  usually  results  from  strains  or  sprains 
of  the  tendons  and  sheaths,  or  from  unaccustomed  excessive  use  of  the  parts, 
especially  if  accompanied  by  exposure  to  cold.  This  form  of  tenosynovitis 
is  most  frequently  observed  in  the  tendons  about  the  wrist  and  those  just 
above  the  ankle.  The  symptoms  are  pain,  loss  of  power  in  the  affected 
muscles,  and  a  xieculiar  crepitus  when  the  tendon  is  moved  in  its  sheath, 
which  is  sometimes  mistaken  for  the  crepitus  of  fracture. 

Treatment. — The  treatment  of  nonsuppurative  tenosynovitis  consists 
in  the  application  of  tincture  of  iodine  over  the  course  of  the  inflamed 
tendon,  or  light  stroking  of  the  surface  of  the  skin  over  the  tendon  with 


Lengthening  of 
a  tendon. 


Czerny's  method 
of  lengthening  a 
tendon. 


SUPPURATIVE   THECITIS. 


417 


Paqueliu's  cautery,  and  the  use  of  a  splint  to  limit  the  luotlou  of  the  affected 
part.  In  the  later  stage  of  the  affection  the  local  use  of  an  ointment  of 
equal  parts  of  unguentum  belladonnae  and  unguentum  hydrargyri,  or  strap- 
ping, will  often  be  followed  by  good  results.  The  affection  usually  subsides 
under  this  treatment  in  a  short  time.  Some  crepitation  may  remain  upon 
motion  of  the  tendon  long  after  all  inflammatory  symptoms  have  subsided. 

Suppurative  Thecitis. — This  affection  results  from  infection  of  the 
sheath  of  a  tendon  by  pyogenic  organisms  which  have  gained  access  to  it 
through  an  open  or  a  punctm-ed  wound.  In  many  cases  the  wound  may  be 
so  insignificant  as  almost  to  escape  notice.  This  disease  often  affects  the 
flexor  tendons  of  the  hands  and  feet,  and  is  accompanied  by  redness  and 
swelling  of  the  part,  throbbing  pain,  and  marked  constitutional  disturbance. 
Owing  to  the  anatomical  structure  of  the  parts,  the  inflammation  travels 
readily  along  the  sheath  of  the  tendons  and  the  surrounding  connective 
tissue,  and  unless  the  progress  of  the  disease  is  arrested  by  free  incisions 
sloughing  of  the  tendons  and  sheaths  as  well  as  of  the  connective  tissue  is 
apt  to  occur,  and  in  some  cases  necrosis  of  the  adjacent  bones  results. 

Treatment. — This  consists  in  early  and  free  incision  and  the  subse- 
quejit  application  of  warm,  moist  antiseptic  dressings.  If  in  spite  of  early 
incision  the  disease  continues  to  spread  and  involves  other  tendons,  the 
incision  should  be  repeated  at  the  new  positions  of  inflammation.  It  is  only 
by  the  employment  of  early  and  free  inci- 
sions that  sloughing  of  the  tendons  and  of  Fig.  313. 
the  connective  tissue  can  be  avoided.  Fixa- 
tion of  the  inflamed  parts  by  a  splint  is  an 
important  detail  in  the  treatment. 

Palmar  Abscess. — Palmar  abscess 
may  result  from  infection  of  the  connective 
tissue  or  synovial  sheaths  of  the  flexor  ten- 
dons in  the  palm  of  the  hand,  through  a 
punctured  wound,  or  from  suppurative  the- 
citis of  the  sheaths  of  the  flexor  tendons  of 
the  fingers.  Because  of  the  anatomical 
arrangement  of  the  sheaths  of  the  flexor 
tendons,  the  jialm,  thumb,  and  little  finger 
having  a  general  sheath,  and  those  of  the 
fore,  ring,  and  middle  fingers  having  sepa- 
rate sheaths  (Pig.  313),  the  infective  pro- 
cess is  more  likely  to  terminate  in  palmar 
abscess  if  it  originates  in  the  sheath  or  the 

flexor    tendon   of   the    little    finger    or    the  synovial  sheaths  of  fingers  aud  common 

, ,  ,         rni  i.  J.        1  n  sheath  for  tendons  of  the  palm,  little  finger, 

thumb.     The  symptoms  of  palmar  abscess  and  thumb.   (Keen.) 
are   pain,   swelling,   oedema  of  the  dorsal 

surface  of  the  hand,  and  marked  constitutional  disturbance.  If  not  subjected 
to  prompt  treatment,  the  pus  may  burrow  along  the  tendons  and  enter  the 
forearm,  involving  the  connective-tissue  planes  or  the  articulations  of  the 
carpus.  If  the  pus  does  not  extend  in  this  direction,  it  is  apt  to  burrow  back- 
ward and  point  on  the  dorsum  of  the  hand  between  the  metacarpal  bones. 

27 


418  TUBERCULAR  TENOSYNOVITIS. 

Treatment. — This  consists  in  early  and  free  incision  of  the  palm  ;  the 
incision  or  incisions  should  be  made  over  the  metacarpal  bones,  and,  to  avoid 
injury  of  the  superficial  palmar  arch,  they  should  be  made  in  advance  of  the 
first  transverse  line  running  across  the  palm  of  the  hand.  After  the  abscess 
has  been  freely  opened,  moist  antiseptic  dressings  should  be  applied,  and  the 
hand  and  forearm  should  be  fixed  upon  a  splint.  Early  incision  usually 
arrests  the  progress  of  the  trouble,  but  occasionally  in  spite  of  this  treat- 
ment the  infection  spreads  to  the  dorsum  of  the  hand  and  the  forearm,  in 
which  case  incisions  should  be  made  at  a  number  of  points  to  secure  free 
drainage. 

Tuberculous  Tenosynovitis.— This  affection  is  manifested  by  swell- 
ing and  induration  in  and  around  the  sheath  of  a  tendon,  due  to  the  presence 
of  granulation-tissue,  or  there  may  be  irregular  swellings,  which  present 
fluctuation,  and  which  uijon  being  opened  are  found  to  contain  fluid  and 
numerous  whitish  bodies  resembling  grains  of  rice  or  melon-seeds.  Micro- 
scoi^ic  examination  in  these  cases  usually  reveals  the  presence  of  tubercle 
bacilli.  This  disease  is  most  frequently  seen  in  connection  with  tendons  at 
the  wrist,  ankle,  and  knee,  and  may  develoiD  after  a  slight  injury  of  the 
tendons  over  these  joints,  such  as  a  s]3rain  or  wrench,  or  may  follow  a 
tubercular  affection  of  the  joints.      (Fig.  314.)     The  disease  runs  a  slow 


Tuberculous  tenosynovitis  of  tlie  wrist. 

course,  and  even  when  the  swelling  is  marked  there  may  be  little  pain  and 
very  slight  impairinent  of  function.  It  rarely  undergoes  spontaneous  cure, 
but  is  more  apt  to  become  infected  and  su^jpurate,  or  to  break  down,  form- 
ing a  tubercxilar  abscess. 

Treatment. — In  cases  of  tuberculous  tenosynovitis  in  which  there  is 
little  thickening  of  the  sheaths  of  the  tendons,  and  fluid  is  present  in  con- 
siderable quantity,  the  fluid  should  be  removed  by  aspiration  and  the  sac 
injected  with  iodoform  emulsion,  half  a  drachm  being  employed  at  one 
time,  and  the  injections  being  repeated  at  intervals  of  a  week.  Under  this 
method  of  treatment  a  cure  may  result.  Where,  however,  there  is  a  large 
deposit  of  tuberculous  material,  or  where  there  are  rice  or  melon-seed 
bodies,  a  more  radical  operation  is  required. 

The  part  should  be  rendered  bloodless  by  the  application  of  Esmarch's 
bandage,  and  the  swollen  tissues  freely  ex^josed  by  incision  ;  the  thickened 
lining  of  the  sheath  should  then  be  dissected  out,  or,  if  this  is  impossible, 
removed  by  curetting  ;  the  tendons  themselves  can  generally  be  saved,  even 
though  the  sheaths  are  freely  excised.  After  removing  the  diseased  struc- 
tures thoroughly,  the  wound  should  be  closed  by  sutures,  and  if  the  infected 


GANGLION. 


419 


tissue  has  been  completely  removed  a  cure  may  result.  It  is  not  uncommon 
for  the  disease  to  recur  even  after  a  very  thorough  removal  of  the  diseased 
tissue,  in  which  event  the  operation  should  be  repeated.  In  relapsing 
cases  the  prognosis  is  not  good,  the  patient  often  developing  tuberculosis 
of  the  viscera. 

Syphilitic  Tenosynovitis. — There  occasionally  develops  during  the 
course  of  secondary  syphilis  a  distention  of  the  sheaths  of  tendons,  espe- 
cially those  of  the  extensors  of  the  hands  and  feet.  The  affection  is  usually 
symmetrical,  the  swelling  is  marked  but  is  painless,  and  function  is  not 
severely  interfered  with.  In  the  later  stages  of  syphilis  gummata  may 
develop  in  the  tendons  and  their  sheaths.  Treatment. — This  affection 
generally  yields  in-omptly  to  antisyphilitic  treatment. 

Gonorrhoeal  Tenosynovitis. — The  sheaths  of  tendons  may  be  in- 
volved during  the  presence  of  the  acute  symptoms  of  gonorrhoea  or  in  its 
chronic  stage.  The  affection  is  not  apt  to  be  symmetrical ;  the  portion  of 
the  tendon  involved  becomes  swollen  and  painful.  Treatment. — This  con- 
sists in  rest  of  the  diseased  structures  with  counterirritation,  and  is  similar 
to  that  for  gonorrhoeal  arthritis. 

Ganglion. — A  ganglion,  sometimes  called  a  -'weeping  sinew,"  is  a 
round  firm  swelling  in  connection  with  the  sheath  of  a  tendon.  The  gener- 
ally accepted  theory  that  ganglia  were  hernial  protrusions  of  the  sheaths  of 
tendons  has  been  controverted  by  the  recent  researches  of  Ledderhose  and 
Thorn,  who  have  proved  that  they  are  eystomata  arising  from  gelatinoid 
degeneration  of  the  tendon  itself  and  of  the  para-articular  tissues.  They 
are  most  commonly  seen  in  connection  with  the  extensor  tendons  of  the  wrist 
and  hands  or  upon  the  dorsum  of  the  foot.  They 
usually  exist  as  small,  oval,  tense  tumors,  which  Fig.  315. 

contain  a  clear  syrup-like  fluid,  and  may  develop 
slowly  or  rapidly  upon  a  tendon  which  has  been 
subjected  to  uuusual  strain  or  to  more  than 
ordinary  exercise.  These  cysts  may  also  develop 
in  the  capsular  ligaments  of  joints,  with  which 
they  usually  communicate. 

A  compound  ganglion  consists  of  a  dilata- 
tion of  the  sheath  of  a  tendon  or  of  a  number  of 
tendons,  and  is  really  a  form  of  tuberculous 
tenosynovitis.     (Fig.  315.) 

Treatment. — This  consists  in  a  subcutaneous 
ruptui'c  of  the  sac  by  pressure  with  the  thumb  / 
and  finger  or  a  blow  with  a  book,  or  by  a  subcu- 
taneous puncture  with  a  tentotome  followed  by 
pressure,  the  contents  escaiDing  into  the  cellular  , 
tissue  and  being  absorbed  ;  a  compress  and  band- 
age are  then  applied  for  a  few  days.  Eefilling 
of  the  sac,  however,  is  apt  to  occur  in  a  short  time, 
of  treatment  consists  in  exposing  the  tumor  by  incision  and  carefully  dis- 
secting it  out ;  the  connection  with  the  joint  must  be  carefully  sought  for, 
and,  if  present,  the  opening  in  the  sac  should  be  ligated  or  sutured.     In 


m  I  eanglion  of  palm 
and  wrist 


A  more  radical  method 


420  FELON. 

this  operation  the  greatest  care  should  be  observed  to  keep  the  wound 
aseptic.  The  treatment  of  compound  ganglion  is  similar  to  that  of  tuber- 
culous tenosynovitis. 

Tumors  of  Tendons. — Growths  involving  the  tendons  or  their 
sheaths  may  originate  in  the  tendons  primarily  or  may  involve  the  tendons 
by  extension  ;  they  may  be  benign,  malignant,  or  syphilitic.  Occasionally 
a  small  fibroma  is  developed  in  a  tendon,  which  will  produce  a  very  marked 
amount  of  disability  ;  trigger-finger  may  be  due  to  this  cause. 

Treatment. — The  treatment  of  tumors  of  tendons  consists  in  their  re- 
moval by  careful  dissection  ;  if  the  tendon  is  divided,  it  should  be  sutured. 

Ossification  of  Tendons. — Bone  deposits  are  occasionally  found  in 
tendons,  being  most  apt  to  occur  at  their  points  of  insertion.  This  affection 
may  result  from  rheumatoid  arthritis,  or  from  constant  and  prolonged  irri- 
tation, or  from  the  deposit  of  callus  following  injury  of  contiguous  bones. 
Unless  marked  disability  results  from  this  affection,  no  operative  treatment 
should  be  undertaken. 

Felon,  or  Paronychia. — This  is  an  infective  cellulitis  involving  the 
soft  parts  of  the  fingers,  usually  the  pulp  over  the  distal  phalanx,  which 
often  follows  slight  traumatisms,  such  as  punctures,  bruises,  or  scratches, 
and  may  ultimately  involve  the  sheath  of  the  tendons  and  the  periosteum, 
causing  necrosis  of  the  distal  phalanx.  This  accident  is  more  apt  to  occur 
in  case  of  the  distal  jjhalanx  from  the  fact  that  it  has  no  distinct  periosteum, 
the  vessels  supplying  the  bone  ramifying  in  the  dense  fibro-adipose  tissue 
of  the  pulp  of  the  finger.  When  the  tendon  and  its  sheath  are  involved,  a 
suppurative  tenosynovitis  is  set  up,  which  may  terminate  in  sloughing  of 
the  tendon  or  in  palmar  abscess.  There  are  two  varieties  of  this  affection, 
the  superficial  and  the  deep. 

Superficial  Felon. — This  affection  usually  involves  the  tissue  around 
and  under  the  nail,  may  affect  several  fingers  in  turn,  and  is  seen  in  debili- 
tated subjects,  and  often  in  children.  It  is  accompanied  by  pain,  swelling, 
and  redness  of  the  tissues  around  the  nail ;  suppuration  occiu-s,  and  granu- 
lations protrude  around  the  nail,  whose  vitality  is  so  much  impaired  that  it 
is  apt  to  exfoliate.  Treatment. — This  consists  in  the  application  of  a  warm 
antiseptic  gauze  dressing  and  incision  as  soon  as  the  presence  of  pus  is  indi- 
cated. If  the  vitality  of  the  nail  is  destroyed,  and  it  is  surrounded  by 
granulations  and  is  keei^ing  up  irritation,  it  should  be  removed,  and  the 
granulations  dusted  with  powdered  nitrate  of  lead  and  covered  with  a  dry 
antiseptic  gauze  dressing. 

Deep  Felon. — The  symptoms  of  deep  felon  are  swelling,  tension,  fever, 
and  throbbing  pain  of  a  very  severe  character,  which  is  increased  by  the 
dependent  position  of  the  hand.  Treatment. — The  abortive  treatment  by 
the  use  of  tincture  of  iodine  or  nitrate  of  silver  is  usually  unsuccessful.  Hot 
fomentations  or  antiseptic  poultices  often  relieve  the  pain,  and  may  be 
emi)loyed  for  twenty-four  hours  ;  but  the  most  satisfactory  treatment  con- 
sists in  free  incision,  which  is  especially  imjjortant  if  the  distal  phalanx  be 
involved,  to  prevent  necrosis  of  the  bone.  The  incision  should  be  made 
with  aseptic  precautions,  and  carried  down  to  the  bone.  If  the  disease 
involves  higher  parts  of  the  finger,  the  sheath  of  the  tendon  should  be 


BURSITIS.  421 

opened  in  the  incision.  After  making  tlie  incision,  the  part  should  be 
dressed  with  a  warm,  moist  antiseptic  gauze  dressing,  and  the  hand  placed 
upon  a  splint.  A  free  incision  usually  arrests  the  progress  of  the  disease, 
but  if  so  favorable  a  result  does  not  follow,  and  the  inflammation  spreads  up 
the  finger  and  involves  the  j)alm  of  the  hand,  the  same  procedure  may  be 
required  at  higher  points. 

INJURIES   AND   DISEASES   OF   BURS^. 

Synovial  bursse  exist  normally  in  connection  with  tendons  or  with  certain 
joints,  and  may  be  developed  by  continued  friction  or  j)ressure  at  certain 
parts  of  the  body.  Deep  bursse  are  sometimes  connected  with  the  joints,  or 
are  in  very  close  relation  with  them. 

Injuries  of  Bursse. — Wounds  of  bursfe  may  be  either  contused, 
incised,  lacerated,  or  punctured,  and,  if  they  become  infected,  may  prove 
most  serious  injuries.  Treatment. — Xon-infected  wounds  of  bursse  should 
be  treated  by  rest,  sterilized  dressing,  and  cold.  If,  however,  these  wounds 
are  infected,  they  should  be  thoroughly  disinfected  and  drained  ;  to  accom- 
plish this  it  may  be  necessary  to  expose  the  cavity  of  the  bursas  externally. 
In  the  healing  of  such  wounds  obliteration  of  the  sac  may  occur. 

Bursitis. — Inflammation  of  the  bursse  is  often  observed  as  an  acute  or 
chronic  affection  in  the  form  of,  1,  nonsuppurative ;  2,  suppurative ;  3,  chronic  ; 
■4,  tuberculous;  and  5,  syphilitic. 

Non- Suppurative  Bursitis. — This  affection,  sometimes  described  as 
serofibrinous  bursitis,  results  from  continual  irritation  or  excessive  use  of  the 
part.  The  bursa  becomes  distended,  but  pain  is  not  usually  marked,  and 
loss  of  function  may  be  very  slight. 

Treatment. — This  consists  in  rest  of  the  part,  with  the  application  of 
counterirritation,  cold,  or  pressure,  and  in  some  cases  aspiration  may  be 
employed  with  advantage.  If  this  treatment  fails  to  bring  about  a  cure, 
the  bursa,  if  accessible,  may  be  removed  by  dissection. 

Suppurative  Bxusitis.^This  affection  usually  results  from  an  injury 
or  infection  of  a  bursa  from  a  neighboring  wound  or  suppurative  focus,  and 
is  characterized  by  tenderness,  pain,  redness  of  the  skin,  and  swelling  or 
distention  of  the  bursa.  The  inflammation  is  apt  to  extend  to  the  surround- 
ing cellular  tissue,  or,  if  in  close  proximity  to  a  joint,  may  involve  this. 
Bursitis  can  usually  be  diagnosed  from  other  affections  by  the  rapidity  of 
development  of  the  inflammatory  symptoms,  the  location  of  the  swelling 
in  lelation  to  certain  tendons  or  joints,  and  its  globular  shape. 

Treatment. — This  consi.sts  in  incising  the  bursa  as  soon  as  there  is 
evidence  of  suppuration  ;  the  bursa  should  be  freely  opened  and  irrigated 
with  a  solution  of  carbolic  acid  or  bichloride,  and  subsequently  packed  with 
sterilized  or  iodoform  gauze.  Under  this  treatment  the  cavity  soon  becomes 
obliterated  as  healing  occurs.  The  bursse  most  commonly  involved  are 
the  prepatellar,  the  olecranon,  and  that  over  the  metatarsal  joint  of  the 
great  toe. 

Chronic  Bursitis.— This  affection  may  result  from  acute  bursitis  which 
does  not  terminate  in  suppuration,  or  may  develop  slowly  from  long  con- 
tinued irritation  or  pressure,  and  is  accompanied  by  little  pain.     The  most 


422 


SYPHILITIC  BUESITIS. 


Fig.  316. 


Tuberculous  bursitis  of  the  light  li.iiee 


marked  feature  in  chronic  bursitis  is  the  distention  of  the  sac  with  fluid, 
ancl  in  some  cases  the  walls  of  the  sac  become  so  much  thickened  that  the 

bursa  is  converted  into  a  solid  tumor. 

Tuberculous  Bursitis. — This  re- 
sults from  tuberculous  infection  of  the 
bursfe,  and  is  accompanied  by  distention 
of  the  burs?e  and  little  pain.  (Fig.  316. ) 
Treatment.  —  The  treatment  of 
chronic  and  tuberculous  bursitis,  if  the 
sac  is  distended  with  fluid,  consists  in 
removal  of  the  fluid  by  aspiration. 
Compression  and  immobilization  of  the 
part  should  also  be  employed,  and  in- 
jection of  iodoform  emulsion  in  tuber- 
culous cases  is  beneficial.  The  greatest 
care  should  be  observed  to  keep  the 
wound  aseptic.  The  bursa  may  be  re- 
moved by  dissection.  This  is  the  only 
treatment  which  is  likely  to  be  of  use 
in  cases  where  the  bursa  is  very  thick 
or  is  converted  into  a  solid  tumor.  In 
removing  these  growths  by  dissection 
great  care  should  be  exercised  to  avoid  opening  the  neighboring  joints. 
Subligamentous  bursse  are  often  treated  by  aspiration,  as  the  risk  of  opening 
the  joint  is  very  great  if  attempts  are  made  to  dis- 
sect them  out. 

Syphilitic  Bursitis. — Occasionally  effusion 
into  bursae  occurs  during  the  course  of  secondary 
syphilis,  the  bursse  over  the  patella  and  olecranon 
being  those  most  commonly  affected.  During  the 
tertiary  stage  of  syphilis  affections  of  the  bursse 
are  not  common.  There  may  be  primary  gummatous 
degeneration  of  the  bursse,  or  the  aifectiou  may  be 
secondary  to  gummata  in  the  adjacent  tissues,  bones, 
or  joints.  Ulceration  of  the  skin  is  common,  and 
there  results  a  typical  undermined  ulcer. 

Treatment. — This  consists  in  the  administra- 
tion of  mercury  and  the  iodide  of  potassium,  and 
if  ulceration  has  occurred,  the  local  use  of  iodoform 
is  of  value. 

The  following  bursse  are  often  inflamed  and  are 
of  surgical  importance. 

The  Prepatellar  Bursa. — This  is  the  most  fre- 
quently affected  bursa  in  the  body,  and  is  commonly 
known  as  housemaids  knee  (Fig.  317),  and  results 
from  long-continued  pressure  upon  the  knee,  occur- 
ring in  those  whose  occupation  causes  them  constantly  to  bear  pressure  upon 
this  part.     Occasionally  the  bursse  of  both  knees  are  im^olved. 


Clironic  bursitia  of  prepatellar 
bursa,  or  housemaid's  knee. 


BUNION. 


423 


Subligamentous  Bursa. — Disease  of  this  bursa  is  indicated  by  swell- 
ing on  each  side  of  the  ligament  of  the  patella  when  the  knee  is  flexed.  This 
affection  may  be  confounded  with  disease  of  the  knee-joint. 

The  Bursa  under  the  Quadriceps  Extensor  Tendon. — This  bursa 
often  communicates  with  the  knee-joint,  and  is  involved  in  inflammation  of 
the  latter  ;  it  may  also  be  inflamed  independently.  It  is  recognized  as  a  pro- 
jecting tumor  three  fingers'  breadth  above  the  patella. 

The  Popliteal  Bursa. — This  bursa  exists  between  the  tendon  of  the 
semimembranosus  and  inner  head  of  the  gastrocnemius.    It  presents  a  globu- 
lar swelling  at  the  inner  side  of  the  pojaliteal  space, 
which  becomes  prominent  upon  extension  of  the  knee. 

The  Bursa  over  Tubercle  of  the  Tibia. — This 
bursa  is  sometimes  the  seat  of  acute  or  chronic  inflam- 
mation, which  may  involve  the  bursse  of  both  knees ; 
it  may  be  confounded  with  the  prepatellar  bursa,  but 
occupies  a  lower  position  over  the  tubercle  of  the  tibia. 

Bursitis  is  occasionally  observed  in  the  subhyoid 
bursa,  which  extends  from  the  edge  of  the  thyroid  car- 
tilage over  the  thyro-hyoid  ligament ;  in  the  subdel- 
toid bursa,  presenting  a  rounded  tumor  between  the 
deltoid  and  pectoralis  major  muscles,  and  likely  to  be 
confounded  with  disease  of  the  shoulder-joint ;  in  the 
olecranon  bursa,  either  that  OA^er  the  tip  of  the  ole- 
cranon process  {subcutaneous)  or  that  between  the  ten- 
don of  the  triceps  muscle  and  the  olecranon  process, 
known  as  miner'' s  elbow;  in  the  subgluteal  bursa, 
between  the  gluteal  tendons  and  the  great  trochanter  ; 
in  the  bursa  over  the  os  calcis  and  that  between  the 
tendo  AchiUis  and  the  os  calcis ;  the  latter  affection  is 
termed  Achillodynia  ;  also  the  hursm  over  the  tuber  ischii 
and  over  the  external  malleolus,  and  that  between  the 
iliacus  tendon  and  the  capsule  of  the  hip-joint.  A 
bursa  may  develop  over  any  bony  process  where  it  is  habitually  exposed  to 
pressure,  as  is  seen  in  cases  of  club-foot  and  in  laborers  in  whom  certain 
parts  of  the  body  are  subjected  to  continuous  pressure.  Hernial  protrusion 
of  a  portion  of  a  bursa  is  sometimes  seen  after  injuries  of  bursas.    (Fig.  318.) 

Bunion. — This  is  a  bursal  enlargement  over  the  metarso-phalangeal 
articulation  of  the  great  toe  which  is  very  frequently  observed,  hallux 
valgus  being  the  almost  universal  cause.  The  part  is  swollen  and  tender 
upon  pressure,  and  if  suppuration  occurs  the  pain  is  severe,  and  cellulitis  is 
apt  to  develop,  involving  the  surrounding  parts,  or  the  joint  may  be  involved, 
caries  of  the  bones  of  the  articulation  resulting. 

Treatment. — If  supijuration  has  not  occurred,  the  part  should  be  pro- 
tected from  pressure  by  a  circular  shield  of  felt  or  plaster,  but  if  suppuration 
has  taken  jjlace,  the  j)art  should  be  incised  and  drained,  and  if  the  joint  is 
found  diseased  it  should  be  curetted  and  dressed  with  an  antiseptic  dressing  ; 
the  malposition  of  the  toe  should  be  corrected  by  excision  of  the  joint  or  by 
an  osteotomy  of  the  metatarsal  bone  a  little  distance  above  the  joint. 


Hernial  protrusion  *• 
following  an  inji 


CHAPTEE    XXIV. 

SURGERY  OF  THE   OSSEOUS    SYSTEM. 
By  Heney  E.  Whaeton,  M.D. 

INJURIES    OF   BONE. 

Contusions  of  Bone. — Bones  in  exj)Ose(i  positions  are  often  subjected 
to  severe  contusion ;  those  which  are  deeply  seated  may  receive  similar 
injuries,  as  in  the  case  of  gunshot  contusion  of  bone.  Contusion  of  bone 
is  followed  by  more  or  less  swelling  of  the  periosteum,  due  to  extravasation 
of  blood,  which  may  also  occur  in  the  Haversian  and  medullary  canals  ;  later 
there  may  develop  swelling  from  inflammatory  exudates.  Simple  con- 
tusions of  bone  are  usually  not  serious  injuries,  unless  tubercular  or  pyogenic 
organisms  reach  the  injured  part,  in  which  case  tubercular  osteitis  or  an 
acute  suppurative  periostitis,  osteitis,  or  osteomyelitis  may  develop,  causing 
extensive  destruction  of  bone. 

Treatment. — Simple  contusions  of  bone  should  be  treated  by  rest  of  the 
involved  part,  by  the  application  of  cold  by  means  of  an  ice-bag,  by  com- 
pression to  limit  the  amount  of  extravasation,  and  later  by  moist  dressings, 
elastic  compression,  and  massage.  Under  this  form  of  treatment  the  tender- 
ness and  swelling  usually  subside  rapidly.  If,  however,  supi^uration  occurs 
at  the  seat  of  contusion,  evidenced  by  elevation  of  temperature,  pain, 
increase  in  the  swelling,  and  fluctuation,  necrosis  of  the  bone  is  apt  to  occur 
unless  very  prompt  treatment  is  instituted.  Every  surgeon  has  seen  suppura- 
tion and  disastrous  results  follow  contusions  of  bone.  In  siich  cases  the  skin 
surrounding  the  seat  of  injury  should  be  sterilized,  and  a  free  incision  made 
through  the  tissues  down  to  the  bone  to  evacuate  the  pus  and  relieve  tension  ; 
the  wound  should  then  be  irrigated  with  a  solution  of  bichloride  of  mercury 
1  to  2000,  or  with  a  solution  of  acetate  of  aluminum,  and  a  moist  dressing 
applied.  If  the  incision  be  promptly  made  and  the  wound  thoroughly  ster- 
ilized, the  vitality  of  the  bone  may  not  be  impaired,  and  healing  may  take 
place  rapidly. 

Incised  Wounds  of  Bone. — These  may  be  inflicted  with  sharp 
cutting  instruments,  such  as  axes  and  chisels,  or  by  pieces  of  glass,  and  the 
injury  may  vary  from  an  incision  into  the  bone  to  its  complete  division,  or 
a  portion  of  the  bone  with  its  periosteum  may  be  turned  off  as  a  flap. 

Treatment. — In  incised  wounds  of  bone  great  care  should  be  taken 
to  render  the  wound  aseptic,  the  skin  being  carefully  sterilized  and  the 
wound  irrigated  with  an  antiseptic  solution  ;  fragments  of  bone  attached  to 
the  periosteum  should  be  pressed  back  into  place,  and  if  possible  a  few 
catgut  sutures  introduced  into  the  periosteum  to  fix  them.  If  the  bone  be 
completely  divided,  the  ends  should  be  drilled,  and  silver  wire,  catgut, 
or  kangaroo  tendon  sutures  introduced  to  secure  primary  fixation.  After 
424 


FRACTUEES.  425 

replacing  and  fixing  the  fragments  the  external  wound  should  be  closed  and 
covered  with  an  antiseptic  or  a  sterilized  dressing.  Incised  wounds  of  the 
fingers  completely  dividing  the  phalanx  and  completely  or  incompletely 
severing  the  attached  soft  parts  should  be  treated  by  accurately  replacing 
the  parts  and  sustaining  them  in  position  by  sutures,  and  applying  an  anti- 
septic dressing  and  a  fixation  splint. 

FRACTURES. 

A  fracture  may  be  described  as  an  injury  of  bone  in  which,  by  suddeu 
flexion,  contusion,  or  torsion,  there  results  a  solution  in  its  continuity. 
Fractures  are  accidents  of  great  frequency.  Bruns  states  that  of  three  hun- 
dred thousand  cases  of  injury  taken  to  the  London  Hospital  in  thirty-three 
years,  one-seventh  were  fractures.  The  comj)arative  frequency  of  fractures 
of  different  portions  of  the  body  is  shown  in  Stimson's  collection  of  4539 
cases  of  fractures  as  follows :  Head,  5.77  per  cent. ;  face,  8.17  per  cent.  ; 
trunk,  11.55  per  cent.  ;  uj)per  extremity,  52.08  per  cent.  ;  lower  extremity, 
22.40  per  cent. 

Age. — Gurlt,  in  studying  the  relative  frequency  of  fractures  in  different 
ages,  found  that,  by  combining  the  number  of  fractures  in  the  different 
decades  of  life  with  the  statistics  showing  the  relative  niimber  of  people 
living  at  different  ages,  the  highest  proportion  of  fractures  was  in  the 
period  above  sixty  years.  Fractures  during  the  delivery  of  a  child  are  not 
of  infrequent  occurrence,  and  usually  result  from  manual  or  instrumental 
interference,  but  may  occur  by  the  force  of  the  expulsive  efforts  of  the 
mother.  Intrauterine  fractures  have  also  been  observed  which  have  resulted 
from  external  violence  applied  to  the  abdomen,  or  from  forcible  contraction 
of  the  uterus  before  delivery.  Intra-uterine  fractures  may  also  result  from 
malformations,  defects  of  ossification  or  development,  or  from  constitutional 
conditions  such  as  syphilis  or  rhachitis. 

Sex. — Fractures  occur  three  times  more  frequently  in  males  than  in 
females,  but  this  proportion  varies  considerably  at  different  ages  ;  between 
the  ages  of  fifty  and  seventy  years  both  sexes  are  about  equally  affected  ;  in 
middle  life  they  are  ten  times  more  frequent  in  males  than  in  females. 

Season. — This  affects  the  frequency  of  fracture  by  increasing  or  dimin- 
ishing the  exposure  to  the  causes  which  produce  them.  In  this  climate  the 
occurrence  of  fractures  from  falls  due  to  ice  and  snow  would  lead  one  to 
suppose  that  they  were  more  frequent  in  winter  than  in  summer,  but  statistics 
show  that  this  is  not  the  case,  as  fractures  are  more  common  in  mild  weather, 
when  a  much  greater  number  of  persons  are  employed  in  active  out-door 
occupations. 

No  injuries  require  more  care  in  diagnosis  and  treatment  than  fractures, 
as  they  are  a  prolific  source  of  litigation  between  the  patient  and  the 
medical  attendant,  since  it  is  unusual  to  have  a  cure  result  in  a  case  of  frac- 
ture, in  spite  of  the  greatest  skill  and  care  on  the  part  of  the  surgeon,  with  - 
out  more  or  less  deformity,  shortening,  or  thickening  of  the  bone  at  the  seat 
of  fracture,  and  in  case  of  fracture  near  or  involving  the  joints  a  certain 
amount  of  restriction  of  the  motions  of  the  joints  is  apt  to  follow.  The 
result  of  the  injury  may  also  be  largely  due  to  the  conduct  of  the  patient, 


426  CAUSES  OF  FRACTURES. 

"wlio  may  disregard  the  instructions  of  the  medical  attendant  and  may  use 
the  part  or  disturb  the  dressings.  In  view  of  these  facts,  the  practitioner 
in  taking  charge  of  a  case  of  fracture  should  insist  uxDon  implicit  obedience 
to  his  orders  on  the  part  of  the  patient,  and  should  state  to  the  patient  and 
his  friends  the  probability  of  the  occurrence  of  more  or  less  deformity  or  loss 
of  function,  if  the  case  be  one  in  which  such  a  result  is  likely  to  occur,  and 
if  he  finds  that  his  orders  are  not  strictly  obeyed  he  should  withdraw  from 
the  case.  In  complicated  fractui-es  where  a  good  functional  result  is  not 
likely  to  follow,  it  is  also  wise  for  the  practitioner  to  fortify  his  jjosition  by 
a  consultation  with  another  medical  man. 

Causes  of  Fractures. — The  causes  of  fractures  are  predisposing  and 
exciting. 

Predisposing  Causes.— Position. — The  long  bones  of  the  extremities, 
from  their  shape,  mobility,  and  exposed  position,  from  having  powerful 
muscles  inserted  iuto  them,  and  from  being  used  to  j)rotect  the  trunk  from 
injury,  are  more  exposed  to  fracture  than  the  short  and  irregular  bones. 
Form. — The  form  of  the  bone  is  a  predisposing  cause  of  fracture,  the  long, 
partially  curved  bones  having  less  resisting  force  than  the  short,  flat,  or 
irregular  bones.  Structure. — The  strength  and  elasticity  of  a  bone  depend 
upon  its  structure  ;  the  more  elastic  a  bone  is,  the  less  likely  it  is  to  be  frac- 
tured. Pathological  Conditions. — Atrophy  of  bone,  from  disuse  or  dis- 
ease, may  weaken  it  and  make  it  more  liable  to  fracture.  Certain  inflamma- 
tory affections  of  bone,  necrosis  and  caries,  as  well  as  malignant  diseases,  or 
a  tumor  or  gumma  developing  in  the  bone,  may  be  predisposing  causes  of 
fracture.  BJiachitis  is  a  common  predisposing  cause,  as  well  asfragilitas  ossium 
and  osteomalacia.  Absorjption  of  a  portion  of  a  bone  by  the  pressure  of  an 
aneurism  or  a  tumor  may  also  be  a  predisposing  cause  of  fracture.  Nerve 
Affections. — These  conditions,  producing  atrophy  or  degeneration  of  bone, 
may  also  predispose  to  the  production  of  fracture. 

Exciting  Causes. — These  are  external  violence  and  muscular  action. 
External  violence  is  by  far  the  most  frequent  cause  of  fractui-e,  but  it  is 
probable  that  muscular  action  in  many  cases,  by  fixing  the  parts,  causes 
fractures  to  result  from  falls  which  otherwise  would  not  occur.  Violence  may 
produce  a  fracture  when  applied  directly,  as  when  heavy  bodies  come  in 
contact  with  the  bones,  such  as  the  wheels  of  wagons,  or  masses  of  timber, 
iron,  or  stone,  or  the  result  may  occur  from  violence  applied  indirectly,  as 
when  a  fracture  of  the  femur  takes  place  from  a  fall  upon  the  foot.  Mus- 
cular action  is  also  a  frequent  cause  ;  the  patella  is  often  broken  by  this 
means,  as  well  as  other  bones.  Muscular  action  is  probably  a  much  more 
frequent  cause  than  is  generally  supposed,  for  insensible  or  drunken  subjects, 
whose  muscles  are  relaxed,  often  have  the  bones  exposed  to  great  violence 
without  the  production  of  fracture. 

Varieties  of  Fracture. — Fractures  may  be  complete,  when  the  line 
of  fracture  entirely  divides  the  bone,  or  incomplete,  when  the  whole  thick- 
ness of  the  bone  is  not  divided  and  a  portion  remains  unbroken  or  bent. 
(Fig.  319.)  The  latter  variety  of  fracture  is  also  known  as  a  greenstick 
fracture,  and  is  often  seen  in  the  long  bones  of  children.  Among  other 
varieties  of  incomjtlete  fracture  are  impressed  fracture,  in  which  one  sur- 


VARIETIES   OF  FRACTURE. 


427 


face  of  the  bone  is  crushed  in,  and  perforating  fracture,  caused  by  sharp 
instruments.  Subperiosteal  fracture  is  not  iincommon  in  children  from 
direct  violence  ;  deformity  and  mobility  are  not  marked,  as  the  periosteum 
holds  the  fragments  in  place.  They  are  readily  overlooked,  need  no  reduc- 
tion, and  their  repair  is  rapid. 

Fissured  Fracture. — This  is  also  Fig.  319. 

a  variety  of  incomplete  fracture  which 
is  met  with  in  the  bones  of  the  skull 
and  in  flat  bones.  In  such  cases  one 
or  more  lines  of  fracture  may  exist 
which  do  not  extend  over  the  whole 
area  of  the  bone. 

Simple   or  Closed  Fracture. 
This  is  a  fracture  in  which  the  separated  ends  of  the  bone  do  not  communi- 
cate with  the  air  through  an  open  wound. 

Compound  or  Open  Fracture. — This  is  one  in  which  the  separated 

ends  of  the  bone  communicate  with  the  air  through  a  wound  in  the  soft 

parts.     (Fig.  320.)     The  communication  with  air  may  be  through  the  skin 

or  the  mucous  membrane  ;  the  latter  condition  is 

Fig.  320.  generallj'  seen  in  fractures  of  the  jaw. 

Comminuted    Fracture. — This   is   one    in 

which  there  are  several  fragments,  the  lines  of 

fracture  intercom- 


incomplete  fracture  of  the  radius.    (Ferguson.) 


Fig.  321. 


municating.  (Fig. 
321.)  When  the 
fragments  are  ex- 
posed to  the  air 
through   a   wound 

Fig.  322. 


Compound  fracture  of  the  tibia. 
(Miller.) 


Comminuted  fracture  of  the  femur. 

(Agnew.) 


Impacted  fracture  of 
the  neck  of  the  femur. 
(MUler.) 


in  the  surrounding  tissues,  such  a  fracture  is  known  as  a  compound  comminuted 
fracture. 

Multiple  Fracture. — This  is  one  in  which  the  bone  is  separated  at  a 
number  of  xjoints,  and  the  lines  of  fracture  are  distinct  from  one  another. 


428 


VARIETIES   OF  FRACTURE. 


Complicated  Fracture. — In  this  fracture,  in  addition  to  the  separa- 
tion of  the  bone,  there  is  some  serious  injury  to  the  surrounding  or  contigu- 
ous structures.  Thus,  a  fracture  may  be  complicated  by  a  dislocation  or  by 
the  rupture  of  an  important  artery,  nerve,  or  vein  near  the  seat  of  injury,  or 
by  the  destruction  of  a  neighboring  joint,  or  by  a  serious  flesh  wound,  burn, 
or  scald  which  does  not  communicate  with  the  bone  at  the  seat  of  injury. 

Impacted  Fracture. — In  this  form  of  fracture  one  fragment  is  driven 
into  and  fixed  in  the  other.     (Fig.  322.) 

Sprain  Fracture,  or  Fracture  by  Avulsion. — This  is  a  form  of 
fracture  described  by  Callender,  which  is  sometimes  observed  about  the 
joints,  particularly  the  wrist  and  the  ankle,  and  consists  in  the  tearing  off  of 
a  ligament  from  the  bone  with  a  thin  shell  of  its  bony  insertion. 

Direction  of  Fracture. — In  cases  of  fracture  the  line  of  separation 
may  be  oblique,  transverse,  longitudinal,  or  spiral. 


Fig.  324. 


Transverse  fracture  of  the  humerus. 


Fig.  325. 


Oblique  fracture  of  the  femur  with  shortening. 

Oblique  Fracture. — This  is  the  most  common  variety  of  fracture,  and 
is  one  in  which  the  line  of  separation  is  at  an  acute  angle  to  the  long  axis 

of  the  bone.     (Fig.  323.) 

Transverse  Fracture. — 
In  this  fracture  the  line  of 
separation  is  at  right  angles 
to  the  long  axis  of  the  bone  ; 
it  is  much  less  commonly  met 
with  than  oblique  fracture. 
(Fig.  324.)  The  ends  of  the 
bone  in  transverse  fracture  are 
sometimes  dentated,  prevent- 
ing much  displacement  of  the 
fragments.  Transverse  frac- 
tures are  often  seen  in  the  short 
and  flat  bones  and  in  the 
spongy  ends  of  the  long  bones,  and  are  not  infrequent  in  the  long  bones 
in  children. 

Spiral  Fracture.— This  form  of  fracture  is  occasionally  seen  in  the 
long  bones,  and  consists  of  a  fissure  which  winds  around  the  shaft  more  or 
less  obliquely.  (Fig.  325.)  It  is  most  often  observed  in  the  tibia,  femur, 
and  humerus,  and  results  from  violent  torsion  of  the  bone  ;  experiments  with 
fresh  bones  have  demonstrated  that  spiral  fractures  could  be  so  produced. 

Longitudinal  Fracture.— In  this  fracture  the  line  of  separation  runs 
in  tlie  general  direction  of  the  long  axis  of  the  bone.  (Fig.  326.)  This 
form  of  fracture  is  very  rare  in  the  long  bones,  but  may  occur  as  the  result 
of  gunshot  injury. 


Spiral  fracture  of  the  humerus. 


DISPLACEMENT  IN   FRACTURE. 


429 


Displacement  in  Fracture. — The  principal  displacements  in  frac- 
ture are  angular,  lateral,  rotatory,  longitudinal,  and  displacement  by 
depression. 


Longituclinal  Iracture  of  the  femur. 


Angular  Displacement. — This  displacement,  in  which  the  fractured 
ends  of  the  bone  are  at  an  angle  with  each  other  (Fig.  327),  is  very  common, 


Angular  displacement. 


and  results  from  weight  and  muscular  action  ;  it  is  possible  to  have  it  well 
marked  even  in  incom]3lete  fractures,  and  it  is  observed  in  transverse  frac- 
tures, as  well  as  in  oblique  fractures  combined  with  overlajtping  of  the 
fragments. 

Lateral  Displacement. — This  is  usually  observed  in  transverse  frac- 
tures, consisting  in  the  end  of  one  fragment  resting  in  part  against  the  other, 
and  may  be  associated  with  a  certain  amount  of  rotatory  displacement. 

Rotatory  Displacement. — This  consists  in  one  fragment  being  tm-ned 
u]3on  its  axis.     (Fig.  328.)     This  displacement  is  observed  in  fractures  of 


Rotatory  displacement. 

the  bones  of  the  extremities,  and  is  due  to  the  weight  of  the  limb  and  to 
muscular  action.  In  fractures  of  the  femur  and  of  the  bones  of  the  leg  it  is 
a  very  common  deformity. 

Longitudinal  Displacement.— This  is  a  very  common  displacement  in 
fractures  which  take  place  in  the  dii-ection  of  the  length  or  long  axis  of  the 
bone.  In  oblique  fi'actures,  muscular  action  and  the  line  of  fracture  favor 
the  sliding  of  one  fragment  past  the  other,  producing  overlajypmg  or  shorten- 
ing. (Fig.  323.)  Muscular  action  may  also  produce  longitudinal  separation 
of  the  fragments  with  lengthening  in  fractures,  as  is  seen  in  cases  of  trans- 
verse fracture  of  the  patella  and  of  the  olecranon  process. 


4.30  SYMPTOMS  OF  FRACTURE. 

Depression. — This  displacement  consists  in  one  or  more  fragments  being 
depressed  below  the  general  surface  of  the  bone.  This  deformity  is  seen  in 
fractures  of  the  flat  bones,  such  as  the  skull  and  the  scapula,  as  well  as  in 
comminuted  fractures  of  the  long  bones. 

Syraptoms  of  Fracture. — The  most  important  symptoms  of  fracture, 
the  presence  of  w^iich  usually  enables  the  surgeon  to  clearly  demonstrate  its 
existence,  are  deformity,  preternatural  mobility,  loss  of  function,  pain,  mus- 
cular spasm,  and  crepitus. 

Deformity. — This  may  arise  from  swelling  of  the  soft  parts  or  displace- 
ment of  the  fragments,  and  is  usually  the  first  to  attract  the  attention  of 
the  surgeon.  In  the  majority  of  cases  of  fracture  the  injured  part  loses  its 
natural  appearance,  and  this  change  can  usually  be  seen  upon  comparing 
it  with  the  corresponding  part  on  the  sound  side.  The  bony  deformity  arises 
from  external  force,  which  drives  the  fragments  into  unnatural  positions, 
and  from  muscular  action  ;  in  fractures  of  long  bones,  where  bony  resist- 
ance is  lost,  marked  contraction  of  the  muscles  occurs,  producing  extensive 
deformity.  That  due  to  swelling  may  arise  early  from  the  extravasation  of 
blood,  or  later  from  inflammatory  exudates  when  the  process  of  re^sair  has 
been  established.  Deformity  is  recognized  by  inspection,  mea.surement,  and 
palpation.  In  taking  measurements  to  ascertain  the  amount  of  shortening, 
corresponding  measurements  should  be  made  upon  the  injured  and  upon  the 
sound  side.  The  various  bony  prominences  are  used  as  fixed  points  ;  in  the 
lower  extremity  the  anterior  superior  spine  of  the  ilium,  the  edge  of  the 
patella,  the  condyles  of  the  femur,  and  the  malleoli  are  frequently  used, 
while  in  the  upi^er  extremity  the  acromion  process,  the  epicondyles,  the 
olecranon  process,  and  the  head  of  the  radius  are  genei'ally  employed. 

Preternatural  Mobility. — This  important  sign  of  fracture  may  be 
obtained  except  in  a  few  instances.  The  existence  of  mobility  in  the  shaft 
of  a  bone  can  be  due  to  no  other  cause  than  fracture.  In  fractures  near 
articulations  it  is  often  difficult  to  separate  motion  at  the  seat  of  fracture 
from  the  motion  at  the  joint,  and  here  we  have  to  depend  upon  other  signs. 
Impaction  at  the  seat  of  fracture  j)revents  this  sign  from  being  elicited.  In 
examining  for  mobility,  the  manipulations  should  be  made  with  great  gen- 
tleness, to  avoid  giving  the  patient  pain,  as  well  as  to  prevent  injury  to  the 
surrounding  structures  by  the  roughened  ends  of  the  fractured  bone. 

Loss  of  Function. — This  is  usually  a  valuable  sign  of  fracture,  as  there 
is  generally  inability  to  execute  the  normal  movements  of  the  part ;  a  patient 
suffering  from  a  fractured  leg  or  thigh  is  not  able  to  support  his  weight  upon 
it,  and  the  same  may  be  said  as  to  loss  of  function  in  the  bones  of  the  upper 
extremity.  Occasionally,  however,  cases  are  observed  in  which  a  patient 
will  walk  with  a  fractured  leg  in  which  there  is  little  displacement  of  the 
fragments.  In  these  cases  it  is  probable  that  there  has  been  impaction  of 
the  fragments,  which  keeps  up  the  continuity  of  the  bone. 

Pain. — The  pain  in  fracture  is  usually  of  a  severe,  sharp  character,  but 
it  varies  much  with  the  bone  involved,  the  character  of  the  fragments,  and 
the  amount  of  movement  in  the  parts  at  the  seat  of  injury. 

Muscular  Spasm. — This  is  produced  by  irritation  of  the  muscles  and 
nerves  by  the  irregular  fragments  of  the  fractured  bone.     It  is  intermittent, 


EXAMINATION   OF  FRACTURE.  431 

is  accompanied  by  pain,  and  is  apt  to  follow  slight  movements.  It  is  a 
symptom  which  is  often  observed  where  many  of  the  other  signs  of  fracture 
are  absent,  and  is  especially  valuable  as  a  diagnostic  sign  in  fractures  of 
bones  deeply  seated  and  surrounded  by  thick  masses  of  muscular  tissue,  as 
the  femur  and  the  humerus.    * 

Crepitus. — This  is  produced  by  the  grating  of  one  broken  surface 
against  the  other,  and  the  conditions  which  favor  its  production  are  mobility 
at  the  seat  of  fracture,  with  contact  of  the  fragments.  If  impaction  of  the 
fragments  has  occurred,  or  if  there  are  interposed  between  them  shreds  of 
fascia  or  muscles,  crepitus  cannot  be  elicited.  Crepitus  is  affected  by  the 
density  of  the  bone,  being  more  marked  in  fracture  of  the  shaft  of  a  long 
bone,  and  less  distinct  in  that  of  the  cancellous  ends  of  a  long  bone,  in  frac- 
ture of  a  short  bone,  and  in  an  epiphyseal  separation.  The  crepitation 
observed  in  cases  of  tenosynovitis  and  inflammation  of  bursae  and  the  carti- 
lages of  joints  is  sometimes  confounded  with  the  creijitus  of  fracture,  but  it 
is  a  softer  variety  of  crepitus,  resembling  the  sensation  which  is  felt  upon 
rubbing  two  pieces  of  leather  together,  and  is  not  accompanied  by  the  other 
signs  of  fracture.  In  eliciting  crepitus  the  surgeon  should  make  extension 
of  the  injured  parts,  and  gently  rotate  them,  at  the  same  time  grasping  the 
seat  of  fracture  firmly  with  the  hand,  or  the  fragments  may  be  tilted  by 
pressure  with  the  fingers.  Although  it  is  a  valuable  sign  of  fracture,  it  is 
not  justifiable  to  use  any  violent  manipulation  for  its  production,  for  violent 
movements  give  the  patient  pain,  and  may  be  followed  by  injury  of  the  sur- 
rounding soft  parts.  The  fact  that  crepitus  cannot  be  obtained,  does  not 
prove  that  a  fracture  is  not  present. 

Discoloration. — This  may  arise  from  two  sources, — from  the  hemorrhage 
following  rupture  of  the  vessels  in  the  subcutaneous  cellular  tissue,  which  is 
apparent  a  few  hours  after  the  injury,  and  from  the  blood  which  escapes 
from  the  bone  and  deep  structures  at  the  seat  of  fracture,  causing  discolora- 
tion of  the  overlying  skin  some  days  after  the  injury.  As  a  similarly 
developed  discoloration  may  arise  from  contusions  of  deep  structures  or  from 
sprains,  it  is  not  an  important  sign  of  fracture. 

Diagnosis. — The  diagnosis  of  fracture  is  often  easy,  while  at  other  times 
it  is  extremely  difficult,  and  is  made  by  eliciting  and  observing  the  symp- 
toms just  mentioned.  A  very  valuable  aid  to  the  diagnosis  of  fracture  has 
recently  been  introduced  in  the  use  of  the  Eontgen  or  X-rays,  which  are 
often  of  the  greatest  service  in  proving  the  existence  and  location  of  fracture 
in  obscure  cases.  The  application  of  this  method  of  examination  has  added 
much  precise  information  to  our  knowledge  of  fractures. 

Examination  of  Fracture. — In  cases  of  fracture  it  is  always  well 
to  make  a  systematic  examination,  and  the  best  time  to  make  this  examina- 
tion is  as  soon  as  possible  after  the  fracture  has  taken  place,  for  if  it  is 
delayed  for  some  time  there  will  usually  be  so  much  swelling  that  many  of 
the  important  signs  cannot  be  obtained.  The  injured  part  should  be  com- 
pared with  its  fellow,  and  the  bony  prominences  should  be  located  as  guides 
to  displacement.  The  part  should  then  be  firmly  extended,  and  gentle 
manipulations  made  to  obtain  mobility  and  crepitus.  The  use  of  an  antes- 
thetic  is  often  of  the  greatest  value,   as  by  its  employment  the  patient  is 


432  SEPARATION  OF  THE  EPIPHYSES. 

saved  much  paiu,  the  muscular  resistance  is  done  away  with,  and  the  surgeon 
can  accurately  locate  the  seat  and  direction  of  the  fracture  and  coaptate  the 
fragments.  We  consider  it  a  wise  rule  to  administer  an  anaesthetic  for  the 
examination  of  any  case  of  obscure  fracture  or  one  near  or  involving  a  joint. 
The  only  possible  disadvantage  in  its  use  arises  from  the  struggles  of  the 
patient,  which  may  cause  movement  of  the  fragments  with  injury  to  the 
surrounding  parts  ;  this  can  be  guarded  against  by  having  the  part  firmly 
held  or  fixed  by  splints  while  the  anaesthetic  is  being  given.  The  fact  that 
the  examination  is  made  without  pain  to  the  patient  should  not  lead  the 
surgeon  to  make  forcible  movements  to  elicit  mobility  or  crepitus,  for  there 
is  the  same  risk  of  damage  to  the  soft  parts  as  without  anaesthesia,  so  that 
all  maniiDulations  should  be  made  with  extreme  gentleness. 

Every  surgeon  has  met  with  cases  in  which  after  the  most  careful  exami- 
nation he  was  unable  to  determine  the  existence  of  fracture,  although  he 
was  morally  certain  that  such  an  injury  existed  ;  the  safe  rule  of  practice  is 
to  consider  the  case  one  of  fracture  and  treat  it  accordingly. 

SEPAEATION  OF  THE  EPIPHYSES. 

This  lesion,  which  presents  many  symptoms  in  common  with  fracture, 
consists  in  a  separation  of  the  epiphysis  of  the  bone  from  its  diaphysis. 
(Fig.  329.)  The  epiphyses  are  entirely  cartilaginous 
in  infants,  but  ossification  occurs  later  at  various 
periods  for  different  bones.  The  separation  may  occur 
at  any  time  from  birth  up  to  the  twenty-first  year  ; 
the  age  at  which  trau.matic  separation  of  the  epij^hj^ses 
has  been  most  frecjuently  observed  is  from  the  twelfth 
to  the  fifteenth  year.  Epiphyseal  separations  may  be 
cmni)lete  or  incomplete,  the  latter  being  sometimes  de- 
scribed as  a  juxta-epvpliyseal  strain,  multiple,  compound, 
or  complicated.  In  the  latter  class  of  cases  there  may 
be  associated  a  fracture  of  the  epiphysis,  or  a  disloca- 
tion of  the  epiphysis  from  its  articular  relations.  It 
may  also  be  complicated  by  injury  of  adjacent  blood- 
vessels and  nerves,  but  is  rarely  accompanied  by  artic- 
ular lesions.  Traumatic  separations  of  the  epiphyses 
separatiou  oj  the  upper    jjj^y  result  from  direct  Or  indirect  violence,  from  trae- 

€piphysis    of    the   humerus.     ^.  ,         .  -,     .  j.  , 

(Moore.)  tio^i  Or  torsion,    and  in  rare   cases  from  muscular 

action.  The  injury  is  always  accompanied  by  strip- 
ping of  the  periosteum  from  the  end  of  the  shaft  of  the  bone,  but  it  generally 
remains  firmly  attached  to  the  epiphysis.  Separation  of  the  epiphyses  in 
children  results  from  the  application  of  considerable  force ;  according  to 
Poland,  an  injury  which  would  be  liable  to  produce  a  dislocation  in  an  adult 
will  in  a  child  usually  result  in  a  separation  of  an  epiphysis. 

Separation  of  the  epiphyses  may  result  from  disease,  as  in  cases  of  tuber- 
culous and  syphilitic  osteitis,  and  in  acute  infectious  osteitis.  Suppuration 
in  the  region  of  the  epiphysis  may  result  in  its  separation ;  rhachitis  also 
predisposes  to  this  lesion. 

Compound  or  open   separations  of  the  epiphyses  are  frequently  met 


SEPARATION  OF  THE  EPIPHYSES.  433 

with,  being  most  common  at  the  lower  epiphysis  of  the  femnr  and  the  upper 
epiphysis  of  the  humerus.  In  Poland's  collection  of  six  hundred  and  ninety- 
two  cases  of  separation  of  the  epiphyses,  seventy-one  ca.ses  were  compound. 
These  are  grave  injuries,  from  the  fact  that  infection  is  apt  to  occur,  resulting 
in  suppurative  osteomyelitis  and  necrosis,  followed  by  arrest  of  growth  of 
the  limb  and  shortening. 

Syraptoms. — These  are  mobility,  deformitj^,  crepitus,  loss  of  function, 
pain,  and  swelling.  Mobility  which  exists  at  a  point  where  it  should  not  be 
observed  is  a  most  important  symptom,  and  is  most  marked  if  the  separa- 
tion of  the  periosteum  be  extensive.  The  deformity  is  also  more  marked 
than  in  fracture,  from  the  smoothness  of  the  separated  surfaces  permitting 
of  displacement ;  this  varies  with  the  amount  of  displacement  of  the  diaph- 
ysis,  the  amount  and  mode  of  application  of  the  force,  and  according  as 
the  seiiaration  is  a  pure  one,  or  complicated  with  fi-acture  of  the  epiphysis. 
CrepitiLS  is  soft  and  muffled,  loss  of  function  is  usually  marked,  and  pain  and 
swelling  at  the  seat  of  injury  are  soon  followed  by  an  extravasation  of 
blood. 

Diagnosis. — Separations  without  displacement  are  difficult  to  diagnose, 
and  are  often  considered  as  sprains  of  joints.  In  infants  this  lesion  is  diffi- 
cult to  recognize  and  often  escapes  detection,  but  may  be  followed  in  a  few 
weeks  by  swelling  and  suppuration,  and  symptoms  of  chronic  osteomyelitis. 
Separation  of  the  epiphyses  is  most  apt  to  be  confounded  with  fracture  or 
dislocation  ;  the  diagnosis  is  to  be  made  from  fracture  by  observing  the  line 
of  separation,  the  shape  of  the  displaced  epiphyseal  fragment,  the  deformity, 
which  is  very  chai'acteristic  in  certain  sej)arations,  and  the  soft  character  of 
the  crepitus.  From  dislocation  the  diagnosis  is  based  upon  the  following 
signs.  Dislocations  are  rare  in  infants  and  children ;  in  separations  of  the 
epiphyses,  if  the  displacement  is  reduced,  it  tends  to  recur  on  the  removal 
of  the  force ;  while  in  dislocation,  if  reduction  is  accomplished,  it  is  not 
likely  to  recur  when  the  force  is  removed.  Eigidity  is  present  in  dislocation, 
while  preternatural  mobility  is  marked  in  epiphyseal  separation.  In  many 
joints  the  epiphysis  will  be  found  to  be  still  connected  with  the  joint,  and 
retain  its  normal  relations  with  the  surrounding  articular  structures.  In 
compound  separations  of  the  epiphyses  the  diagnosis  can  be  made  by  observ- 
ing that  the  displaced  end  of  the  bone  is  not  covered  by  articular  cartilage. 
The  use  of  the  X-ray  will  in  obscure  cases  render  the  diagnosis  clear. 

Prognosis. — Union  of  a  separated  epiphysis  occurs  by  the  same  pro- 
cess as  that  of  a  fracture.  The  amount  of  callus,  which  is  largely  formed 
by  the  periosteum  uniting  the  fragments,  varies  with  the  completeness  of 
their  reduction.  K"on-union  has  never  been  observed  in  this  injury.  Anky- 
losis of  the  neighboring  joint  may  result  in  spite  of  the  greatest  care  in  the 
reduction  of  the  deformity  and  treatment,  yet  permanent  deformity  may  be 
present  and  interfere  very  little  with  function  of  the  limb.  Arrest  of  growth 
of  the  limb  after  this  injury  in  young  subjects  may  be  observed,  but  is  not  a 
necessarj'  result,  for  the  epiphyseal  cartilage  may  perform  its  function  as 
completely  as  before  the  injury,  but  it  is  more  apt  to  occur  if  the  separation 
takes  place  between  the  epiphysis  and  epiphyseal  cartilage,  or  if  the  carti- 
lage is  itself  severely  injured.     Arrest  of  growth  is  not  marked  in  many 

28 


434  TREATMENT  OF  FRACTURES. 

cases  for  the  reason  that  the  injury  occurs  at  a  period  when  the  growth 
of  the  skeleton  is  almost  complete. 

Treatment. — This  consists  in  the  reduction  of  the  deformity,  which  in 
many  cases  is  difficult  unless  an  anaesthetic  be  administered,  and  fixation  of 
the  parts  after  reduction  by  the  use  of  splints  and  bandages,  fixation  being 
required  for  a  less  period  of  time  than  in  fracture  of  the  bone  at  a  corre- 
si^onding  point.  Muscular  wasting  should  be  j)revented  by  the  early  em- 
ployment of  massage.  Compound  separations  of  the  epii^hysis  are  treated 
in  the  same  manner  as  compound  fractures,  great  care  being  taken  to  render 
the  wound  aseptic  and  maintain  it  in  this  condition.  Enlargement  of  the 
wound,  or  resection  of  the  end  of  the  diaphysis  may  be  necessary  to  accom- 
plish the  reduction,  and  in  a  few  cases  where  it  was  found  impossible  to 
maintain  the  reduction,  wiring  of  the  epiphysis  to  the  diajDhysis  has  been 
practised  with  good  results. 

TREATMENT  OF   FRACTURES. 

Various  methods  of  treatment  of  these  injuries  have  at  different  times 
been  advocated  and  practised,  such  as,  1,  massage  ;  2,  fixation  by  splints  and 
bandages  ;  3,  fixation  by  extension  ;  4,  fixation  and  the  ambulant  treatment. 
The  method  which  has  been  most  widely  employed  is  that  which  consists  in 
approximation  of  the  fractured  ends  of  the  bone  by  extension  and  manipula-  ' 
tion  and  their  retention  in  place  by  splints  or  mechanical  apijliances  and  by 
position. 

Massage. — Lucas-Championniere  advocates  and  practises  immediate  and 
continuous  massage  in  the  treatment  of  fractures,  and  holds  that  by  its  use 
pain  is  diminished,  the  repair  of  bone  hastened  by  the  profuse  deposit  of 
callus,  and  the  atrophy  of  muscles  and  stiffening  of  joints  avoided.  Mas- 
sage is  applied  as  soon  as  possible  after  the  fracture  has  occurred,  and  con- 
sists in  manipulations  with  the  thumb,  the  fingers,  or  the  whole  hand.  The 
limb  is  held  by  a.n  assistant  and  extension  is  made,  or  it  is  placed  upon  a 
firm  pillow  or  a  sand  cushion.  The  manii^ulations  should  be  made  in  the 
direction  of  the  muscular  fibres  and  of  the  blood-current,  and  firm  jaressure 
should  not  be  made  directly  over  the  seat  of  fracture.  Massage  should  be 
practised  for  from  fifteen  to  twenty  minutes  daily,  and  no  retention  aj)pa- 
ratus  should  be  applied  in  the  intervals  unless  there  is  marked  tendency  to 
displacement  of  the  fragments,  when  some  form  of  retention  apparatus  or 
splint  may  be  used.  These  manipulations  should  be  continued  for  some  weeks, 
until  union  is  firm  at  the  seat  of  fracture.  Massage  has  also  been  combined 
with  the  ambulatory  method  of  treatment  of  fractures  of  the  lower  extremity. 
This  method  of  treating  fractures  may  be  said  to  be  still  on  trial,  sufiBcient 
experience  not  yet  having  accumulated  to  i^rove  that  it  possesses  marked 
advantages  over  the  generally  adopted  treatment  by  immobilization.  There 
is  no  doubt  that  excellent  results  follow  a  judicious  combination  of  the  two 
methods. 

Provisional  Dressings  of  Fractures. — It  usually  happens  that  a 
fracture  occurs  at  a  locality  more  or  less  distant  from  the  place  where  its 
treatment  is  to  be  conducted  ;  the  transportation  of  the  patient  and  the  tem- 
porary dressing  of  the  fracture  are  therefore  matters  of  great  importance. 


REDUCTION   OF  FRACTURES.  435 

In  simple  fractures  of  the  upper  extremity  the  clothing  need  not  be 
removed  ;  the  arm  should  be  bound  to  the  side  by  some  article  of  clothing, 
or  supported  in  a  sling  made  from  handkerchiefs  or  the  clothing,  and  the 
patient  can  then  usually  ride  or  walk  without  inconvenience  and  without 
injury  to  the  parts  in  the  region  of  the  fracture.  When,  however,  the  bones 
of  the  lower  extremity  or  of  the  trunk  are  involved,  the  transportation  of 
the  patient  is  a  matter  of  much  greater  difficulty.  When  the  bones  of  the 
trunk  are  involved,  the  part  should  be  surrounded  by  a  binder,  firmly  pinned 
or  tied,  made  from  the  clothing  or  from  sheets  or  any  other  strong  material 
which  may  be  at  hand.  When  the  bones  of  the  loioer  extremity  are  involved, 
if  the  fracture  be  a  simple  one,  the  clothes  need  not  be  removed,  and  the 
motion  of  the  fragments  at  the  seat  of  fracture  should  be  prevented  by 
applying  to  the  sides  of  the  limb,  extending  above  and  below  the  seat  of 
fracture,  strips  of  wood,  shingles,  or  jjasteboard,  bundles  of  straw,  strips 
of  bark  taken  from  trees,  or  bundles  of  twigs,  these  being  held  in  place  by 
handkerchiefs  or  strips  torn  from  the  clothing.  Umbrellas,  canes,  or  broom- 
sticks applied  in  the  same  manner  may  be  employed,  the  object  of  all  of 
these  dressings  being  to  secure  temporary  fixation  of  the  fragments,  or  the 
injured  limb  may  be  bandaged  to  the  sound  one.  If  the  fragments  are  not 
fixed  in  some  way,  but  are  allowed  to  move  about  during  the  transportation 
of  the  patient,  much  damage  maj^  result  to  the  soft  parts  around  the  frac- 
tured bone,  and  simple  fractures  may  become  compound  by  the  bones  being- 
forced  through  the  skin,  the  discomfort  and  danger  to  the  patient  being 
thus  much  increased.  In  compound  fractures  some  form  of  sterile  occlusive 
dressing  should  be  applied  to  the  wound. 

Reduction  or  Setting  of  Fractures.— Before  attempting  the 
reduction  of  a  fracture  it  is  necessary  to  remove  the  portion  of  the  clothing 
covering  the  injured  part,  and  in  doing  this  the  part  should  be  firmly  held, 
extension  being  made  while  an  assistant  either  cuts  away  the  clothing,  or 
rips  it  so  that  it  can  be  removed  freely  so  as  to  exj)Ose  the  parts. 

Eeduction  or  setting  of  fractures  consists  in  bringing  the  fragments  by 
extension  and  manipulation  as  nearly  as  possible  into  their  normal  position, 
and  is  accomplished  by  making  extension,  counterextension,  and  manipu- 
lation with  the  hands,  care  being  taken  to  use  no  more  force  than  is  neces- 
sary to  attain  this  object.  The  principal  obstacle  to  the  reduction  of  frac- 
tures is  muscular  spasm,  which  may  be  overcome  by  placing  the  parts  in 
such  a  position  as  to  relax  the  muscles  which  cause  the  displacement,  or  by 
the  administration  of  an  anaesthetic.  Eeduction  in  cases  of  fracture  should 
be  effected  as  soon  as  possible  after  the  occurrence  of  the  injury,  and  as  soon 
as  the  surgeon  is  prepared  to  apply  the  dressings  which  are  to  be  employed 
in  the  treatment  of  the  case.  Reduction  at  an  early  period  is  less  painful 
to  the  patient  and  is  accomj)lished  with  more  ease  by  the  surgeon  than  at  a 
later  period,  when  marked  swelling  or  inflammation  is  present  at  the  seat  of 
fracture.  When  the  reduction  has  been  accomplished,  the  fragments  are 
retained  in  position  by  the  application  of  sj)lints  or  dressings. 

Materials  and  Appliances  used  in  the  Dressing  of  Frac- 
tures.— The  Fracture-Bed. — Many  ingenious  and  complicated  forms  of 
fracture-bed  have  been  devised  and  used,    but  they  are  now  not  much 


436  FKACTUEE  DRESSINGS. 

employed.  In  tlie  treatment  of  fractures  of  tlie  trunk  or  of  the  lower 
extremity  it  will  be  found  most  convenient  to  iise  a  single  bed,  not  over 
thirty-two  to  thirty-six  inches  in  width,  with  a  iirm  hair  mattress.  It  is  not 
necessary  that  this  be  perforated,  as  a  bed-pan  can  iisually  be  slipped 
under  the  patient  without  difficulty.  An  ordinary  shallow  tin  plate, 
covered  with  a  piece  of  old  muslin,  to  receive  the  fecal  evacuations,  may  be 
substituted  for  the  bed-pan,  and  will  be  found  in  many  instances  more  satis- 
factory, especially  in  the  case  of  children. 

Splints. — After  the  reduction  of  the  fragments  in  cases  of  fracture  they 
are  usually  retained  in  position  until  union  has  occurred  by  use  of  splints 
held  in  position  by  means  of  bandages.  Splints  may  be  made  of  wood, 
metal,  binder's  board,  leather,  felt,  paper,  and  plaster  of  Paris. 

Wooden  Splints. — The  simplest  and  cheapest  splints  are  made  from 
wood :  white  pine,  willow,  and  poplar  are  the  best  materials  for  their  con- 
struction, being  sufBciently  strong  and  at  the  same  time  light.  These  splints 
are  from  one-eighth  to  one-quarter  of  an  inch  in  thickness,  and  may  be 
employed  in  the  form  of  straight  or  angular  splints.  Wooden  splints  before 
being  applied  should  be  well  padded  with  cotton  or  oakum.  The  carved 
wooden  splints  sold  by  the  instrument-makers  are  not  to  be  recommended, 
as  a  rule,  for  unless  the  surgeon  has  a  large  number  to  select  from  it  is  rarely 
that  a  splint  can  be  obtained  to  fit  accurately  any  individual  case. 

Metallic  Splints. — Splints  constructed  of  tin  or  wire  are  sometimes 
used,  and  if  carefully  fitted  and  padded  may  serve  a  useful  purpose. 

Binder's  Board  or  Pasteboard. — This  is  an  excellent  material  from 
which  to  construct  splints.  It  is  first  soaked  in  boiling  water,  and  when 
sufficiently  soft  is  padded  with  cotton  or  a  layer  of  lint,  moulded  to  the  x^art, 
and.  secured  in  position  by  a  bandage.  As  it  becomes  dry  it  hardens  and 
retains  the  shape  into  which  it  was  moulded.  Undressed  leather  is  also  a 
good  material  fi-om  which  to  construct  splints,  and  is  applied  by  first  soak- 
ing the  leather  in  hot  water,  and,  after  jDadding  it  with  cotton  or  lint,  mould- 
ing it  to  the  part  and  retaining  it  in  f)osition  by  a  bandage ;  or  it  may  be 
moulded  upon  a  plaster  cast  taken  from  the  part. 

Felt. — This  is  made  from- wood  saturated  with  shellac  and  pressed  into 
sheets,  and  is  also  a  satisfactory  material  from  which  to  construct  splints.  It 
is  prepared  for  application  bj'  heating  it  before  a  fire  until  it  becomes  pliable, 
or  by  dipising  it  into  boiling  water. 

Plaster  of  Paris,  starch,  chalk,   gum,  or  silicate  of  potassium  or  of 

sodium  may  be  employed  in  the  construction  of  splints,  either  movable  or 

immovable,  for  the  treatment  of  fractures.    Of  these, 

Fig.  330.  f\yQ  plaster-of-Paris  dressing  is  the  one  which  is  now 

most  generally  employed. 

Fracture-Box.— This  is  a  form  of  splint  used 

in  the  treatment  of  fractures  of  the  lower  extremity, 

and  consists  of  a  board  eighteen  or  twentj^  inches  in 

Fracture-box.  length  and  eight  inches  in  width,  with  a  foot-board 

secured  to  its  lower  extremity,  and  sides  which  are 

secured  by  hinges,  which  allow  them  to  be  raised  or  lowered.     (Fig.  330.) 

When  a  fracture-box  is  used  it  is  padded  by  placing  in  it  a  soft  pillow.     A 


FRACTURES  OF  THE  NASAL  BONES.  437 

fracture-bos  of  greater  length  is  required  for  the  treatment  of  fractures  about 
the  knee-joint. 

Bran,  Sand,  or  Junk  Bags. — These  bags  are  frequently  employed  in 
the  treatment  of  fractures  of  the  femur.  The  bag,  made  from  a  piece  of 
unbleached  muslin  from  three  to  five  feet  in  length  and  fourteen  and  a  half 
inches  in  width,  is  filled  with  dry  sand,  bran,  hair,  or  cotton,  and  its  mouth 
closed  by  stitches  or  by  tying. 

Bandages. — Bandages  used  in  the  treatment  of  fractures  are  ordinarily 
made  of  muslin,  being  employed  to  retain  splints  in  place,  and  sometimes 
applied  directly  to  the  injured  part  before  the  application  of  splints,  to 
control  muscular  spasm  and  limit  the  amount  of  swelling.  When  a  bandage 
is  used  for  this  purpose  it  is  known  as  a  primary  roller.  The  primary 
roller  is  sometimes  of  the  greatest  service  in  the  dressing  of  fractures,  but 
when  used  the  case  should  be  under  constant  observation,  for  if  swelling- 
occurs  it  will  require  prompt  removal. 

Compresses. — These  are  employed  to  retain  fragments  in  position  or  to 
make  localized  pressure  over  certain  points,  and  are  made  from  a  number  of 
folds  of  lint,  cotton,  or  oakum.  Compresses  are  held 
in  position  by  strips  of  adhesive  plaster  or  by  a  few 
turns  of  a  roller  bandage.  They  are  sometimes  em- 
ployed to  protect  bony  prominences  from  the  pressure 
of  the  splints.  This  purpose  is  often  better  effected 
by  the  use  of  small  pieces  of  soap  plaster  spread  on 
chamois,  soft  leather,  or  kid,  and  fitted  around  the  Fracture-rat'T. 

prominent  points. 

Rack  or  Cradle. — This  is  made  of  wire  or  wooden  hoops,  and  is  often 
employed  to  support  the  weight  of  the  bedclothes  in  fractures  of  the  lower 
extremity.     (Fig.  331.) 

Repair  of  Fractures  is  considered  on  page  80. 

FRACTURES   OF   SPECIAL   BONES. 

Fractures  of  the  Nasal  Bones. — These  are  usually  produced  by 
direct  force,  and  the  line  of  fracture  may  be  either  transverse  or  oblique  ; 
the  former  are  most  common,  and  the  seat  of  fracture  is  usually  about  half 
an  inch  above  the  lower  margin  of  the  bone  ;  the  upper  and  frontal  portions 
of  these  bones  are  very  thick  and  strong  and  will  resist  a  great  degree  of 
force.  The  line  of  fracture  may  extend  to  the  superior  maxilla  or  to  the 
cribriform  plate  of  the  ethmoid  bone  ;  the  latter  is  a  dangerous  complication 
because  of  the  liability  to  septic  meningitis.  .These  fractures  may  be  com- 
minuted or  compound,  either  through  the  skin  or  the  mucous  membrane. 

Deformity." — As  the  soft  parts  swell  quickly  after  the  injury,  the 
deformity  following  this  fracture  is  often  masked  unless  the  case  is  seen 
early.  The  deformity  consists  in  lateral  displacement,  the  nose  being 
turned  to  one  side,  or  the  fragments  may  be  depressed. 

Symptoms. — The  symptoms  of  fracture  of  the  nasal  bones  are  epis- 
taxis,  deformity,  mobility,  and  crepitus.  If  there  is  flattening  or  lateral 
deviation  of  the  nose,  even  though  crepitus  is  not  discovered,  the  existence 
of  fracture  may  be  assumed. 


438  FRACTUEES   OF  THE   UPPER  JAW. 

Complications. — Hemorrhage  is  often  at  first  profuse  in  fractures  of 
the  nasal  bones,  but  usually  subsides  quickly  ;  however,  cases  are  occasion- 
ally seen  in  which  the  hemorrhage  continues  and  is  so  severe  that  plugging 
of  the  nasal  cavity  -with  antiseptic  gauze  may  be  required. 

Emphysema. — In  compound  fractures  of  the  nasal  bones  in  which  the 
mucous  membrane  and  the  periosteum  have  been  torn,  air  may  pass  into 
the  cellular  tissue  of  the  face.  This  is  not  a  serious  complication,  as  the  air 
gradually  disappears  as  the  healing  of  the  fractui-e  advances. 

Treatment. — This  consists  in  replacing  the  fragments,  if  displacement 
exists,  by  manipulation  with  the  fingers  over  the  seat  of  fracture,  and  bj^ 
pressure  made  from  within  the  nostrils  by  a  probe  or  steel  director,  the  end 
of  which  is  wrapped  with  a  little  cotton.  Before  resorting  to  any  manipula- 
tion within  the  nasal  cavities  the  mucous  membrane  should  be  thoroughly 
cocainized,  to  render  the  operation  painless.  When  there  is  depression  of 
the  fi-agments  or  displacement  of  the  septum,  after  correcting  the  deformity 
by  raising  the  depressed  fragments  or  bending  the  septum  into  place  with  a 
director,  the  parts  may  be  held  in  position  by  packing  the  nasal  cavities 
firmly  with  strips  of  antiseptic  gauze  around  pieces  of  rubber  catheter  intro- 
duced into  the  lower  nasal  fossa,  or  by  the  use  of 
Fig.  332.  Asch's  tubes.    (Fig.  332.)   In  lateral  displacement 

of  the  nasal  bones,  after  reducing  the  displacement, 
a  small  compress  held  over  the  fragments  by  strijjs 
of  adhesive  plaster  will  be  the  only  dressing  re- 
quired ;  indeed,  in  many  cases  when  the  displace- 
Aseh'stube.  ~  nieut  is  oncc  corrected  it  does  not  recnr  and  no 
dressing  is  required.  Where  the  fragments  are 
depressed  and  cannot  be  held  in  position  by  packing  the  nares  with  gauze, 
a  sterilized  steel  needle  may  be  passed  through  the  skin  below  them  and 
brought  out  upon  the  other  side  of  the  nose,  and  a  strip  of  adhesive  plaster 
passed  over  the  bridge  of  the  nose  and  fastened  to  the  ends  of  the  needle  to 
steady  the  fi'agments ;  the  needle  should  remain  in  position  from  eight  to 
ten  days. 

Compound  fractures  of  the  nasal  bones  through  a  wound  in  the  skin 
are  usually  not  serious  injuries  ;  detached  fragments  should  be  removed,  but 
fragments  having  vital  attachments  should  be  pressed  back  into  position 
and  the  wound  covered  with  an  antiseptic  dressing.  Compound  fractm-es 
involving  the  mucous  membrane  of  the  nose  are  more  serious  injuries,  on 
account  of  the  greater  liability  to  infection ;  the  nasal  cavities  should  be 
irrigated  with  a  mild  antiseptic  solution  and  packed  with  iodoform  gauze. 

Fractures  of  the  Upper  Jaw. — These  fractures  usually  result  from 
force  directly  applied,  and  may  involve  the  body,  the  nasal  i^rocess,  or  the 
alveolar  process.  As  these  fractui-es  are  usually  the  result  of  the  application 
of  great  force,  comminution  of  the  bone  is  not  uncommon,  and  they  are  often 
associated  with  fracture  of  other  bones  of  the  face.  If  the  injury  is  confined 
to  the  bones  of  the  face,  although  there  may  be  extensive  comminution, 
recovery  usually  follows,  with  more  or  less  deformity. 

Complications. — Fractures  involving  the  nasal  process  with  laceration 
of  the  mucous  membrane  may  be  followed  by  emphysema  of  the  face,  or,  as 


FRACTURE  OF  THE  MALAR  BONE. 


439 


Dressing  for  fracture  of  the  upper 


These 


the  nasal  process  contributes  to  the  formation  of  the  lachrymal  canal,  its 
injury  may  be  followed  by  obstruction  to  the  passage  of  tears.  Fracture  of 
the  superior  maxillary  bone  may  also  be  complicated  with  fracture  of  the 
base  of  the  skull.  The  infra-orbital  nerve  may  be  injured  in  fractures  near 
the  orbital  plate,  which  may  give  rise  to  neui-al- 
gia  or  sensory  paralysis.  Hemorrhage  in  com- 
pound fractures  of  the  upper  jaw  may  be  profuse. 

Treatment. — In  the  treatment  of  these  frac- 
tures all  fragments  and  splinters  of  bone  having 
vital  attachments  should  be  replaced,  if  any 
teeth  have  been  displaced  they  should  be  re- 
placed, and  if  there  is  comminution  of  the  ah  !■ 
olus  the  teeth  may  be  fastened  together  by  fim- 
silver  wire ;  the  lower  j  aw  should  then  be  brought 
in  contact  with  the  upi^er  jaw  to  act  as  a  splint, 
and  the  jaws  should  be  secured  together  by  the 
application  of  a  Barton's  bandage.  (Fig.  333.) 
Interdental  splints  made  of  cork,  with  grooves  to 
fit  the  teeth,  or  of  gutta-percha,  are  also  some- 
times employed  in  the  dressing  of  these  frac- 
tures. The  patient  should  not  be  allowed  to 
move  the  jaw  in  mastication,  and  should  be 
nourished  with  liquid  and  semisolid  food.  The 
bandage  should  be  removed  and  reapplied  every  second  or  third  day. 
fractures  are  usually  fi,rmly  united  at  the  end  of  four  or  five  weeks. 

Fracture  of  the  Malar  Bone.— This  is  usually  the  result  of  direct 
force,  and  unless  the  antrum  is  broken  into  there  will  not  be  much  displace- 
ment. This  fractu.re  is  often  associated  with  a  fissure  which  passes  into  the 
orbit,  terminating  in  the  sphenoidal  fissure. 

Symptoms. — The  signs  of  this  accident  are  pain,  discoloration,  occa- 
sionally mobility  and  crepitus,  and  some  degree  of  deformity.  If  the  line 
of  fracture  extends  into  the  orbit,  extravasation  of  blood  at  the  outer 
canthus  of  the  eye  is  frequently  present.  If  the  infra-orbital  branch  of  the 
fifth  pair  of  nerves  is  involved,  there  may  be  loss  of  sensation  in  some  of 
the  anterior  teeth  and  in  the  gums,  and  also  in  the  ala  of  the  nose. 

Treatment. — If  there  is  displacement,  it  should  be  corrected  by  pressm-e 
applied  inside  of  the  mouth  or  outside  of  the  cheek.  If  the  body  of  the 
bone  is  depressed  by  being  driven  into  the  antrum,  if  a  wound  is  present 
the  fragment  may  be  raised  by  means  of  an  elevator,  or  if  no  wound  is 
present  a  screw  elevator  may  be  introduced  through  a  piuncture  in  the  soft 
parts,  and  it  may  be  raised  by  this  means  ;  a  compress  should  be  applied  over 
the  seat  of  fracture  and  held  in  position  by  adhesive  straps. 

Fracture  of  the  Zygomatic  Arch.— This  bone  is  occasionally 
broken,  but  the  accident  is  a  rare  one.  It  is  usually  produced  by  direct 
force,  and  is  apt  to  involve  that  portion  which  is  attached  to  the  temporal 
bone,  which  is  the  weaker  part. 

Symptoms. — The  swelling  and  contusion  of  the  soft  parts  usually  mask 
the  condition,  and,  unless  there  is  great  deformity  or  irregularity  the  diag- 


440  FRACTUEES   OF  THE  LOWER  JAW. 

nosis  is  often  difficult.  If  the  fragment  is  depressed,  it  may  press  upon  tlie 
masseter  muscle  or  the  tendon  of  the  temporal  muscle,  and  interfere  with 
the  movements  of  the  lower  jaw. 

Treatment. — In  cases  of  fracture  of  the  zygomatic  arch  without  dis- 
placement, the  jaws  should  be  fastened  together  with  a  Barton's  bandage  to 
secure  rest  of  the  masseter  and  temporal  nruscles.  When  the  fragment  is 
displaced  and  there  is  involvement  of  the  tendon  of  the  temporal  muscle, 
if  no  wound  is  present  exposing  the  seat  of  fracture  it  may  be  necessary  to 
make  an  incision,  introduce  an  elevator,  and  raise  the  fragment  into  its 
normal  position,  or  the  fragment  may  be  raised  by  a  loop  of  strong  silver 
wire  passed  beneath  it  with  a  curved  needle.  In  fractures  of  the  malar 
bone  and  zygomatic  arch,  when  the  deformity  has  once  been  corrected  there 
is  little  tendency  to  its  reproduction,  and  union  is  usually  quite  firm  at  the 
end  of  three  weeks. 

Fractures  of  the  Lower  Jaw. — These  fractures  are  generally  pro- 
duced by  direct  force  applied  either  to  the  side  of  the  bone  or  upon  the 
chin,  and  frequently  result  from  falls  or  blows  upon  the  chin.     Fractures 
of  the  inferior  maxillary  bone  may  involve  the  body,  the  ramus,  or  the 
processes.     A  fracture  involving  the  body  of 
Fig.  334.  the  bone  may  occur  at  any  point  from  the 

angle  to  the  symphysis,  and  may  involve  the 
entire  thickness  of  the  bone  or  be  confined  to 
a  portion  of  the  alveolar  process.  Fractures 
of  the  body  of  the  bone  are  usually  compound 
through  the  mucous  membrane  of  the  mouth. 
Multiple  fracture  of  the  body  of  the  bone  is 
not  an  uncoramoii  accident.  About  fifty  per 
Fracture  of  the  lower  jaw.  ccut.  havc  more  than  oue  fissurc,  and  they 

are  often  symmetrical.  The  most  common  seat 
of  fracture  is  near  the  anterior  dental  foramen  (Fig.  334),  which  is  sometimes 
associated  with  a  fracture  near  the  angle  on  the  opposite  side.  Fracture 
may  also  occur  at  the  symphysis,  through  the  ramus,  at  the  neck  of  the 
condyloid  process,  or  the  coronoid  process  ;  both  of  the  latter  are  very  rare. 
Symptoms. — These  are  pain  and  inability  to  move  the  jaw,  mobility, 
crepitus,  and  deformity  ;  the  latter  depends  largely  upon  the  situation  of  the 
fracture.  When  the  fracture  is  at  the  symphysis  one  fragment  Mill  usually 
be  a  triiie  higher  than  the  other,  and  the  line  of  the  dental  arch  will  be  dis- 
placed ;  there  may  also  be  overriding  or  separation  of  the  fragments.  In 
fractures  in  front  of  the  masseter  muscle — that  is,  near  the  anterior  dental 
foramen — the  posterior  fragment  will  generally  be  found  external  to  the 
anterior  fragment,  the  overlapping  being  produced  by  the  action  of  the 
digastric  muscle  on  the  injured  side  and  the  iniiuence  of  the  internal  ptery- 
goid and  the  external  portion  of  the  masseter  muscle  on  the  sound  side  ;  these 
two  forces  act  upon  the  anterior  fragment,  while  the  internal  pterygoid  and 
the  deep  masseter  muscle  affect  the  j)osterior  fragment.  In  symmetrical 
double  fracture  between  the  dental  foramina  the  central  fragment  is  tilted 
by  the  tongue  muscles  and  may  be  displaced  backward,  allowing  the  tongue 
to  fall  back  and  produce  suffocation.     When  the  ramus  of  the  lower  jaw  is 


FRACTURE   OF  THE   HYOID   BONE.  441 

broken  there  is  generally  very  little  displacement  of  the  fragment,  from  the 
fact  that  the  masseter  and  pterygoid  muscles  cover  the  part  and  act  as  splints. 
When  the  neck  of  the  condyloid  process  is  broken  there  is  usually  deep- 
seated  pain  in  front  of  the  ear,  aggravated  by  movements  of  the  jaw,  and 
the  lower  fragment  is  usually  divSplaced  forward  and  upward  by  the  external 
pterygoid  muscles,  and  the  chin  may  be  drawn  towards  the  injured  side. 

Oomplications. — It  is  rare  for  serious  complications  to  follow  fractures 
of  the  inferior  maxillary  bone.  The  inferior  dental  nerve  appears  usually 
to  escape  injury,  but  permanent  ausesthesia  of  the  chin  occasionally  results, 
and  bleeding  has  been  observed  from  the  ears,  from  force  transmitted  to  the 
external  auditory  canal  through  the  condyles  of  the  jaw.  Cranial  compli- 
cations have  been  observed  from  force  transmitted  through  the  condyles. 

Prognosis. — Bony  union  is  the  rule,  but  may  be  delayed,  and  the 
deformity  resulting  is  slight.  As  these  fractures  are  usually  compound 
through  the  mouth,  infection  and  abscess  are  common,  but  septicsemia  is 
rare  ;  necrosis  frequently  occurs  and  retards  repair. 

Treatment. — In  fractures  of  the  body  or  ramus  of  the  lower  jaw,  the 
.deformity  should  be  reduced  by  manipulation,  and  the  lower  jaw  should  be 
brought  up  against  the  teeth  of  the  upper  jaw  and  fixed  in  this  position  by 
the  application  of  a  Barton's  bandage.  (Fig.  333.)  A  cup-shaped  splint 
of  binder's  board  may  be  moulded  to  the  chin  and  held  on  by  the  Barton's 
bandage  to  give  additional  fixation  to  the  parts.  If  there  is  very  great  dis- 
placement of  the  fragments,  this  can  be  remedied  and  the  fragments  secured 
in  their  natural  position  by  exposing  the  fragments,  drilling  them,  and 
securing  them  in  position  by  the  application  of  one  or  two  silver  wire  or 
catgut  sutures.  Where  the  alveolar  process  only  is  separated,  this  should  be 
pushed  back  into  place,  and  by  wiring  together  the  teeth  of  the  fragments 
they  may  be  held  securely  in  place.  When  the  services  of  a  competent 
dentist  are  obtainable,  fractures  with  much  tendencj^  to  displacement  are 
best  treated  with  an  interdental  splint  made  of  rubber,  gold,  or  aluminum, 
which  fits  over  the  crowns  of  the  teeth,  and  in  some  cases,  as  in  Kingsley's 
splint,  is  provided  with  arms,  which  permit  the  application  of  a  bandage, 
binding  the  splint  firmly  to  the  jaw.  The  patient  should  be  fed  upon  liquid 
or  semiliquid  diet  until  there  is  union  at  the  seat  of  fracture. 

The  dressing  should  be  changed  at  intervals  of  two  or  three  days,  and 
can  usually  be  permanently  removed  after  five  or  six  weeks.  In  extensive 
compound  fractures  of  the  jaw  it  is  often  advisable  to  pack  the  wound  with 
iodoform  gauze,  which  requires  removal  at  intervals  of  two  or  three  days. 

Fracture  of  the  Hyoid  Bone. — The  hyoid  bone  from  its  position  is 
not  often  fractured,  yet  occasionally  this  accident  has  occurred  as  the  result 
of  blows  upon  the  neck,  of  constriction  of  the  parts,  or  in  hanging. 

Symptoms. — The  most  marked  symptom  is  pain  in  the  submental 
region,  which  may  be  very  severe,  and  is  aggravated  by  movements  of  the 
neck  or  of  the  tongue  ;  swallowing  is  also  accompanied  by  pain,  and  crepitus 
may  sometimes  be  obtained.  Displacement  of  the  fragment  can  best  be 
detected  by  introducing  the  finger  into  the  pharynx. 

Treatment. — If  there  is  displacement,  this  should  be  reduced  by  intro- 
ducing one  finger  into  the  pharynx,  and  with  the  fingers  upon  the  outside 


442 


FEACTUEES   OF  THE  BIBS. 


Common  positions  of  fractures  of  tlie  ribs. 


of  the  neck,  over  the  position  of  the  bone,  pushing  the  fragment  outward 
and  forward.  The  patient  should  abstain  for  a  few  days  as  far  as  possible 
from  moving  the  jaw  and  from  swallowing.  The  head  and  neck  should 
be  fixed  by  sand -bags.  If  inflammatory  symptoms  are  present,  active  local 
treatment  should  be  emj)loyed.  If  cough  is  a  prominent  symptom,  it  should 
be  controlled  by  opium.  A  splint  of  pasteboard  or  leather  moulded  to  the 
anterior  surface  of  the  neck  has  been  used  in  some  cases  with  advantage. 
Rectal  feeding  and  rest  in  bed  should  at  the  same  time  be  employed. 

Fractures  of  the  Ribs. — These  fractures  are  very  frequent,  and  may 
occur  at  all  ages,  but  are  most  common  in  middle  and  advanced  life.  In 
children  the  mobility  and  elasticity  of  the  thoracic  walls  cause  this  injury 
to  be  much  less  frequent.  Fractures  of  the  ribs  may  be  caused  by  blows, 
falls,  or  the  passage  of  heavy  bodies  over  the  chest,  or  by  the  chest  being- 
caught  between  comj)ressing  forces,  and  are  apt  to  occur  in  the  anterior  or 

the  posterior  portion  of  the 
Fig- 335.  rib.     (Fig.  .335.)    The  ribs 

most  frequently  broken  are 
those  from  the  third  to  the 
eighth  ;  the  first  and  second 
ribs  are  seldom  broken. 
The  displacement  in  frac- 
tures of  the  ribs  is  usually 
slight,  being  prevented  by 
the  intercostal  muscles  and  aponeuroses,  although  in  fractures  produced  by 
direct  violence  there  may  be  an  inward  displacement  of  the  rib,  causing  injury 
of  the  lung  ;  this  may  be  spontaneously  reduced  by  a  cough  or  sneeze  or  may 
remain  permanently.  Overriding  is  rare  unless  several  ribs  have  been  broken. 
Oomplications. — The  principal  complications  following  fractures  of 
the  ribs  are  injury  of  the  pleura  or  lung,  producing  hemorrhage,  i^neu- 
monia,  and  emphysema,  or  laceration  of  the  intercostal  vessels  followed  by 
hemorrhage.  Profuse  hemorrhage  is  rare,  but  moderate  haemothorax  is  not 
nncommon,  especially  in  fractures  from  the  sixth  to  the  ninth  rib. 

Symptoms. — These  are  diminished  respiratory  movements  upon  the 
injured  side  and  pain  at  the  seat  of  injury,  which  is  increased  by  attempts 
to  take  a  full  breath,  or  by  coughing.  Crepitus  may  in  many  cases  be 
obtained  by  placing  the  hand  over  the  seat  of  injury  and  directing  the 
patient  to  take  a  full  breath.  When  the  pleura  has  been  punctured  and  the 
lung  has  been  injured,  emphysema  of  the  cellular  tissues  over  the  region  of 
the  fracture  can  usually  be  felt,  and  in  cases  of  injury  of  the  lung  haemop- 
tysis may  also  be  present. 

Prognosis. — In  uncomplicated  cases  the  prognosis  is  favorable.  Com- 
pound fractures,  however,  or  those  whicli  are  accomj)anied  by  injury  of  the 
pleura  or  the  lung,  although  many  cases  recover,  are  serious  injuries. 

Treatment. — A  satisfactory  temporary  dressing  consists  in  surrounding 
the  chest  with  a  broad  binder  of  stout  linen  or  muslin,  which  restricts  the 
respiratory  movements  and  relieves  the  patient's  discomfort,  but  cannot  be 
recommended  as  a  permanent  dressing,  as  it  also  restricts  the  respiratory 
movements  upon  the  uninjured  side  of  the  chest.      The  best  permanent 


FRACTTJEES   OF  THE   COSTAL   CARTILAGES. 


443 


dressing  for  fractures  of  the  ribs  consists  in  enveloping  the  side  of  the  chest 
on  which  the  rib  or  ribs  are  broken  with  broad  strips  of  adhesive  plaster. 
(Fig.  336.)  To  apply  this  dressing  strips  of  resin  or  adhesive  plaster,  two  and 
a  half  inches  in  width,  from  eighteen  to  twenty  inches  in  length,  and  long 
enough*  to  extend  from  the  spine  to  the  median  line  of  the  sternum,  are 
required.  The  extremity  of  the  first  strip  is  placed  upon  the  spine  opposite 
the  lower  portion  of  the  chest ;  it  is  then  carried  around  the  chest,  and  its 
other  extremity  is  fixed  upon  the  skin  in  the  median  line  of  the  sternum. 
Successive  strips  are  applied  from  be- 
low upward  in  the  same  manner,  each  Fig.  337. 

Fig.  336. 


strapping  of  the  chtst 


Union  of  adjacent  ribs  by  callus.    (Malgaigne. ) 


strip  overlapping  one-third  of  the  preceding  one,  until  the  axillary  fold  is 
reached.  A  second  layer  of  strips  may  be  applied  over  the  first  if  additional 
fixation  is  desired.  This  dressing  usually  gives  the  patient  much  comfort, 
and  the  strips  need  not  be  removed  until  they  become  slightly  loosened 
at  the  end  of  a  week  or  ten  days,  when  they  should  be  reapplied  in  the  same 
manner. 

The  dressing  is  usually  dispensed  with  at  the  end  of  three  or  four  weeks, 
as  repair  is  well  advanced  by  this  time.  In  the  repair  of  fractures  of  the 
ribs  a  considerable  amount  of  callus  is  deposited  around  the  seat  of  fracture, 
and  in  fractures  of  adjacent  ribs  they  may  be  permanently  bound  together 
by  callus.     (Fig.  337.) 

Fractures  of  the  Costal  Cartilages. — These  fractures  are  occa- 
sionally met  with .  The  cartilages  of  the  seventh  and  eighth  ribs  appear  to 
be  the  ones  most  commonly  broken,  and  there  is  generally  some  outward 
displacement  of  either  the  sternal  'or  the  vertebral  end  of  the  cartilao-e. 
These  fractures  usually  result  from  force  directly  applied,  or  from  pressure 
upon  the  anterior  and  posterior  portions  of  the  chest.  The  repair  of  fi-ac- 
tures  of  the  costal  cartilages  may  be  by  fibrous  tissue  or  by  a  ferrule  of  bone 
which  surrounds  the  fragments. 

Symptoms. — These  are  pain,  which  is  Increased  with  respiratory  move- 
ments, deformity,  which  usually  consists  in  undue  prominence  at  the  seat  of 


444 


FRACTUEES  OF  THE  STERXUM. 


The  treatment  is  the   same  as  for 


Fig  338 


Fracture  ot  the  ster- 
num. 


fi-actm-e,   mobility,   and  soft  crepitus, 
fractures  of  the  ribs. 

Fractures  of  the  Sternum. — These  are  rare  injuries,  from  the  fact 
that  the  boue  has  elastic  attachments  which  allow  it  a  considerable  amount 
of  motion.  As  a  complete  joint  sometimes  exists  between 
the  manubrium  and  the  body,  it  is  often  impossible  to  say 
whether  the  injury  is  a  diastasis  or  a  fracture.  The  seat 
of  fracture  may  be  in  the  manubrium  or  at  the  junction  of 
the  latter  with  the  body,  occurring  here  in  twenty-five  per 
cent,  of  the  cases,  or  the  body  of  the  bone  may  be  broken 
(Fig.  338),  or  the  xiphoid  cartilage  may  be  detached.  The 
displacement  in  this  fracture  depends  upon  the  fracturing 
force.  When  produced  by  extreme  extension  of  the  body, 
the  lower  fragment  may  be  displaced  forward  and  overlap 
the  upper  one  ;  this  is  the  ordinary  displacement  observed  ; 
when,  however,  it  is  produced  by  flexion,  the  uj)per  frag- 
ment takes  a  position  in  front  of  the  lower  one.  When 
produced  by  direct  force,'  the  fragments  may  be  driven 
inward. 

Symptoms. — These  are  pain  at  the  seat  of  injury, 
which  is  aggravated  by  a  full  respiratory  movement,  by 
pressure,  or  by  coughing  ;  crepitus  may  also  be  detected, 
.  and  occasionally  emphysema  may  be  observed  if  the  lung- 
has  been  injured  by  the  fragments.  In  fractures  of  the  xijjhoid  cartilage 
accompanied  by  inward  displacement  persistent  vomiting  is  said  to  be  a  not 
infrequent  symptom.  We  had 
under  our  care  a  boy  who  had  re-  -^''^ 

ceived  a  kick  in  the  epigastrium 
and  exhibited  an  inward  displace- 
ment of  the  xiphoid  cartilage,  in 
whom  this  symptom  was  very  prom- 
inent for  some  weeks,  but  finally 
disappeared.  In  other  cases  this 
symptom  has  been  relieved  by  re- 
placement of  the  fragment  by  inci- 
sion, or  by  digital  reduction. 

Complications. — The  mortal- 
ity of  recorded  cases  has  been  high 
because  of  the  frequency  of  serious 
complications.  The  most  dangerous 
complication  is  inward  displace- 
ment of  the  fragments,  causing 
injury  of  the  lung,  and  accom- 
panied by  emphysema,  dyspncea, 
and  expectoration  of  blood  ;  abscess  also  may  follow  Ixacture  of  the  sternum, 
which  may  point  at  the  lateral  margins  of  the  sternum  or  at  the  xiphoid 
cartilage.  Compmmd  fractures  of  the  sternum  may  be  followed  by  abscess  or 
necrosis  of  the  bone. 


Dressing  for  fracture  of  the  ste 


FRACTURE   OF  THE  CLAVICLE. 


445 


'  ■v.vV^^ 


t  the  claviole 


Treatment. — If  displacemeut  of  the  fragments  is  present,  attempts 
should  be  made  to  relieve  it  by  extension  or  flexion  of  the  body  and  by 
manipulation  with  the  fingers.  If  the  deformity  is  not  reduced  by  these 
manipulations  and  causes  the  patient  discomfort,  the  fragments  should  be 
exposed  by  incision,  elevated,  and  wired,  if  necessary.  After  reducing  the 
deformity,  a  compress  should  be  placed  over  the  seat  of  fracture,  and  the 
chest  movements  should  be  restricted  by  applying  adhesive  straps,  two  and 
a  half  inches  in  width,  which  should  extend  from  the  middle  of  the  ribs  on 
one  side  to  the  same  point  on  the  opposite  side  and  should  cover  in  the  chest 
for  some  distance  above  and  below  the  seat  of  fracture.  (Fig.  339.)  This 
dressing  should  be  retained  for  at  least  four  weeks,  being  renewed  at  the 
end  of  a  week  or  ten  days  if  it  becomes  loose. 

FRACTURE   OF   THE   CLAVICLE. 

This  is  a  very  common  fracture,  due  largely  to  the  exposed  position  of  the 

bone  and  its  attachment  to  the  sternum  and  acromion  process  of  the  scap)ula, 

which  latter  causes  it  to 

receive  a  part  of  all  forces  Fig.  340. 

which      are      transmitted 

through  the  arm  or  shoul- 
der.   It  is  more  common 

in  children  than  in  adults  ; 

more  than  one-third  of  the 

cases    occur    in    children 

under  five  years  of  age  ;  and  it  may  exist  as  a  partial  or  a  complete  fracture  ; 

one-fifth  of  the  fractures  in  children  are  partial.     Bilateral  fractures  of  the 

clavicle  have  also  occasionally  been  ob- 
served. Fracture  of  the  clavicle  may  occur 
at  any  part  of  the  bone.  Fractures  of  the 
middle  third  of  the  bone  are  the  most  com- 
mon variety,  constituting  about  five-sixths 
of  the  cases,  and  may  be  oblique  (Fig.  340) 
or  transverse  ;  the  former  is  the  most  com- 
mon in  adults,  the  latter  in  children.  Com- 
pound fractures  of  the  clavicle  are  very  rare 
and  when  met  with  are  often  comminuted. 
Fracture  of  the  clavicle  may  result  from  in- 
direct violence,  such  as  falls  upon  the  hands 
or  the  shoulder,  from  crushing  force  ajsplied 
to  the  upper  part  of  the  chest,  from  muscular 
action,  as  in  striking  or  lifting,  and  from 
direct  violence. 

Symptoms. — These  are  loss  of  power, 
pain  upon  pressure,  and  deformity.  The 
patient  usually  supports  the  arm  of  the 
injured  side  at  the  elbow  with  the  hand  of 

the  uninjured  arm,  and  is  generally  unable  to  carry  the  hand  of  the  injured 

side  to  the  head  or  to  the  opposite  shoulder  ;  the  affected  shoulder  is  lower 


Fig.  341. 


Deformity  i 


t  recent  fracture  of  the  right 
clavicle. 


446 


FRACTURE  OF  THE  CLAVICLE. 


Fig 


J\\ 


Dibplacement  ol  fragments  in 
fracture  of  the  clavicle. 


and  farther  forward  than  its  fellow  (Fig.  341)  ;  crepitus  can  generally  be 
obtained  by  grasping  the  injured  aria  and  carrying  it  upward,  outward,  and 
backward  while  the  fingers  are  placed  over  the  seat  of  the  fracture.  Disa- 
bility may  be  very  slight  in  incomplete  fractures. 

Deformity. — In  oblique  fractures  in  the  middle  third  of  the  clavicle 
the  sternal  fragment  will  be  drawn  upward  by  the  clavicular  fibres  of  the 
sternocleidomastoid  muscle  ;  the  acromial  fragment  is  carried  downward 
by  the  weight  of  the  shoulder  and  the  action  of  the  serratus  magnus,  the 
latissimus  dorsi,  and  the  pectbralis  major  and  minor 
muscles,  so  that  the  fragment  falls  below  the  level  of 
the  sternal  fragment :  the  overlapping  is  produced  by 
the  acromial  fragment  being  drawn  inward  and  for- 
ward by  the  action  of  the  pectoralis  major  muscle. 
(Pig.  342.)  In  some  cases  both  ends  of  the  broken 
bone  may  be  drawn  upward. 

Fracture  of  the  outer  third  of  the  clavicle  is  not 
usually  accomj)anied  by  much  deformity  if  it  takes 
place  within  the  limits  of  the  coraco-clavicular  liga- 
ment, as  the  attachment  of  the  latter  to  the  perios- 
teum serves  to  resist  displacement  of  the  fragments  ; 
beyond  the  ligament  the  deformity  may  be  marked. 
In  fracture  of  the  inner  third  of  the  bone,  if  situated 
within  the  limits  of  the  costo- clavicular  ligament, 
there  is  A^ery  little  displacement. 
Complications. — These  are  rare  even  in  gunshot  injuries.  The  most 
serious  complications  are  injuries  of  the  lung,  the  brachial  plexus,  and  the 
subclavian  vessels ;  the  brachial  plexiis  may  be  injured  at  the  time  of  the  acci- 
dent by  a  displaced  fragment,  or  may  be  involved  in  the  callus  during  the 
repair  of  the  fracture,  causing  paralysis  of  the  arm.  A  disjjlaced  fragment 
of  the  clavicle  has  also  produced  injury  of  the  internal  jugular  vein  and  the 
subclavian  artery  or  vein,  but  such  injuries  are  extremely  rare.  Exuberant 
callus  has  been  known  to  unite  the  clavicle  to  the  coracoid  process  or  the  ribs. 
Prognosis. — Fractures  of  the  clavicle  unite  promptly,  and  examples  of 
non-union  in  this  fracture  are  not  common.  Repair  of  this  injury  without 
deformity  is  also  a  very  rare  occurrence  ;  there  is  usually  some  shortening 
with  more  or  less  angular  deformity  following  cases  of  oblique  fracture  of 
the  clavicle,  but,  although  the  deformity  may  be  marked,  the  functional 
result  is  generally  very  satisfactory. 

Treatment. — In  the  treatment  of  fracture  of  the  clavicle  the  jjrincipal 
indication  is  to  carry  the  shoulder  upward,  outward,  and  backward, — that  is, 
to  restore  it  to  its  normal  position,  and  thus  bring  the  acromial  fragment, 
the  one  principally  displaced,  to  its  proper  place.  Although  this  may  be 
easily  accomplished  by  manipulation,  great  difficulty  is  experienced  in 
keeping  the  shoulder  in  this  position,  for  the  unsupported  weight  of  the 
shoulder  tends  to  cause  a  reproduction  of  the  deformity.  The  movement  of 
the  scapula  is  an  important  factor  in  the  xDroduction  of  deformity  after  frac- 
ture of  the  clavicle,  and  any  dressing  which  does  not  secure  fixation  of  this 
bone  cannot  fulfil  the  indications  in  treatment. 


FRACTURE  OF  THE   CLAVICLE. 


447 


Treatment  in  the  Recumbent  Posture. — By  this  method  of  treat- 
ment excellent  results  may  be  obtained  with  the  least  amount  of  deformity, 
but  the  position  is  irksome,  and  many  patients  will  not  submit  to  it.  The 
patient  should  be  placed  upon  a  firm  mattress,  and  the  head  placed  on  a  low 
pillow,  with  the  chin  slightly  depressed,  so  as  to  relax  the  sterno-cleido- 
mastoid  muscle  and  relieve  the  tension  uijon  the  sternal  fragment  of  the 
clavicle.  A  folded  towel  should  be  placed  in  the  axilla,  to  protect  the  sur- 
face of  the  arm  and  chest  from  excoriation,  and  the  arm  and  forearm  on  the 
injured  side  should  be  flexed  and  placed  across  the  chest,  so  that  the  fingers 
of  the  arm  of  the  injured  side  will  touch  the  opposite  shoulder.  In  this 
position  the  inferior  angle  of  the  scapula  moves  forward  and  the  superior 
angle  backward,  the  weight  of  the  body  upon  the  lower-  angle  keeijing  it  in 
this  position.  The  arm  should  be  seciu-ed  in  i^lace  by  broad  strijjs  of  adhe- 
sive plaster  or  by  a  few  turns  of  a  roller  bandage.  It  is  remarkable  in  cases 
of  fracture  of  the  clavicle  with  great  deformity  how  the  parts  assume  their 
normal  position  if  the  patient  is  placed  in  the  recumbent  posture  with  the 
arm  in  the  position  just  described.  After  the  patient  has  remained  two  or 
three  weeks  at  rest  in  this  position,  union  is  generally  sufficiently  firm  to 
allow  him  to  get  out  of  bed  and  be  about  with  the  arm  bound  to  the  side  and 
tlie  forearm  carried  in  a  sling,  or  with  a  Velpeau  bandage  applied. 

Temporary  Dressing. — This  may  be  accomplished  by  the  application 
of  a  sling  and  bandage  securing  the  arm  to  the  side,  or  of  a  four-tailed 
bandage,  Diade  from  a  jjiece  of  muslin  two  yards  in  length  and  fourteen 
inches  in  width.  A  hole  is  cut  in  the  centre,  about  four  inches  from  its 
mai-gin,  to  receive  the  point  of  the  elbow ;  the  bandage  is  then  split  into 
four  tails  in  the  line  of  the  hole  and  to 
within  six  inches  of  it.  The  body  of  the 
bandage  should  be  applied  so  that  the 
point  of  the  elbow  rests  in  the  hole,  and, 
a  folded  towel  being  jplaced  in  the  axilla, 
the  lower  tails  should  be  carried,  one  ante- 
riorly, the  other  posteriorly,  diagonally 
across  the  chest  and  back  to  the  neck  ou 
the  side  opposite  the  seat  of  fracture,  and 
secured  ;  the  remaining  tails  are  next  car- 
ried around  the  lower  part  of  the  chest 
and  secured,  so  as  to  fix  the  arm  to  the 
side  of  the  body.  The  same  indications 
may  be  met  by  utilizing  the  clothing  to 
secure  the  arm  to  the  side  and  to  form  a 
sling,  supporting  the  elbow  from  the  oppo- 
site shoulder. 

The  Velpeau  Dressing. — This  dress- 
ing will  be  found  a  most  satisfactory  one 
in  a  large  number  of  cases.  The  flexed  arm  carried  across  the  chest  draws 
the  lower  angle  of  the  scapula  forward  by  making  tense  the  teres  major 
muscle,  and  causes  the  acromial  fragment  of  the  clavicle  to  rise  upward  and 
backward.     The  position  of  the  arm  upon  the  chest  also  serves  to  keep  the 


Fig.  343. 


Velpeau's  dressing  for  fracture  of  the  clavicle. 


448 


FRACTURE   OF  THE   CLAVICLE. 


scapula  outward.  (Fig.  343.)  The  arm  on  the  injured  side  should  be  flexed 
and  brought  across  the  front  of  the  chest  so  that  the  hand  will  rest  upon  the 
shoulder  of  the  sound  side  ;  a  folded  towel  should  be  placed  in  the  axilla  and 
between  the  arm  and  side  of  the  chest,  to  prevent  excoriations  of  the  skin 
surfaces.  A  Yelpeau  bandage  is  then  aj)i)lied.  A  modified  form  of  the 
Velpeau  dressing  is  applied  as  follows  :  A  soft  towel  or  piece  of  lint  should 
be  placed  in  the  axilla  and  allowed  to  extend  over  the  side  and  fi'ont  of  the 
chest  and  held  in  position  by  a  strip  of  adhesive  plaster.  The  arm  is  next 
placed  in  the  Yelpeau  position,  and  a  good-sized  pad  of  lint  is  applied  over 
the  scapula  and  held  in  place  by  a  broad  strip  of  adhesive  plaster,  two  and 
a  half  inches  in  width  and  one  and  a  half  yards  in  length.  This  strip  is 
continued  downward  and  forward  so  as  to  pass  over  the  point  of  the 
elbow,  and  is  carried  diagonally  across  the  chest  to  the  shoulder  of  the 
opposite  side,  and  secured.  A  hole  should  be  cut  in  it  to  receive  the 
olecranon  process.  A  comj)ress  of  lint  is  placed  over  the  seat  of  frac- 
ture and  held  in  place  by  a  strip  of  adhesive  plaster ;  an  additional  strijj 
of  jjlaster  is  next  carried  over  the  spine,  around  the  arm  and  chest,  and 
secured  on  the  opposite  side  of  the  chest.  (Fig.  344.)  Circular  turns  of  a 
roller  bandage  are  then  passed  around  the 
chest,  including  the  arm,  from  below  upward, 


Fig.  345. 


Fig.  344. 


Compresses  aud  adhesive  strips  applied  in 
dressing  for  fracture  of  the  clavicle. 


Modified  Velpeau  dressing  for  fracture  of  the 
clavicle. 


until  the  arm  is  securely  fixed  to  the  body,  and  the  dressing  is  finished  by 
making  one  or  two  turns  of  the  third  roller  of  Desault.     (Fig.  345.) 

The  dressing  should  be  removed  at  the  end  of  the  second  or  third  day, 
the  parts  inspected,  and  the  skin  sponged  off  with  dilute  alcohol ;  the  dress- 
ings are  then  reapplied,  and  if  the  patient  is  comfortable  and  the  parts  in 
good  position  the  dressings  should  be  made  at  less  frequent  intervals  until 
union  is  comx^leted.  Union  is  generally  quite  firm  at  the  end  of  four 
or  five  weeks,  and  at  this  time  the  dressings  may  be  removed  and  the 


FRACTURE  OF  THE  CLAVICLE. 


449 


patient  allowed  to  carry  the  arm  in  a  sling  for  several  weeks,  but  he  should 
not  make  forcible  movements  of  the  arm  for  eight  or  ten  weeks. 

Sayre's  Dressing, — This  dressing  consists  of  two  strips  of  adhesive 
plaster  three  and  a  half  inches  wide  and  two  yards  in  length.  The  end  of 
the  first  strip  is  made  into  a  loop  and  secured  by  stitches,  the  loop  is  passed 
around  the  arm  just  below  the  axillary  margin,  and  the  arm  is  then  drawn 
downward  and  backward  until  the  clavicular  portion  of  the  pectoralis  major 
muscle  is  put  sufficiently  on  the  stretch  to  overcome  the  action  of  the  sterno- 
cleido-mastoid  muscle,  and  in  this  way  draws  the  sternal  fragment  of  the 
clavicle  down  to  its  place.  The  strip  of  plaster  is  then  carried  completely 
around  the  body  and  fastened  or  stitched  to  itself  on  the  back.  Before  the 
elbow  is  secured  by  the  second  strip  of  plaster  it  should  be  pressed  well 
forward  and  inward,  and  the  forearm  should  rest  across  the  anterior  surface 
of  the  chest.  The  second  strip  is  next  applied,  commeucing  upon  the  front 
of  the  shoulder  of  the  sound  side.  From  this  point  it  is  carried  over  the 
top  of  the  shoulder  diagonally  across  the  back,  under  the  elbow,  and  across 


Say^e''^  dressing  for  fracture  of  the  clavicle. 

the  front  of  the  chest  to  the  point  of  starting,  where  it  is  secured.  (Fig. 
346).  A  slit  should  be  made  in  this  strip  to  receive  the  projecting  point 
of  the  olecranon  process. 

Fracture  of  the  Clavicle  in  Children. — The  deformity  following  this 
fracture  in  infants  and  children  is  much  less  than  that  which  is  observed  in 
adults.  The  fracture  of  the  bone  may  be  j)artial  or  complete,  and  the  line 
of  fracture  transverse  or  oblique.  In  partial  fracture  where  the  deformity 
consists  in  bending  of  the  bone,  it  may  be  reduced  by  drawing  the  shoulders 
backward.  If,  however,  the  deformity  is  slight,  it  is  better  not  to  attempt 
to  correct  it,  as  by  so  doing  an  impacted  or  incomplete  fracture  may  be 
converted  into  a  complete  one.  In  the  treatment  of  fractures  of  the  clavicle 
in  children  we  usually  apply  the  Velpeau  or  the  modified  Yelpeau  dressing, 

29 


450 


FEACTUEES   OF  THE   SCAPULA. 


and,  as  these  patients  are  particularly  apt  to  disarrange  their  dressings,  it 
is  well  to  render  it  additionally  secure  by  applying  a  few  broad  strij)s  of 
adhesive  plaster  over  the  turns  of  the  roller  bandage,  the  strips  following 
the  turns  of  the  bandage  ;  or  a  starched  bandage  may  be  used. 

The  most  troiablesome  comiilication  in  the  treatment  is  caused  by  excori- 
ation of  the  skin  where  the  surface  of  the  arm  comes  in  contact  with  the 
skin  of  the  chest.  This  may  be  guarded  against  by  using  a  dusting  powder 
and  by  placing  a  fold  of  dry  lint  between  the  arm  and  the  side  of  the  chest. 
The  time  required  for  union  is  shorter  than  in  adults,  and  the  dressings  may 
be  removed  at  the  end  of  three  weeks. 

Separation  of  the  Epiphysis  of  the  Clavicle. — This  injury  is  rare 
and  is  limited  to  the  sternal  end  of  the  bone,  as  the  acromial  end  has  no 
epiphysis,  and  may  occur  from  the  eleventh  to  the  twentieth  year.  It  may 
result  from  the  same  kind  of  violence  which  produces  fracture  of  the  clavicle. 
Symptoms. — These  are  practically  those  of  dislocation  of  the  sternal  end 
of  the  clavicle,  and  the  diagnosis  from  the  latter  injury  mainly  rests  xipon 
the  age  of  the  patient  and  the  fact  that  the  displaced  end  of  the  bone  is  not 
covered  by  cartilage.  Treatment. — This  consists  in  reducing  the  displace- 
ment by  manij)ulation,  applying  a  compress  over  it,  and  fixing  the  arm  to 
the  side.     Eepair  takes  place  jDromptly  with  a  good  functional  result. 


FRACTURES   OF   THE   SCAPULA. 

Fracture  of  the  scapula  is  a  rare  accident,  and  the  infrequency  of  its 
occurrence  may  be  explained  by  the  fact  that  the  bone  is  co's^ered  with  large 
muscles  and  moves  freely  over  the  surface  of  the  chest.     Fractures  of  the 
scapula  may  involve  the  body  or  the  angle  of  the  bone,  the  neck,  the  acro- 
mion or  the  coronoid  process,   and  the  glenoid 
Fig.  3-17.  cavity,  and  result  from  violence  directly  applied 

or  by  indirect  force  transmitted  through  the  arm. 
Fractures  of  the  Body  and  Angles  of 
the  Scapula. — Fractures  involving  these  por- 
tions of  the  scapula  are  generally  produced  by 
direct  violence,  and  may  be  partial,  complete,  or 
comminuted.  Fractures  of  the  body  of  the  bone 
are  rare  and  are  usually  situated  below  the  spine. 
(Fig.  347.) 

Symptoms. — If  the  body  of  the  scapula  or 
the  inferior  angle  is  broken,  crepitus  and  mobility 
may  be  elicited  by  grasping  the  inferior  angle 
with  one  hand  while  with  the  other  hand  the  spine 
of  the  scapula  is  fixed.  When  the  spine  of  the 
scapula  is  fractured,  the  seat  of  fracture  may  be 
located  by  i^assing  the  fingers  along  the  spine  of 
the  bone.  In  incomplete  fractures  it  is  impossible  to  make  an  accurate  diag- 
nosis ;  in  complete  fractures,  however,  thei'e  is  usually  more  or  less 
deformity.  ' 

Treatment. — After  reducing  the  deformity  by  manipulation,  a  compress 
should  be  placed  over  the  seat  of  fracture  and  held  in  position  by  broad 


f  the  body  of  the  scapula. 
(Agnew.) 


FRACTURE  OF  THE  CORACOID  PROCESS. 


451 


Fracture  of  the  acromion  pro- 
cess. 


strips  of  adhesive  plastei' ;  the  arm  should  then  be  fixed  against  the  side  of 
the  chest  and  held  in  position  by  a  Velpeau's  bandage  or  by  the  arm  and 
chest  bandage,  the  dressings  being  changed  at  intervals  and  retained  for 
about  four  weeks. 

Fracture  of  the  Acromion  Process. — This  is  the  most  common 
fracture  of  the  scai3ula,  and  may  be  produced  by  direct  violence  applied  from 
above  or  by  the  head  of  the  humerus  being  driven 
forcibly  upward  against  the  acromion,  or  by  muscular  Fig.  348. 

action.     (Pig.  348.) 

Symptoms. — These  are  flattening  of  the  shoulder, 
disability  of  the  arm,  mobility,  and  crepitus.  Crepi- 
tus may  be  obtained  by  placing  the  fingers  over  the 
acromion  process  and  jjushing  the  head  of  the  humerus 
upward. 

Diagnosis. — This  may  be  difficult  if  the  fragment 
is  small,  when  there  will  be  little  deformity  and  crepi- 
tus may  be  wanting.  It  may  be  confounded  with 
dislocation  of  the  acromial  end  of  the  clavicle.  This 
injur  J'  has  been  mistaken  for  dislocation  of  the  head 
of  the  humerus;    in  the  latter  injury  the  acromion 

process  stands  out  boldly,  while  in  fracture  the  shoulder  is  flattened  and  the 
process  is  not  prominent.  In  fracture  the  deformity  may  be  reduced  by 
pushing  the  head  of  the  humerus  upward,  but  the  deformity  recurs  when 
the  head  of  the  humerus  is  allowed  to  drop  downward. 

Treatment. — In  treating  this  fractirre  a  folded  towel  should  be  placed 
between  the  arm  and  the  chest ;  the  arm  should  be  placed  vertically  along 
the  side  of  the  chest,  and  the  forearm  should 
be  flexed  across  the  chest  and  secured  firmly 
by  the  application  of  a  Velpeau's  bandage. 
This  dressing  should  be  retained  for  four 
weeks ;  the  patient  should  then  be  allowed 
to  carry  the  arm  in  a  sling  for  several  weeks 
longer.  Union  in  this  fracture  is  usually 
fibrous,  but  in  spite  of  this  very  little  per- 
manent disability  i-esults. 

Fracture  of  the  Coracoid  Pro- 
cess.— This  fracture  is  extremely  rare,  and 
may  be  produced  by  direct  violence  or  by 
force  transmitted  through  the  head  of  the 
humerus  and  by  muscular  action.  (Fig.  349. ) 
Symptoms. — The  signs  of  this  injury  are  pain,  mobility,  and  crepitus. 
If  the  finger  be  pressed  firmly  upon  the  coracoid  process  and  the  humerus 
be  moved  upward  and  downward,  if  fracture  is  present  the  fragment  will  be 
found  to  follow  the  movements  of  the  arm,  and  not  those  of  the  scapula,  in 
consequence  of  its  connection  with  the  coraco-brachialis  and  biceps  muscles. 
Crepitus  may  also  be  felt  during  these  manipulations. 

Treatment. — This  consists  in  applying  a  folded  towel  in  the  axilla 
and  bringing  the  arm  against  the  side  of  the  body  in  the  Velpeau  position 


Fracture  of  the  coracoid  process  of  the 
scapula.    (Neill.) 


452 


FEACTURES  OF  THE   HUMERUS. 


Fig.  350. 


Fracture  of  the  neck  of  the  scapula. 
(Fergusson.) 


and  securing  it  by  a  Velpeau's  bandage.     This  dressing  should  be  retained 
for  four  or  five  weeks.     Union  after  this  fracture  is  fibrous. 

Fracture  of  the  Neck  and  Glenoid  Cavity  of  the  Scapula. — 
Fracture  of  the  anatomical  neck  of  the  scapula  is  a  rare  injury,  but  fracture 
of  the  surgical  neck  and  of  the  glenoid  cavity 
is  not  uncommon,  and  is  probably  often  asso- 
ciated with  dislocation  of  the  head  of  the 
humerus.     The  fracture  may  extend  to  the 
glenoid  cavity,  or  may  seiiarate  the  glenoid 
cavity  and  the  coracoid  process  from  the  body 
of  the  scapula,  or  may  simply  separate  the 
glenoid  cavity  from  the  scapula.     (Fig.  350.) 
Symptoms. — The  most  marked  symptom 
in  fracture  of  the  neck  of  the  scaj)ula  is  the 
loss  of  the  rotundity  of  the  shoulder,  with 
unusual  prominence  of  the  acromion  process. 
This  deformity  i-esults  from  the  sinking  down- 
ward of  the  head  of  the  humerus  and  from  the 
contraction  of  the  coraco-brachialis  and  the 
short  head  of  the  biceps  muscle.     Crepitus 
may  be  obtained  by  pushing  the  head  of  the 
humerus  upward. 
Treatm.ent. — Eeduction  is  easy  and  there  is  no  rigidity  as  in  dislocation 
of  the  head  of  the  humerus.     In  treating  this  fracture,  a  wedge-shaped  pad 
five  inches  long  and  three  inches  wide  should  be  placed  with  its  base  in  the 
axilla,  and  the  arm  fastened  against  the  side  of  the  body  by  the  apj)lication 
of  a  Velpeau's  bandage.     At  the  end  of  four  weeks  the  dressing  should  be 
permanently  removed,  and  passive  movements  made  to  restore  the  function 
of  the  shoulder -joint. 

Separation  of  the  Coracoid  Epiphyses  of  the  Scapula. — Separa- 
tion of  the  epiphyses  of  the  coracoid  either  of  that  forming  the  glenoid 
cavity  or  of  the  apex  of  the  bone  may  occur  in  subjects  under  seventeen 
years  of  age.  A  few  cases  have  been  recorded  which  resulted  from  violent 
crushing  force  applied  to  the  scapula. 

Symptoms. — These  are  pain,  mobility,  inability  to  raise  or  abduct  the 
arm,  and  soft  crepitus,  which  can  be  obtained  by  manipulation  over  the 
coracoid  process  or  by  placing  the  finger  on  this  process  and  moving  the 
shoulder -joint.  The  displacement  is  slight  if  the  glenoid  epiphysis  is  sepa- 
rated, owing  to  the  attachments  of  the  coraco-clavicular  and  coraco-acromial 
ligaments,  but  may  be  marked  if  the  epiphysis  at  the  apex  is  separated  from 
the  action  of  the  pectoralis  minor,  coraco-brachialis,  and  biceps  muscles. 

Treatment. — The  forearm  should  be  flexed  and  the  arm  bound  to  the 
body  in  the  Velpeau  position. 


FRACTURES   OF   THE   HUMERUS. 

Fractures  of  the  humerus  are  very  frequent  injuries,  constituting  about 
eight  per  cent,  of  all  fractures,  and  may  involve  the  upper  extremity,  the 
shaft,  or  the  lower  extremity  of  the  bone.     Fractures  of  the  upper  extremity 


FEACTUEES  OF  THE  HUMEEUS. 


453 


of  the  humerus  include  (1)  fracture  of  the  head  and  anatomical  neck  of  the 
bone,  (2)  fracture  through  the  tuberosities,  (3)  fracture  of  the  tuberosities, 
(4)  separation  of  the  upper  epiphysis,  and  (5 )  fracture  of  the  surgical  neck. 

Fracture  of  the  Head  and  Anatomical  Neck  of  the  Hu- 
merus.— This  fracture,  which  is  not  a  common  one,  consists  in  a  separation 
of  the  head  of  the  bone  from  the  tuberosities.  The  line  of  separation  is 
usually  in  the  slight  constriction  or  groove  which  separates  the  head  from  the 
tuberosities,  and  may  fall  within  the  boundary  of 
the  insertion  of  the  capsular  ligament,  but  is  seldom  Fic  351 

purely  intracapsular.  (Fig.  351.)  This  fracture 
appears  always  to  result  from  direct  violence,— that 
is,  heavy  falls  or  blows  upon  the  shoulder.  The 
separated  head  of  the  bone  may  remain  loose  within 
the  capsule  and  be  disjilaced  forward  or  backward 
from  the  shaft,  or  may  be  impacted  into  the  upper 
end  of  the  shaft,  or  may  be  reversed  so  that  the 
fractured  surface  presents  in  the  glenoid  cavity. 
The  usual  deformity  is  upward  displacement  of  the 
shaft  and  tuberosities  of  the  humerus.  Marked  dis- 
Ijlacement  of  the  separated  head  is  often  prevented, 
however,  by  the  capsule  and  the  tendons.  The 
appearance  presented  after  this  fracture,  if  much 
fixation  of  the  shoulder  exists,  is  very  similar  to 
that  after  dislocation  of  the  head  of  the  humerus. 
The  acromion  becomes  prominent  from  wasting  of 
the  deltoid  muscle  from  disuse,  but  the  humerus 

occupies  a  position  in  relation  to  the  chest  which  is  not  possible  in  any  form 
of  dislocation  of  the  head  of  the  bone.  Union  in  fractures  of  the  anatomical 
neck  of  the  bone  may  be  unsatisfactory,  and  the  head  of  the  bone  may  become 
atrophied  and  remain  ununited. 

Symptoms. — These  are  laain  in  the  joint,  loss  of  motion,  and  indistinct 
crepitus.  If  the  shaft  of  the  bone  be  drawn  inward  by  the  action  of  the 
pectoralis  major,  latissimus  dorsi,  and  teres  major  muscles,  the  upper  end 
of  the  lower  fragment  may  be  felt,  provided  there  is  not  too  much  swelling. 
In  impacted  fracture  of  the  anatomical  neck  of  the  humerus,  the  shoulder 
becomes  somewhat  broadened,  the  tuberosities  with  the  upper  portion  of 
the  shaft  of  the  bone  are  carried  upward  and  somewhat  outward,  the  acromion 
process  becomes  less  j)rominent,  and  the  arm  shortened. 

Diagnosis. — This  injury  is  most  likely  to  be  confounded  with  dislocation 
of  the  shoulder-joint  or  separation  of  the  upper  epiphysis  of  the  humerus. 
In  this  fracture  the  acromion  process  is  less  prominent,  there  is  no  rigidity  of 
the  shoulder-joint,  and  crepitus  may  be  obtained  in  some  cases,  while  in 
dislocation  there  is  marked  flattening  of  the  shoulder  with  prominence  of 
the  acromion  process,  and  the  motion  of  the  shoulder-joint  is  much  restricted. 
From  separation  of  the  upper  epiphysis  the  diagnosis  is  made  by  observing 
that  there  is  absence  of  the  characteristic  deformity,  and  the  age  of  the 
patient  will  also  assist  in  the  diagnosis,  for  these  fractures  are  very  rare  in 
subjects  under  twenty-five  years  of  age. 


riacture  of  the  anatomical  neck 
of  the  humerus 


454  FRACTURES   OF  THE   HUMERUS. 

Prognosis. — The  surgeon  should  always  give  a  guarded  prognosis  as 
regards  the  restoration  of  function  in  cases  of  fracture  of  the  head  and  ana- 
tomical neck  of  the  humerus.  If  the  fracture  passes  entirely  through  the 
anatomical  neck  of  the  bone,  separating  the  head  from  all  connections  with 
the  lower  fragment,  union  is  not  likely  to  take  place.  The  head  may  lie 
loosely  in  the  joint,  and  become  wasted  as  it  is  deprived  of  its  blood-supply. 
When  the  separation  is  not  complete  and  some  fibres  of  the  capsular  liga- 
ment serve  as  a  bond,  union  is  possible,  as  also  in  cases  of  impacted  fracture 
or  in  those  which  are  i^artly  within  and  partly  without  the  capsule. 

Treatment. — The  administration  of  an  anaesthetic,  both  for  the  pur- 
pose of  accurate  diagnosis  and  for  reduction  of  the  disi^lacement,  is  a  very 
essential  point  before  any  dressing  is  applied  for  the  treatment  of  these  frac- 
tures. While  the  patient  is  under  the  influence  of  the  anaesthetic  the  surgeon 
should  attempt,  by  manipulation,  to  reduce  as  far  as  possible  the  deformity. 
If  the  head  of  the  bone  is  driven  forward  or  backward,  by  making  extension 
upon  the  arm  and  pressure  upon  the  displaced  head  with  the  fingers  it  may 
be  forced  into  its  normal  position.  The  dressing  is  similar  to  that  described 
for  fracture  of  the  surgical  neck  of  the  humerus,  page  457.  • 

Compound  Fracture  of  the  Anatomical  Neck  of  the  Hume- 
rus.— This  constitutes  a  most  grave  injury,  and  one  in  which  it  is  often 
advisable  to  enlarge  the  wound  and  remove  the  separated  head  of  the  bone. 
We  are  strongly  of  the  opinion  that  the  functional  result  is  much  more 
satisfactory  where  the  head  of  the  bone  is  removed,  even  though  it  may  be 
possible  for  recovery  to  take  place  without  such  a  procedure.  Indeed,  we 
believe  that  if  all  simple  fractures  of  the  anatomical  neck  of  the  humerus 
were  treated  by  incision  and  removal  of  the  separated  head  of  the  bone, 
the  functional  result  would  be  much  more  satisfactory  than  is  the  case 
where  more  conservative  methods  of  treatment  are  employed. 

Complications. — One  of  the  most  serious  complications  occurring  in 
fracture  of  the  anatomical  neck  of  the  humerus  is  the  disijlacemeut  of  the 
head  of  the  bone  through  the  rent  in  the  capsular  ligament.  Various  pro- 
cedures have  been  recommended  to  return  the  displaced  head  of  the  bone  to 
its  normal  position,  such  as  manipulation,  incision,  and  the  introduction  of 
a  screw  elevator  into  the  displaced  head  to  force  it  back  to  its  normal  posi- 
tion. If  it  cannot  be  replaced  by  manipulation,  it  should  be  freely  exposed 
by  incision,  reduced  and  fixed  by  a  pin  or  screw,  or  removed. 

Fracture  through  the  Tuberosities  of  the  Humerus.— This 

fracture  is  probably  much  more  common  than  that  of  the  anatouiical  neck  of 
the  bone,  but  may  exist  in  conjunction  with  the  latter,  the  lines  of  fracture 
passing  from  the  neck  of  the  bone  through  the  tuberosities.  The  lesion 
results  from  violence  applied  to  the  upjjer  end  of  the  front  or  outer  portion 
of  the  humerus.  There  is  also  more  displacement  of  the  upi^er  fragment 
than  in  cases  of  fracture  lower  down  in  the  shaft,  and  this  may  be  con- 
founded with  a  separation  of  the  upper  epiphysis.  In  the  repair  of  this 
injury  a  large  amount  of  callus  is  usually  formed  which  may  materially 
restrict  the  motions  of  the  joint.  The  treatment  is  similar  to  that  employed 
in  fractures  of  the  anatomical  neck  of  the  humerus.  Early  passive  motion 
should  be  practised. 


SEPARATION  OF  THE  TJPPEE  EPIPHYSIS  OF  THE  PIUMEEUS.       455 


Fractures  of  the  Tuberosities  of  the  Humerus. — These  are 
rare  iojuries.  Fracture  of  the  greater  tuberosity  is  occasioually  seeu  as  the 
result  of  force  directly  applied,  or  may  occur  iu  conuectiou  with  the  anterior 
dislocation  of  the  head  of  the  bone.  The  lesser  tuberosity  of  the  humerus 
is  seldom  fractured  ;  the  few  cases  that  have  been  reported  have  occurred  in 
connection  with  the  upward  dislocation  of  the  head  of  the  bone. 

Symptoms. — "When  the  greater  tuberosity  is  separated  it  will  be  drawn 
backward  by  the  action  of  the  suijraspinatus,  infrasj)inatus,  and  teres  minor 
muscles,  while  the  shaft  of  the  humerus  will  be  carried  inward  by  the  sub- 
scapularis  and  forward  by  the  pectoralis  major  muscle  ;  the  articulation  will 
be  increased  in  breadth,  and,  if  the  swelling  is  not  too  great,  both  the  head 
of  the  bone  and  the  tuberosity  may  be  felt ;  there  will  be  loss  of  voluntary 
outward  rotation,  and  upon  manij)ulation  pain  and  crepitus. 

Treatmient. — The  dressing  employed  in  fracture  of  the  greater  tuberos- 
ity of  the  humerus,  if  there  is  marked  displacement  of  the  fragment,  consists 
in  holding  the  arm  in  an  abducted  position  by  a  triangular  pad  in  the  axilla. 
If,  on  the  other  hand,  the  displacement  is  slight,  a  dressing  similar  to  that 
employed  iu  fracture  of  the  surgical  neck  of  the  humerus  may  be  used.  In 
this  fracture  union  is  fibrous. 

Separation  of  the  Upper  Epiphysis  of  the  Humerus. — This  injury, 
which  is  not  uncommon  in  children,  has  most  frecxuently  been  observed 

between  the  tenth  and  seventeenth  years, 
and  cannot  occur  after  twenty  years  of 


Fig.  353. 


Fig.  352. 


Deformity  in  sepanitif 

of  tlie  rjg-ht  111] 


upper  epiphysis 


skiigrai  h  of  ser  ii  Uion  of  the  upper  epiphysis 
of  the  humerus.     (By  Professor  Goodspeed.) 


age,  at  which  time  bony  union  of  the  epiphysis  has  occurred.  Separation 
of  the  upper  epiphysis  of  the  humerus  does  not  necessarily  open  the  shoulder- 
joint.  It  usually  results  from  falls  upon  the  shoulder,  or  from  force  trans- 
mitted through  the  arm,  or  from  tractiou  upon  the  arm.  It  may  be  complete 
or  incomx^lete,  and  in  the  latter  class  of  cases  there  will  be  very  little  deform- 
ity, and  even  in  complete  seijarations  it  may  not  be  present. 

Symptoms. — These  are  pain,  mobility,  creiiitus,  and  loss  of  function. 
In  infants  separation  of  the  cartilaginous  head  of  the  humerus  may  present 


456       SEPAEATION  OF  THE  UPPER  EPIPHYSIS   OF  THE  HUMERUS. 


uo  symptoms  other  than  pain  and  tenderness  over  the  site  of  the  epiphysis 
on  motion  or  pressure,  and  deformity  is  not  usually  observed.  There  may 
be  very  little  deformity  if  a  portion  of  the  periosteum  remains  untoru  ;  in  a 
large  proportion  of  cases,  however,  a  wedge-shaped  prominence  can  be  felt 
(Pig.  352)  immediately  external  to  the  coracoid  process  of  the  scapula  in 
front  of  the  shoulder,  which  moves  with  motions  of  the  shaft  of  the  bone, 
and  is  the  iipper  end  of  the  lower  fragment.  The  deltoid  muscle  is  tense, 
and  the  head  of  the  bone  can  be  felt  to  occupy  its  normal  position.  The 
deformity  is  shown  in  Pig.  353.  To  obtain  crepitus  it  is  necessary  to  make 
extension  upon  the  arm  and  to  push  the  shaft  of  the  humerus  backward 
and  then  rotate  it  gently.  The  crepitus  in  this  injury  is  softer  and  less 
distinct  than  that  which  is  elicited  in  fracture. 

Treatment. — An  anesthetic  should  be  given,  and  manipulation  should 
be  practised  to  bring  the  separated  surfaces  of  the  bone  in  contact.  As  the 
upper  fragment  is  usually  rotated  outward  and  backward,  this  is  often  diffi- 
cult. It  may  be  accomplished  by  pushing  the  end  of  the  lower  fragment 
backward  and  inward  to  bring  it  in  contact  with  the  upper  fragment,  or  by 
carrying  the  arm  upward  and  backward,  pressing  the  eiid  of  the  shaft 
against  the  fragment  and  then  bringing  it  downward.  In  spite  of  the 
complete  reduction  of  the  deformity  at  the  time  of  the  dressing,  it  is  very 
usual  to  have  the  shaft  of  the  bone  drawn  forward  and  upward  by  the  action 
of  the  deltoid,  pectoralis  major  and  minor  muscles.      If  the  deformity  is 

slight  or  can  be  reduced  by  manipu- 
lation and  does  not  recur,  the  dressing 


Fig.  355. 


Fig.  354. 


Skiagraph  of  case  shown  in  Fig.  352,  one  year 
after  the  injury.    (By  Professor  Goodspeed.) 


Fracture  of  the  surgical  neck  of  the 
humerus. 


is  similar  to  that  employed  in  fractures  of  the  surgical  neck  of  the  humerus 
(page  457.)  In  some  cases  the  application  of  a  comjjress  may  be  required 
in  addition  to  retain  the  fragments  in  position  after  reduction  ;  and  in  others 
satisfactory  coaptation  of  the  fragments  can  only  be  obtained  by  placing 
and  fixing  the  arm  in  such  a  position  that  the  lower  fragment  is  brought  in 
contact  with  the  upper  one.     If  it  be  found  impossible  to  retain  the  frag- 


FEACTUEE  OF  THE  SUEGICAL  NECK   OF  THE  HUMEEUS. 


457 


ments  in  position,  incision  and  fixation  by  nails  or  screws  may  be  employed. 
The  skiagraph  (Fig.  354)  shows  the  condition  of  the  bone  in  the  case  of 
epiphyseal  separation  (Fig.  352)  one  year  after  the  injury.  In  this  case 
the  restoration  of  function  of  the  shoulder -joint  was  almost  perfect. 

Fracture  of  the  Surgical  Neck  of  the  Humerus.— This  frac- 
ture may  involve  any  portion  of  the  shaft  of  the  bone  below  the  line  of  the 
upper  epiphysis  in  the  uj)per  fourth  (Fig.  355),  and  is  usually  produced  by 
direct  violence  received  when  the  arm  is  near  the  chest ;  the  dii-ection  of 
the  fracture  may  be  transverse  or  oblique  and  the  lower  fi-agment  may  be 
impacted  in  the  upper  one.     It  is  a  very  common  fracture  in  adults. 

Symptoms. — The  most  marked  signs  of  this  fracture  are  loss  of  function 
in  the  arm,  pain,  shortening,  which  is  most  marked  if  the  fracture  is  oblique, 
preternatural  mobility,  and  crepitus  ;  the  latter  symptom  may  be  elicited  by 
making  traction  upon  the  arm  and  rotating  it.  If  the  lower  fragment  be 
impacted  in  the  upper  fragment,  shortening  to  the  extent  of  an  inch  may 
exist,  but  crepitus  cannot  be  obtained.  The  nerves  and  blood-vessels  are 
rarely  injured  in  this  fracture. 

Deformity. — The  displacement  in  this  fracture  is  largely  confined  to  the 
lower  fragment,  which  is  drawn  inward  by  the  pectoralis  major,  latissimus 
dorsi,  and  teres  major  muscles.     The  upward  displacement  is  produced  by 

the  clavicular  fibres  of  the  pectoralis  major 

Fig.  357. 


Displacement  in  fracture  of  tfie  surgical  ShouMer-cap, 

neck  of  the  humerus,  posterior  view.    (Ag- 
new.) 

and  the  coraco-brachialis  and  biceps  and  triceps  muscles.  The  upper  frag- 
ment is  usually  rotated  upward  and  outward,  but  is  occasionally  rotated 
inward.     (Fig.  356.) 

Prognosis. — The  functional  results  following  this  fracture  are  usually 
very  satisfactory  ;  although  some  deformity  may  exist,  examples  of  non-union 
are  very  rare. 

Treatment. — After  reducing  the  deformity  by  extension  and  mauiprda- 
tion,  the  treatment  of  this  fracture,  as  well  as  of  fracture  of  the  anatomical 
neck  or  the  greater  tuberosity,  and  separation  of  the  upper  epiphysis  of  the 
humerus,  consists  in  the  application  of  a  primary  roller  from  the  fingers  to  the 
shoulder,  and  a  well-padded  felt  or  binder' s  board  or  plaster-of-Paris  shoulder- 
cap  (Fig.  357),  extending  from  the  acromion  process  to  the  lower  third  of  the 


458 


FRACTURE  OF  THE  SHAFT  OF  THE  HUMERUS. 


humerus  and  envelopiug  about  one-iialf  of  the  circumference  of  the  arm  (Fig. 
358),  which  should  be  held  in  position  by  the  turns  of  a  roller  bandage,  and 
finished  with  sjjica  turns  of   the  shoulder. 
A  folded   towel   should   next  be  placed  in  Fig.  3.59. 

Fig.  3.58. 


Application  of  primary  roller  and  shoulder-cap. 


Dressing  for  fractures  of  the  upper  por- 
tion of  the  humerus. 


the  axilla  and  between  the  arm  and  the  side  of  the  chest ;  the  arm  should 
then  be  brought  against  the  chest  and  secured  in  contact  with  it  by  circular 
turns  of  a  bandage  ;  the  forearm  should  next  be  supported  at  the  wrist  in  a 
sling  from  the  neck,  so  that  the  weight  of  the  arm  and  forearm  may  act  as 
an  extending  force  from  the  elbow.  (Fig.  359.)  When  marked  shortening- 
is  present  weight  extension  may  be  made  from 
the  elbow.  This  dressing  should  be  renewed  at 
intervals  of  two  or  three  days,  and  should  be  re- 
tained for  five  or  six  weeks.  After  the  third  week 
gentle  passive  motion  should  be  made  at  each  dress- 
ing, to  produce  movement  at  the  shoulder-joint. 

Fracture  of  the  Shaft  of  the  Humerus. 

— This  fracture  may  take  place  at  any  point  between 
the  surgical  neck  and  the  condyles  of  the  bone. 
The  direction  of  fracture  is  generally  oblique.  In 
children,  transverse  and  incomplete  fractures  may 
occur.  It  usually  results  fi-om  direct  violence,  but 
numerous  cases  are  recorded  in  which  it  was  due 
to  muscular  action.  Spiral  fractures  of  the  humerus 
occasionally  occur,  involving  a  large  extent  of  the 
shaft,  and  are  produced  by  forcible  twisting  of  the 
bone. 

Symptoms. — These  are  deformity,  mobility, 
and  crepitus.  In  fractures  below  the  insertion  of 
the  deltoid,  the  upper  fragment  may  be  little 
changed  in  its  position,  as  the  deltoid  on  the  one 
side  and  the  jpectoralis  major,  latissimus  dorsi,  and 
teres  major  on  the  other  antagonize  one  another  ;  the  lower  fragment  may 
be  drawn  upward  and  inward  by  the  biceps  and  triceps  muscles.    In  oblique 


Fracture  of  the  lower  third  of  the 
humerus.    (Agnew.) 


FRACTUEE  OF  THE  SHAFT  OF  THE  HUMERUS. 


459 


fractures  in  the  lower  third  of  the  bone,  the  lower  fragment  is  likely  to  slip 
behind  the  upper  one,  and  in  this  case  the  shortening  is  very  marked,  by 
reason  of  the  contraction  of  the  biceps  and  triceps  muscles.     (Fig.  360.) 

Prognosis. — In  simple  fractures  the  results  are  usually  satisfactory  ; 
ununited  fractures  of  the  shaft  of  the  humerus,  however,  are  not  uncommon. 
In  these  cases  the  failure  of  union  often  results  from  the  interposition  of 
muscular  tissue  or  fascia  between  the  ends  of  the  bone  or  from  imperfect 
immobilization  of  the  fragments.  These  fractures  are  also  sometimes  com- 
plicated by  paralysis  from  injury  of  the  nerves  of  the  arm  at  the  time  of  the 
accident  or  from  involvement  of  the  musculo-.spiral  nerve  in  the  callus 
thrown  out  in  the  repair  of  the  fracture.  Gangrene  has  followed  fracture 
of  the  shaft  of  the  humerus  from  pressure  of  the  fragment  upon  the  brachial 
artery  and  vein.  In  many  cases  a  certain  amount  of  deformity  or  over- 
lapping of  the  bones  results  in  spite 
of  the  most  careful  treatment,  but 
this  does  not  affect  the  subsequent 
strength  and  usefulness  of  the  arm. 

Treatment. — This  consists,  first, 
in  making  extension  and  manipula- 
tion to  reduce  the  deformity  ;  a  pri- 
mary roller  should  then  be  applied  to 
the  arm  from  the  tips  of  the  tingers 
to  the  axilla  ;  a  well-padded  internal 
angular  splint  (Fig.  361)  applied  to 

the  inner  surface  of  the  arm,  extending  from  the  tips  of  the  fingers  to  the 
axilla,  and  a  well-padded  shoulder-cap  of  binder's  board  or  leather,  extend- 

FiG.  362. 


Fig.  361. 


ing  from  above  the  acromion  to  a  point  just  above  the  condyles,  should  next 
be  fitted  upon  the  outer  surface  of  the  arm  (Fig.  362),  and  secured  by  a 
bandage  carried  from  the  hand  to  the  shoulder.  (Fig.  363.)  The  arm  should 
then  be  carried  in  a  sling  suspended  from  the  neck.  Another  very  satisfac- 
tory dressing  for  fi-acture  of  the  shaft  of  the  humerus  consists  in  the  appli- 
cation of  a  i^rimary  roller,  as  described,  and  a  short,  well-padded  splint, 


460 


FRACTURE  OF  THE  SHAFT  OF  THE  HUMERUS. 


extending  from  the  axilla  to  the  inner  condyle ;  three  narrow  coaptation 

splints,  extending  from  the  shoulder  to  the  elbow,  are  next  applied  to  the 

anterior,  outer,  and  posterior  surfaces  of  the  ai'm, 

being  held  in  position  by  a  roller  bandage.     After  ^^'^-  ^^'^■ 

the  splints  have  been  securely  fixed,  the  arm  should 

be  bound  to  the  side  of  the  chest  by  circular  turns 

of  the  bandage,  and  the  forearm  carried  in  a  sling 

suspended  from  the  neck.     In  the  employment  of 

Fig.  363. 


Dressing  for  fracture  of  the  shaft  of  the  humerus. 


Weight  extension  in  fracture  of 
tlie  humerus. 

either  of  these  methods,  the  dressings  should  be  removed  on  the  second  day, 
the  arm  sj)onged  with  alcohol,  and  the  splints  reapplied  in  the  same  manner. 
The  subsequent  di-essings  should  be  made  at  intervals  of  two  or  three  days, 
and  the  use  of  the  splints  continued  for  about  six  weeks.  During  the  changing 
of  dressings  the  patient  will  be  saved  much  pain  and  the  deformity  will  be 
lessened  if  an  assistant  keeps  up  extension  of  the  arm  from  the  elbow. 

If  there  is  great  overlapping  of  the  fragments,  producing  marked  short- 
ening, the  patient  should  be  put  to  bed  with  the  elbow  flexed,  and  weight 
or  elastic  extension  should  be  made  by  adhesive  straps  applied  to  the  arm, 
short  coaptation  splints  being  applied  to  the  arm  at  the  same  time.  If  the 
patient  is  treated  as  a  walking  case,  the  same  result  can  be  accomplished 
with  a  bag  of  shot  or  similar  weight  fastened  to  the  arm  so  as  to  hang  below 
the  elbow.  (Fig.  364.")  Plaster  of  Paris  may  be  employed,  the  dressing- 
being  api^lied  while  extension  is  made,  and  the  bandages  taking  in  the 
entire  upper  extremity,  shoulder,  and  upper  part  of  chest.  Stromeyer's 
cushion  is  also  sometimes  useful  in  maintaining  the  correction  of  the 
deformity.  Finally,  for  persistent  deformity,  not  to  be  overcome  by  other 
means,  it  will  be  justifiable  to  cut  down  on  the  fracture  and  accurately  fix 
the  fragments  by  silver  wire  sutures,  or  silver  splints  secured  to  the  bone 
by  screws. 


STJPRACONDYLOID  FRACTURE  OF  THE   HUMERUS. 


461 


Fig.  365. 


FRACTURES  OF  THE  LOWER  EXTREMITY  OF  THE  HUMERUS. 

No  fractures  which  come  under  the  care  of  the  surgeon  are  accompanied 
by  more  anxiety  as  to  the  functional  results  than  those  involving  the  con- 
dyles of  the  humerus,  for  in  many  cases,  in  spite  of  the  most  judicious 
treatment,  a  certain  amount  of  impairment  of  the  motion  of  the  elbow-joint 
or  change  in  the  relation  of  the  forearm  to  the 
arm,  producing  a  change  in  the  carrying  angle, 
or  gunstock  deformity,  is  apt  to  follow.  (Fig. 
365.)  The  unfavorable  results  in  these  cases 
cannot  be  attributed  to  a  lack  of  care  on  the 
part  of  the  surgeon,  but  are  rather  due  to  the 
character  of  the  fracture  itself.  The  displaced 
condyle  may  be  in  such  a  position  that  it  is 
impossible  to  reduce  it  completely,  and  it  may 
interfere  with  the  flexion  or  extension  of  the 
arm,  or  disturb  the  relation  of  the  bones  of  the 
forearm  to  the  arm,  or  the  callus  thrown  out 
in  the  repair  of  the  fracture  may  prevent  the 
motions  of  flexion  and  extension  being  satis- 
factorily accomplished.  Fractures  of  the  con- 
dyles of  the  humerus  are  more  apt  to  involve 
the  medical  attendant  in  medico-legal  difficul- 
ties than  any  other  fractures.  In  all  cases  of 
fracture  involving  the  lower  extremity  of  the 
humerus,  we  consider  it  essential  that  the  pa- 
tient be  placed  under  the  influence  of  an  anesthetic  and  carefully  examined, 
so  that  the  surgeon  may  have  the  fullest  opportunity  to  locate  definitely  the 
nature  and  extent  of  the  fracture,  to  reduce  the  deformity,  and  to  apply  the 
dressing  proper  for  the  special  fracture. 

The  principal  fractures  involving  the  lower  end  of  the  humerus  are 
supracondyloid  fracture,  T-fracture  of  the  condyles,  fracture  of  the  articu- 
lar process,  fracture  of  the  internal  condyle,  fracture  of  the  external  con- 
dyle, fracture  of  the  internal  and  external  epicondyle,  and  separation  of  the 
lower  epiphysis  of  the  humerus. 

Supracondyloid  Fracture.— This  consists  in  a  fracture  through 
the  lower  extremity  of  the  humerus  just  above  the  limits  of  the  expanded 
condyles  up  to  the  upper  limit  of  the  attachment  of  the  supinator  longus 
muscle.  (Fig.  366,  A, A.)  The  fi-acture  just  above  the  condyles  may  be 
oblique  or  transverse,  but  is  usually  more  or  less  oblique.  (Fig.  367.) 
Supracondyloid  fractures  result  from  force  applied  directly  to  the  elbow 
or  transmitted  through  the  bones  of  the  forearm. 

Symptoms. — These  are  shortening  of  the  arm,  crepitus,  and  deformity. 
Upon  careful  examination  of  the  region  of  the  elbow  a  projection  will 
usually  be  discovered  in  front  of  the  elbow,  which  is  caused  by  the  lower 
end  of  the  upper  fragment.  A  posterior  prominence  may  also  be  felt,  which 
is  due  to  the  upper  end  of  the  lower  fragment.  The  deformity  in  this  frac- 
ture so  closely  resembles  a  backward  dislocation  of  the  bones  of  the  forearm 


Deformity  following  fracture  of  the  con- 
dyle of  the  left  humerus. 


462 


SUPRACONDYLOID  FEACTUEE   OF  THE  HUMEEUS. 


at  the  elbow  that  a  careful  examination  has  to  be  made  before  the  variety 
of  injury  can  be  determined.  In  cases  of  supracondyloul  fracture  there  is 
shortening  of  the  arm  ;  the  condyles  of  the  humerus  and  the  olecranon  pro- 
cess are  in  tlie  same  line  ;  the  end  of  the  upper  fragment  is  above  the  bend 

Fig.  .366. 


A.  A,  supracondYloid  fracture  1  i  B,  B,  T-fracture ;  C,  C,  fracture  of  articular  process ;  Z>,  X>,  frac- 
ture of  internal  condyle  E,  E  fracture  of  external  condyle ;  F,  F,  fracture  of  external  epicondyle ;  G,  6, 
fracture  of  internal  epicond^  ie,  M  H  separation  of  lower  epiphysis  of  humerus. 

of  the  elbow ;  the  forearm  is  movable,  and  there  will  be  crepitus  ;  reduc- 
tion is  easily  effected  by  extension  and  counterextension,  but  the  deformity 
reappears  with  the  withdrawal  of  this  force.  In  jjosterior  dislocation  there  is 
no  shortening  of  the  arm  ;  the  relation  between  the  olecranon  process  and 
the  condyles  is  changed,  the  olecranon  being  behind  the  condyles  ;  there  is 
no  crepitus,  and  the  broad  end  of  the  humerus  may  be  felt  above  the  bend  of 
the  elbow.  There  is  also  more  or  less  rigidity  at  the  elbow,  and  the  deformity 
when  once  reduced  does  not  tend  to  recur. 

Treatment. — This  consists,  first,  in  making  extension  and  counter- 
extension,  and  in  using  manipulation  to  bring  the  lower  end  of  the  bone 


Fig.  36 


skiagraph  of  supracondyloid  fracture  of  the  humerus. 

into  position.  The  forearm  is  next  placed  at  an  obtuse  angle,  or  at  an  angle 
of  less  than  ninety  degrees,  with  the  arm,  the  angle  depending  upon  the 
amount  of  deformity  resulting  from  greater  or  less  flexion  of  the  lower 


SUPRACONDYLOID  FRACTURE   OF  THE  HUMERUS. 


463 


Fig.  368. 


fragment,  and  is  covered  by  a  primary  roller  from  the  fingers  to  the  axilla. 
A  well-padded  anterior  angular  splint  (Fig.  368)  is  next  placed  npon  the 
anterior  surface  of  the  arm  and  fore- 
arm (Fig.  369),  and  is  secured  in 
position  by  ascending  turns  of  a 
roller  bandage.  (Fig.  370.)  For 
additional  fixation  a  posterior  rec- 
tangular gutter  of  binder's  board 
or  leather  may  be  fitted  to  the  pos- 
terior surface  of  the  arm.  The 
dressing  should  be  removed  at  the 

end  of  twenty-four  hours,  as  more  or  less  swelling  is  apt  to  occur  in  the 
region  of  the  elbow-joint,  and  the  same  dressing  may  be  reapplied,  and 

Fig.  369. 


I'riiiiary  roller  unci  splint  applied. 

after  this  period  may  be  changed  at  intervals  of  two  or  three  days  until 
four  or  five  weeks  have  expired,  at  the  end  of  which  time  the  dressings  may 

Fig.  370. 


Dressing  for  fractures  of  the  lower  end  of  the  humerus. 

be  permanently  removed.  For  the  first  week  frequent  inspection  of  the  seat 
of  fracture-  is  desirable  to  prevent  deformity.  After  three  weeks  passive 
motion  should  be  carefully  made,  the  arm  being  fixed  at  the  seat  of  fracture, 
while  the  forearm  is  flexed,  extended,  prouated,  and  supinated.  This  frac- 
ture may  also  be  dressed  by  fixing  the  arm  in  the  position  described  above, 
and  afterwards  padding  the  region  of  the  elbow-joint  with  cotton  and 


464  FRACTURES  OF  THE  CONDYLES  OF  THE  HUMERUS. 

applying  a  plaster-of-Paris  bandage  extending  from  the  fingers  to  the  axilla. 
This  dressing  should  be  removed  in  two  weeks,  and  a  fresh  bandage  applied, 
to  be  worn  for  two  or  three  weeks  longer. 

Condyloid  Fractures  of  the  Humerus.— Fractures  involving  the 
condyles  of  the  humerus  may  separate  either  the  external  or  the  internal 
condyle,  or  a  transverse  fracture  may  occur  through  the  condyles  while 
a  vertical  fracture  separates  them  from  each  other ;  this  is  known  as  a 
T-fracture,  or  there  may  be  a  fracture  of  the  articular  process,  which  sepa- 
rates the  articular  process  of  the  humerus,  with  a  portion  of  the  condyles, 
from  the  shaft  of  the  bone.  Fractures  of  the  condyles  of  the  humerus  may 
involve  the  epicondyle,  in  which  case  the  articulation  is  not  implicated,  or 
may  involve  the  external  or  internal  condyles  and  communicate  with  the 
elbow-joint.  Fractures  of  the  condyles  are  very  common  in  children,  but 
rather  infrequent  in  adults.  Tbey  result  from  falls  or  blows  in  which  the 
force  is  applied  to  the  side  or  the  point  of  the  elbow  or  is  transmitted 
through  the  bones  of  the  forearm. 

Prognosis. — In  all  fractures  involving  the  condyles  there  is  apt  to  be 
more  or  less  stiffness  or  loss  of  motion  at  the  elbow-joint,  either  from  dis- 
placement of  the  fragments  or  from  the  peculiar  disposition  of  the  callus 
resulting  from  the  repair  of  the  fracture. 

T-Fracture  of  the  Condyles  of  the  Humerus.— This  fracture 
consists  in  a  transverse  separation  of  the  humerus  through  the  condyles, 
with  a  vertical  fracture  extending  into  the  articulation.  (Fig.  366,  A,  A, 
B,  B.)  This  results  from  force  applied  to  the  back  of  the  elbow  while  the 
arm  is  flexed,  driving  the  olecranon  forward  against  the  condyles. 

Symptoms. — The  most  marked  symptoms  of  this  fracture  are  increased 
breadth  of  the  elbow  in  consequence  of  the  separation  of  the  condyles, 
crepitus  elicited  when  the  condyles  are  moved  either  backward  or  forward 
or  when  they  are  forced  together,  and  mobility  when  the  condyles  are 
pressed  in  opposite  directions. 

Fracture  of  the  Articular  Process  of  the  Humerus.— This 
consists  in  a  fracture  passing  in  a  more  or  less  transverse  direction  through 
the  condyles  of  the  humerus  and  separating  the  articular  surface  of  the  bone 
with  a  portion  of  the  condyles  from  the  shaft  of  the  bone.  (Fig.  366,  C,  C.) 
The  injury  is  likely  to  be  confounded  with  separation  of  the  lower  epiphysis 
of  the  humerus,  and  in  some  cases  it  is  difficult  to  differentiate  the  injuries. 


Guribtock  def^l^mlt^  after  fiacture  ni  the  internal  cuinh  le  oi  the  humerus 


Fracture  of  the  Internal  Condyle  of  the  Humerus. — Here  the 

line  of  fracture  is  oblique  to  the  longitudinal  axis  of  the  bone,  and  usually 
involves  the  joint  to  a  greater  or  less  extent.     (Fig.  366,  D,  D.) 


FRACTTJEE  OF  THE  EXTERJs'AL  CONDYLE  OF  THE  HUJIEEI'S.     465 

S5maptoins. — These  are  pain  and  rapid  swelling,  and  upon  extension 
the  forearm  is  inclined  inward,  causing  the  deformib,"  which  is  known  as 
••guustock  deformity"  (Fig  371),  resulting  fi-om  the  internal  condyle  being 
displaced  upward  ;  the  cari-ying  angle  of  the  arm  is  lost  if  the  internal 
condyle  is  displaced  one-fourth  of  an  inch  upward.  By  grasping  the 
internal  condyle  between  the  thumb  and  the  fingers  crepitus  may  be 
elicited,  and  preternatural  mobility  may  be  felt  if  the  humerus  and  forearm 
are  moved  laterally. 

Fracture  of  the  External  Condyle. of  tlie  Humerus.— In  this 
fracture  the  line  of  separation  is  usually  oblique,  and  includes  the  articular 
surface  of  the  hiinierus.     (Fig-  366,  E,  E.) 

Syraptoms. — These  are  pain,  swelling,  deformity,  crepitus,  and  mo- 
bility. When  the  arm  is  extended  it  inclines  to  the  ulnar  side.  Deformity 
in  this  fracture  results  from  downward  or  upward  displacement  of  the 
external  condyle,  the  latter  exaggerating  the  carrying  angle  of  the  arm. 

Diagnosis. — Fractm-es  of  the  condyles  of  the  humerus  are  often  con- 
founded with  dislocations  at  the  elbow,  but  if  the  surgeon  beai-s  in  mind  the 
facts  that  in  dislocations  the  epicondyloid  eminences  are  in  line,  whereas 
in  fractures  one  is  higher  or  lower  than  the  other,  that  crepitus  can  be 
obtained  in  fractures  and  is  not  present  in  dislocations,  and  that  the  forearm 
is  flexed  upon  the  arm  in  posterior  dislocation,  whereas  it  may  be  extended 
in  fractures  of  the  condyles,  little  difficulty  in  diagnosis  will  be  experienced. 

Prognosis. — In  fractures  of  the  condyles  a  guarded  prognosis  should 
always  be  given,  for,  in  spite  of  the  most  carefiil  treatment,  more  or  less 
stiffness  and  restriction  of  the  motions  of  the  elbow-joint,  with  deformity, 
may  result. 

Fracture  of  the  Internal  Epicondyle.— Separation  of  the  internal 
epicondyle  is  not  an  uncommon  accident,  and  results  from  force  directly 
applied  or  from  muscular  action.  In  children  separation  of  the  internal 
epicondyle  with  its  epiphysis  is  by  no  means  a  rare  accident.  As  the  line  of 
fracture  is  within  the  attachment  of  the  capsular  ligament,  it  is  not  unusual 
to  have  more  or  less  hemorrhage  into  the  elbow -joint.     (Fig.  366,  (?,  G.) 

Symptoms. — The  most  marked  symptoms  of  fracture  of  the  epicondyle 
are  pain,  swelling,  mobility,  and  crepitus.  The  displacement,  as  a  rule,  is 
a  little  downward  and  forward,  due  to  the  action  of  the  pronator  and  flexor 
muscles.  The  ulnar  nerve,  from  its  close  relation  to  this  prominence,  is 
occasionally  injured  in  this  fracture,  which  is  shown  by  disordered  sensi- 
bility in  the  parts  to  which  it  is  distributed,  especially  paralysis  of  the 
interossei  muscles.  This  fracture  is  not  so  liable  to  be  followed  by  stiflEness 
of  the  articulation  as  are  fractures  involving  either  the  external  or  the 
internal  condyle. 

Treatment  of  Fractiires  of  the  Lower  Extremity  of  the  Hume- 
rus.— Some  diversity  of  opinion  exists  among  surgeons  as  to  the  advisa- 
bility of  treating  these  fractui-es  in  the  extended  or  in  the  flexed  position. 
Tliere  is  no  doubt  that  the  deformity  can  best  be  reduced  and  the  reduc- 
tion maintained  by  keeping  the  arm  in  the  extended  position,  and  that 
the  "carrying  function"  of  the  arm  is  best  preserved  by  this  position,  as 
has  been  pointed  out  by  Allis,     On  the  other  hand,  if  stiffness  or  ankylosis 

30 


466 


COMPOUND  FRACTURES  OF  THE  HUMERUS. 


Fig.  372. 


of  the  elbow  results,  an  arm  wjiidi  jg  flexed  is  much  more  useful  to  the 
patient  than  one  which  is  iixed  in  the  extended  position.  In  view  of  these 
facts,  we  are  inclined,  as  a  rule,  to  treat  the  arm  in  the  flexed  position, 
unless  it  is  found  that  it  is  impossible  to  maintain  reduction  of  the  deformity, 
in  which  case  we  consider  it  good  practice  to  treat  the  arm  in  the  extended 
position  for  two  weets,  until  the  fragments  have  attained  some  fixation,  and 
then  to  administer  an  anaesthetic  and  flex  the  arm  to  a  right  angle,  applying  a 
splint  to  keep  it  in  this  position.  The  dressing  of  condyloid  fractures  consists 
in  applying  first  a  jjrimary  roller  from  the  tii^s  of  the  fingers  to  the  axilla, 
and  then  either  an  anterior  straight  splint  or  an  anterior  angular  splint, 
securing  the  splint  in  position  by  the  turns  of  a  roller  bandage.  (Fig.  370. ) 
These  fractures  may  also  be  treated  by  reducing  the  deformity,  and,  after 
applying  a  roller  and  cotton  padding  to  the  elbow,  fixing  the  arm  in  the 
extended  or  in  the  flexed  position  by  a  plaster- of-Paris  bandage.  In  chil- 
dren, at  the  end  of  three  weeks  the  union  is  usually  sufficiently  firm  to 
allow  the  splints  to  be  permanently  removed,  and  at  this  time  passive  motion 
should  be  made  by  grasping  the  condyles  of  the  humerus  with  one  hand 
and  flexing,  extending,  supinating,  and  pronating  the  forearm  with  the 
other.  In  many  of  these  cases,  for  some  months  after  removal  of  the  splints" 
marked  impairment  of  motion  is  present,  which  seems  largely  to  be  due  to 
the  deposition  of  callus,  interfering  with  the  motions  of  extension  and 
flexion  of  the  forearm.  If  a  case  which  jsresents  very  marked  disability 
shortly  after  fracture  be  examined  some 
months  later,  it  is  surprising  to  find  how  the 
motion  of  the  elbow  has  returned  as  the  callus 
has  been  absorbed. 

A  method  of  treating  fractures  of  the 
condyles  of  the  humerus  which  has  recently 
attracted  some  attention  both  in  this  country 
and  abroad  consists  in  reducing  the  deformity 
under  an  anaesthetic  and  then  placing  the 
elbow  in  a  position  of  acute  flexion,  main- 
taining this  position  by  securing  the  arm  and 
forearm  together  by  broad  strips  of  adhesive 
plaster  ;  the  arm  is  then  supported  in  a  sling 
from  the  neck  or  is  secured  to  the  body  by 
the  turns  of  a  bandage.  (Fig.  372.)  This 
dressing  is  applied  for  three  or  four  weeks,  and  is  then  removed  and  the  arm 
gradually  extended.  It  is  held  that  by  this  method  of  dressing  better 
motion  is  obtained  and  the  tendency  to  gunstock  deformity  is  lessened. 

Compound  Fractures  of  the  Humerus. — These  may  involve  any 
portion  of  the  bone.  In  compound  fractures  of  the  head  of  the  humerus, 
primary  excision  of  the  head  of  the  bone  offers  the  patient  the  best 
functional  result.  In  compound  fractures  of  the  shaft  of  the  humerus, 
after  thoroughly  sterilizing  the  wound,  if  there  is  difficulty  in  retaining  the 
fragments  in  good  position,  the  treatment  consists  in  securing  primary 
fixation  of  the  fragments  by  means  of  heavy  silver  wire  or  kangaroo  tendon 
sutures,  or  by  silver  splints  fixed  to  the  fragments  by  means  of  screws.     The 


Dressing  of  fracture  of  the  condyle  of 
the  humerus  in  acute  flexion. 


SEPAEATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  HUMERUS.      467 


subsequent  treatment  consists  in  the  use  of  drainage,  closure  of  the  wound,  the 
application  of  an  antiseptic  gauze  dressing,  and  the  use  of  fixation  dressings 
similar  to  those  employed  in  cases  of  simple  fi-actures  of  the  humerus. 

lu  compound  fractures  involving  the  condyles  of  the  humerus  and  the 
eWoro-joint  it  is  a  question  whether  it  is  wise  to  attempt  to  obtain  primary 
fixation  of  the  fragments,  as  in  spite  of  the  greatest  care  in  the  treatment 
a  certain  amount  of  loss  of  function  results.  It  is  better  in  these  cases  to 
resort  to  partial  excision  of  the  elbow-joint,— that  is,  the  removal  of  frag- 
ments and  excision  of  the  lower  end  of  the  humerus, — to  give  a  good  surface 
for  articulation  with  the  bones  of  the  forearm,  to  drain  the  wound,  apply  an 
antiseptic  gauze  dressing  and  splint  for  a  few  weeks,  fixing  the  arm  in 
the  flexed  or  partly  extended  position,  and  after  this  time  to  encourage 
motion  at  the  elbow  to  obtain  a  movable  joint. 

Separation  of  the  Lower  Epiphysis  of  the  Humerus.— As  the 
result  of  injury  to  the  lower  end  of  the  humerus,  the  lower  epiphysis  may 
be  separated  from  the  diaphysis,  or  the  epiphysis  of  the  internal  or  external 
epicondyle  may  be  separated.  The  epiphyseal  line  in  infants  is  transverse 
to  the  long  axis  of  the  humerus,  and  is  some  distance 
from  the  articular  surface  ;  in  a  few  years  the  epiphyseal 
line  becomes  decidedly  oblique  and  comes  nearer  the 
articular  surface  of  the  humerus.  (Fig.  373.)  The  rela- 
tion of  the  synovial  membrane  to  the  epiphyseal  line  is 
such  that  the  elbow -joint  is  very  apt  to  be  opened  in 
separation  of  this  epiphysis.  The  injury  is  most  common 
between  the  second  and  fourteenth  years.  The  separation 
may  be  simple  or  compound,  comxjlete  or  partial,  and  may 
be  complicated  with  a  slight  fracture  of  the  diaphysis. 

Symptoms. — The  symptoms  of  separation  of  the 
epiijhysis  without  displacement  are  pain,  swelling,  loss 
of  function,  and  mobility  ;  if  there  is  anterior  or  posterior 
displacement  of  the  separated  epiphysis,  there  is  in  addi- 
tion marked  deformity. 

Diagnosis. — This  injury  is  most  likely  to  be  con- 
founded with  a  transverse  fracture  of  the  condyles  of  the 
humerus,  fracture  of  the  articular  process,  or  posterior 
dislocation  of  the  elbow-joint.  From  dislocation  the  diag- 
nosis largely  rests  upon  the  rigidity  of  the  joint  in  the 
latter  injury,  and  from  fracture  we  are  led  to  a  diagnosis 
by  observing  the  position  of  the  line  of  separation  and  '°'''<"^  epiphysis  of  the 

,,         ,  ,  p.,  .,  ,,,  ,.  humerus  at  sixteen  and 

the  character  oi  the  crepitus,  although  m  many  cases  an  a  half  years.  (Poland.) 
absolute  diagnosis  is  impossible. 

Treatment. — This  consists  in  reducing  the  deformity,  if  present,  and 
applying  to  the  limb  an  anterior  angular  splint,  or  in  placing  the  arm  in  the 
position  of  acute  flexion,  if  this  maintains  the  reduction  more  satisfactorily. 
The  arm  should  be  kept  at  rest  for  from  four  to  six  weeks. 

Compound  Separations. — These  are  serious  injuries,  and  may  be 
complicated  by  infection  of  the  wound  and  injury  of  the  blood-vessels  and 
nerves,  from  the  displaced  diaphysis.     Treatment. — This  consists  in  steril- 


Separation     of    the 


468        FEAOTUEES  OF  BOTH  BONES  OF  THE  FOREARM. 

izing  the  wound  and  reducing  displaced  fragments,  resecting  a  portion  of  the 
diaphysis  if  necessary  to  accomplish  the  reduction,  in  wiring  the  epiphysis 
to  the  diaphysis  in  some  cases  to  maintain  the  reduction,  and  obtaining 
fixation  of  the  parts  by  the  use  of  a  splint  or  the  plaster-of-Paris  dressing. 

Separation  of  Internal  Epicondylar  Epiphysis. — Separation  of  this 
epiphysis  may  occur  as  the  result  of  direct  or  indirect  violence  or  muscular 
action,  and  may  complicate  dislocation  of  the  elbow  and  will  be  extra- 
articular. It  is  most  common  from  the  tenth  to  the  eighteenth  year,  at  which 
time  consolidation  takes  place.  Symptoms. — These  are  pain,  swelling, 
mobility,  muffled  crepitus,  and  displacement,  which,  if  posterior,  may 
cause  disordered  symptoms  from  injury  or  ijressure  on  the  ulnar  nerve. 
Treatment. — The  fragment  if  displaced  should  be  replaced  by  manipula- 
tion, a  compress  should  be  placed  over  the  epicondyle,  and  the  flexed  arm 
should  be  placed  upon  an  anterior  angular  splint.  Union  may  be  fibrous 
or  bony. 

Separation  of  External  Epicondylar  Epiphysis.— This  epiphysis 
may  be  separated  by  direct  or  indirect  violence  up  to  the  sixteenth  year  ;  it 

is  in  close  relation  with  the  synovial  sac 
Fig.  374.  of  the  joint.     Symptoms. — These  are 

swelling,  crepitus,  and  displacement. 
Treatment. — Displacement  should  be 
reduced  by  manipulation,  and  the  arm, 
in  the  extended  position,  should  be 
[)laced  upon  a  sj)lint.  Union  may  occur 
by  fibrous  tissue  or  bone. 

PEACTUKES  OF  BOTH  BONES  OF  THE 
FOEBAEM. 

Fractures  of  both  bones  of  the  forearm 
are  injuries  of  frequent  occurrence.  The 
bones  may  be  broken  at  the  same  time, 
or  either  may  be  broken  separately.  The 
radius,  fi-om  its  direct  articulation  with 
the  bones  of  the  carpus,  is  much  more 
frequently  the  seat  of  fracture  than  the 
ulna.  These  fractures  occur  at  all  pe- 
riods of  life,  and  are  very  frequently  seen 
in  children,  and  may  result  from  blows 
directly  on  the  forearm,  or  from  falls  in 
which  the  force  is  transmitted  from  the 
hand. 

Skiagraph  (ij  a  II, !•  tim  uf  both  lioues  of  the  ^-r»j.TT-»j-  j 

forearm.  FractiiTes  of  Both  Radius  and 

Ulna. — These  fractures  may  take  place 
at  any  portion  of  the  bones,  but  are  most  frequently  met  with  below  the 
middle  of  the  forearm.  They  are  produced  by  direct  or  indirect  force,  and 
result  from  falls  upon  the  hand,  from  blows  upon  or  the  passage  of  heavy 
bodies  over  the  forearm.  When  fracture  of  both  bones  of  the  forearm  results 
from  direct  force,  the  bones  are  apt  to  be  broken  upon  the  same  level.   (Fig. 


FEACTUEES   OF  EADIUS   AND  ULNA. 


469 


Deforinitj  in  fiacture  of  both  bones  of  the  forearm. 


374.)     When,  however,  the  fracture  occurs  from  indirect  force,  the  radius 
is  apt  to  give  way  at  a  higher  level  than  the  ulna. 

Symptoms. — The  most  marked  signs  in  these  fractures  are  deformity 
(Fig.  375),  which  may  be  lateral,  anterior,  or  posterior,  preternatural 
mobility,  crepitus,  and  loss  of  function.  Great  deformity  is  often  seen  in 
children,  in  whom  the  fractui-es  are  often  incomplete,  and  constitute  what 
are  known  as  "greenstick"  fractures. 

Prognosis. — As  a  rule,  the  results  following  these  fractures  are  good 
where  the  deformity  has  been  satisfactorily  reduced  and  the  parts  have 
been  immobilized  by  proper 

dressing.     Where  the  immo-  •^^<^-  ^''^• 

bilization  of  the  fragments  is 
insufficient  or  the  displace- 
ment is  not  corrected,  contact 
of  the  bones  or  fusion  of  the 
callus  may  interfere  with  the 
motions  of  pronation  and 
supination  of  the  forearm. 
Non-union  is  not  uncommon 
in  fractures  of  the  bones  of 
the  forearm. 

Treatment.  —  The  fore- 
arm should  be  flexed,  to  relax 
the  muscles  which  arise  from 
the  humerus,  and  extension  and  counterextension  made ;  at  the  same  time 
the  fragments  should  be  pressed  into  their  proper  position.  Considerable 
diversity  of  opinion  exists  among  surgeons  as  to  the  position  in  which 
the  forearm  should  be  placed  in  the  treatment  of  these  fractures.  Some 
surgeons  prefer  the  position  between  pronation  and  supination,  while 
others  prefer  the  supine  position.  Our  experience  has  led  us  to  think  that 
the  best  results  are  obtained  by  treating  fractures  of  the  forearm  in  the 
supine  position,  as  advocated  by  Lonsdale,  where  the  radius  is  broken  above 
the  insertion  of  the  j)ronator  radii  teres,  for  the  reason  that  the  biceps 
muscle,  inserted  into  the  tuberosity  of  the  radius,  acts  as  a  supinator  of  the 
forearm.  If  the  upper  fragment  of  the  radius  is  supinated  by  the  action  of 
the  biceps,  and  the  forearm  is  placed  in  the  position  between  pronation  and 
supination,  the  lower  fragment  of  the  radius  in  half  supination  will  then  be 
united  to  the  upper  fragment  in  full  supination,  and  axial  deformity  will 
result,  the  patient  being  unable  to  supinate  the  arm  fully,  thus  losing  the 
advantage  of  full  rotation  ;  whereas  if  the  lower  fragment  is  sui^inated  to 
corresiDond  with  the  supination  of  the  upper  fragment  the  line  of  the  radius 
will  be  complete.  We  therefore  treat  these  fractures  in  suj)ination,  and 
apply  a  well-padded  flat  straight  splint  to  the  anterior  surface  of  the  fore- 
arm, extending  from  the  bend  of  the  elbow  to  a  little  beyond  the  tips  of  the 
fingers.  A  well-padded  splint  is  next  applied  to  the  posterior  surface  of  the 
arm,  from  the  tip  of  the  olecranon  to  a  point  just  below  the  wrist.  (Fig. 
376.)  The  splints  are  held  in  position  by  the  application  of  a  roller  bandage 
(Fig.  377),  and  the  forearm  should  be  supported  in  a  broad  sling.     Care 


470 


FEACTURES  OF  RADIUS  AND   ULNA. 


sliould  be  taken  that  the  anterior  splint,  if  it  be  applied  while  the  arm  is 
extended,  does  not  press  against  the  brachial  artery  at  the  bend  of  the  elbow 
when  the  arm  is  flexed.  This  fractm-e  may  also  be  dressed  by  apjjlying  a 
long  straight  splint  to  the  posterior  surface  of  the  arm,  extending  from  the 

Fig.  ,376. 


Application  ol  splints  in  fractinre  of  both  bones  of  the  forearm. 

elbow  to  the  tips  of  the  fingers,  and  a  short  anterior  splint  extending  from 
the  elbow  to  the  wrist,  both  being  held  iu  jDlace  by  a  bandage.  A  plaster- 
of- Paris  bandage  may  be  employed  to  secure  the  splints,  and  a  few  turns  of 
the  bandage  may  be  carried  around  and  above  the  elbow  to  prevent  rotation 


I  trcssing  for  fracture  of  both  bones  of  the  forearm. 


of  the  forearm.  'No  primary  roller  should  ever  be  applied  in  cases  of  frac- 
ture of  the  bones  of  the  forearm.  The  use  of  a  primary  roller  in  these 
cases,  with  the  pressure  of  the  anterior  splint  against  the  brachial  artery, 
possibly  accounts  for  the  cases  of  gangrene  of  the  forearm  which  have 
occasionally  followed  these  fractures.  Care  should  be  taken  that  the  splints 
are  a  little  wider  than  the  arm,  for  if  narrow  sijlints  be  used  the  lateral 
pressure  of  the  bandage  may  tend  to  force  the  bones  together  and  thus 
diminish  the  interosseous  space,  and  as  a  result  union  by  callus  between  the 
bones  may  occur  and  prevent  the  motions  of  pronation  and  supination. 
The  subsequent  dressings  are  made  every  second  or  third  day,  and  at  the 
end  of  four  weeks  union  is  sufficiently  firm  to  permit  of  the  permanent 
removal  of  the  sj)lints.  After  three  weeks  passive  motion  should  be  made, 
pronation  and  supination  of  the  forearm  and  flexion  and  extension  of  the 
wrist  being  practised  at  each  dressing. 

Incomplete  or  Greenstick  Fractures  of  both  Bones  of  the  Fore- 
arm.— These  fractures  are  seen  in  infants  and  children,  and  are  often 
accompanied  by  marked  deformity ;  one  bone  may  be  com^Dletely  broken, 
while  the  other  is  partially  broken  or  bent,  or  both  bones  may  present 
incomxjlete  fractures.     Treatment. — The  most  important  point  is  to  reduce 


FRACTURES   OF  THE  RADIUS.  471 

the  deformity ;  this  is  accomj)lislied  by  making  pressure  upou  the  bones, 
and  in  reducing  the  deformity  the  incomplete  fractirre  is  generally  converted 
into  a  complete  one.  The  dressing  consists  in  the  application  of  splints,  as 
in  cases  of  ft-actures  of  both  bones  of  tlie  forearm. 

Fracture  of  the  Head  and  Neck  of  the  Radius. — Fracture  of 

the  head  or  neck  of  the  radius  was  formerly  considered  a  rare  injury,  but 
since  the  X-ray  examinations  have  been  employed  a  number  of  cases  have 
been  recorded,  and  it  is  probably  more  common  than  generally  supposed. 
The  diagnosis  of  fracture  of  the  neck  of  the  bone  from  fracture  of  the  head  of 
the  bone  will  in  most  cases  be  difficult  without  an  X-ray  examination.  The 
most  prominent  sign  of  this  injury  is  failure  of  the  head  of  the  radius  to 
rotate  with  the  movements  of  the  shaft,  and  in  making  these  movements,  if 
a  fi-acture  exists,  crepitus  can  usually  be  detected. 

Prognosis. — Good  functional  results  have  followed  this  injury  in  certain 
cases,  but  in  others  more  or  less  interference  with  pronation  aud  supination 
of  the  forearm  and  flexion  and  extension  of  the  elbow-joint  have  resulted. 

Treatraent. — The  forearm  should  be  flexed,  to  relax  the  biceps  muscle, 
and  a  well-padded  anterior  angular  splint  should  be  applied  to  the  forearm 
and  arm,  and  held  in  j)osition  by  a  roller  bandage.  The  dressing  should  be 
changed  at  intervals,  aud  the  splint  should  be  removed  at  the  end  of  four 
weeks.  The  plaster-of- Paris  bandage  may  also  be  employed.  Passive 
motion  should  be  practised,  to  regain  the  motions  of  pronation  and  supina- 
tion of  the  forearm.  Primary  excision  of  the  head  of  the  bone  has  been 
practised  with  good  results,  and  secondary  excision  should  be  resorted  to  if 
the  functional  residt  is  unsatisfactory. 

Separation  of  the  Upper  Epiphysis  of  the  Radius. — This  epiph- 
vsis,  which  becomes  firmly  united  to  the  diaphj-sis  about  the  seventeenth 
year,  may  be  separated  by  direct  or  indirect  violence.     The  symptoms  are 
those  of  fracture  of  the  neck  of  the 
radius,  and  the  treatment  is  similar 
to  that  for  fi'acture  of  the  head  and 
neck  of  the  bone. 

Fracture  of  the  Shaft  of 

the  Radius. — This  fracture  usu- 
ally results  from  direct  violence, 
but  may  follow  a  fall  upon  the 
hand. 

Symptoms. — In  this  injury 
there  is  loss  of  both  pronation  and 
supination  ;  the  upi^er  end  of  the 
radius  when  the  hand  is  rotated  remains  fixed  ;  pain,  crepitus,  and  preter- 
natural mobility  may  also  be  present.  The  displacement  consists  in  tilting 
forward  of  the  uj)per  fragment  by  the  action  of  the  biceps  muscle,  and  rota- 
tion inward  by  the  action  of  the  pronator  teres  ;  the  lower  fi-agment  is  drawn 
towards  the  ulna  by  the  action  of  the  pronator  quadratus  and  the  supinator 
radii  longus.     (Figs.  378  and  379.) 

Prognosis. — The  results  following  this  fi-acture  are  iisually  very  satis- 
factory, unless  the  lower  fragment  is  drawn  so  close  to  the  ulna  that  the 


a^^ 


fracture  of  the  ^halt  ol  the  radius 
(.Agnew.) 


472 


FEACTUKES  OF  THE  RADIUS. 


callus  forms  an  attachment  to  the  ulna  and  interferes  with  the  motions  of 
pronation  and  supination. 

Treatment. — The  arm  should  be  flexed,  to  relax  the  biceps,  and  the  hand 
adducted,  and  the  forearm  should  be  placed  in  the  supine  position.     Well- 
padded     anterior     and     posterior 
straight  splints  should  be  applied 
and  held  in  position  by  a  bandage. 

Fractures  of  the  Lower 
End  of  the  Radius.— These  are 
frequent  injuries.  They  may  be 
produced  by  dix-ect  force,  yet  in  the 
great  majority  of  cases  they  are 
caused  by  violence  transmitted 
through  the  carpus  by  falls  upon 
the  palm  of  the  hand,  in  which 
case,  the  weight  of  the  body  being 
received  upon  the  ball  of  the  hand, 
the  impact  of  the  carpal  bones 
causes  a  fracture  of  the  lower  end  of 
the  radius.  The  occurrence  of  this  fracture  is  also  exjjlained  by  cross-break- 
ing strain,  the  weight  of  the  body  being  received  upon  the  ball  of  the  hand, 
the  resistance  offered  by  the  antero-radio-carpal  ligament  to  extreme  exten- 
sion causing  a  transverse  or  oblique  fracture  of  the  lower  end  of  the  bone. 

The  most  common  fi-acture  of  the  lower  end  of  the  radius  is  known  as 
Colles's  fracture ;  it  occupies  a  i^osition  from  half  an  inch  to  an  inch  and  a 
half  above  the  articular  surface  of  the  bone,  and  pre- 
sents a  very  characteristic  deformity,  known  as  the 
silver  fork  deformity.  (Fig.  .380.)  The  deformity 
may  be  slight  as  the  result  of  impaction  or  locking  of 
the  fragments.     The  fracture  may  consist  in  an  ob- 


Skiagraph  of  fracture  of  the  shaft  of  the  radius. 
(Leonard.) 


Fig.  381. 


■|r^ 


Deformity  in  Colles's  fracture. 


Comminuted  fracture  of 
the  lower  end  of  the  radius. 
(Agnew.) 

lique  or  a  transverse  separation  of  the  bone  above  the  articular  extremity  ; 
it  may  be  comminuted  (Fig.  381),  or  it  may  consist  in  a  separation  of  the 
ftosterior  lip  of  the  articular  surface  of  the  radius ;  the  latter  is  extremely 
rare,  and  is  known  as  Barton's  fracture.  Eecent  studies  of  these  fractures  by 
X-ray  examinations  have  shown  that  they  are  much  more  complicated  in- 
juries than  generally  supposed,  being  often  comminuted  or  impacted  or 
associated  with  a  dislocation  or  fracture  of  the  styloid  process  of  the  ulna,  or 
a  fracture  of  the  scaphoid  or  semilunar  bones. 


FRACTURES  OF  THE  RADIUS. 


473 


Symptoms. — These  are  mobility,  pain,  disability,  and  crepitus.  There 
is  also  usually  a  prominence  on  the  back  of  the  arm,  due  to  the  upper  end 
of  the  lower  fragment,  and  another  in  front  of  the  arm,  due  to  the  lower  end 
of  the  ux^per  fragment.  There  is  a  certain  amount  of  inclination  of  the 
hand  to  the  radial  side  of  the  arm,  accompanied  by  prominence  of  the 
styloid  process  of  the  ulna. 

Diagnosis. — Fracture  of  the  lower  end  of  the  radius  may  be  confounded 
with  dislocation  at  the  wrist ;  this  is  an  extremely  rare  accident,  while  frac- 
ture is  a  very  common  one.  In  dislocation  there  is  no  crepitus,  but  in 
fracture  this  can  usually  be  recognized,  except  in  cases  of  impacted  fracture. 
Examination  will  also  show  marked  prominence  of  the  lower  end  of  the 
ulna,  due  to  displacement  of  the  carpus  and  the  fragment  of  the  radius 
upward  and  to  the  radial  side. 

Prognosis. — The  results  following  fracture  of  the  lower  end  of  the 
radius  are  generally  satisfactory  if  the  primary  displacement  is  corrected, 
but  occasionally  a  certain  amount  of  impairment  of  motion  of  the  wrist  is 
observed,  and  sometimes  interference  with  pronation  and  supination  results 
in  spite  of  the  most  careful  treatment. 

Treatment. — The  reduction  of  the  deformity  is  the  most  important  point 
in  the  treatment.  This  is  accomplished  by  grasping  the  forearm  above  the 
seat  of  fracture  and  with  the  other  hand  grasping  the  hand  of  the  fractured 
arm  and  making  extension,  at  the  same  time  tilting  the  lower  fragment 
backward  by  bending  the  hand  back ;  then  by  suddenly  flexing  the  hand 
the  lower  fragment  is  brought  downward  and  forward  and  the  deformity  is 
corrected.  We  are  satisfied  that  many  of  the 
unsatisfactory  results  following  fractures  of  ^"^^-  3S2. 

the  lower  end  of  the  radius  are  due  to  an       , 
imperfect  reduction  of  the  fragments  at  the 

time  of  the  first  dressing,  and  with  this  fact  

in  view  we  think  it  is  advisable  to  antes-  3^^,^  ^^^^^^ 

thetize  the  patient  and  use  considerable  force 

if  necessary  to  place  the  fragment  in  its  proper  j)osition.  The  forearm 
should  next  be  placed  upon  a  well-padded  Bond  splint  (Fig.  382),  which 
consists  of  a  splint  with  a  block  of  wood  set  obliquely  upon  it,  upon  which 

Fig.  383. 


the  hand  rests,  causing  its  adduction.  In  addition  to  this  splint  two  folded 
compresses  of  lint  are  applied,  one  over  the  lower  end  of  the  upper  fragment 
and  the  other  over  the  upper  end  of  the  lower  fragment.  (Fig.  383.)  The 
arm  should  be  fixed  in  the  supine  position,  or  in  the  position  between  supiua- 


474 


FEACTUEES   OF  THE  EADIUS. 


^\ 


tion  and  pronation,  and  the  splint  and  compresses  lield  in  place  by  tlie  tiirns 
of  a  bandage.  (Fig.  384.)  The  after-treatment  consists  in  the  renewal  of 
the  dressings  after  twenty-four  hours,  and  after  this  the  dressings  can  be 
changed  at  intervals  of  two  or  three  days,  and  at  the  end  of  four  weeks  the 
splint  should  be  removed  and  the  patient  encouraged  to  use  the  arm.     The 

Bond   splint  allows   the    patient 
Fig.  .384.  ^q  move  the  fingers  during  the 

course  of  the  treatment  without 
interfering  with  the  fixation  of 
the  fragments. 

Another  method  of  treating 
Colles's  fracture  after  the  reduc- 
tion of  the  deformity  consists  in 
placing  upon  the  dorsal  surface 
of  the  forearm  a  padded  straight 
splint,  extending  from  the  elbow 
to  the  tips  of  the  fingers,  with  a 
compress  over  the  upper  part  of 
the  lower  fragment,  and  a  short  straight  splint  upon  the  palmar  surface  of 
the  arm,  extending  from  the  elbow  to  a  little  below  the  wrist,  with  a  com- 
press over  the  lower  end  of  the  u^jper  fragment.  (Fig.  385.)  These  splints 
are':held  in  position  by  a  bandage,  and  the  forearm  is  cari-ied  in  a  sling 

Fig.  385. 


Dressing  for  Colles's  fracture. 


Dressing  for  Colles's  fracture  "vvith  two  splints. 

with  the  hand  inclined  to  the  ulnar  side.  The  hand  should  be  bandaged 
to  the  po.sterior  splint  for  about  seven  days  and  then  set  free,  so  that  the 
weight  of  the  hand  can  draw  the  fragment  to  the  ulnar  side  as  it  hangs  over 
the  sling,  and  so  that  the  patient  can  move  the  joint  in  flexion.  The  pos- 
terior splint  should  be  left  long  for  another  week  ;  at  the  end  of  this  time 
it  should  be  shortened  so  as  to  extend  only  to  the  wrist-joint,  and  the  patient 
should  be  encouraged  to  use  the  fingers  and  make  motions  of  the  wrist.  At 
the  end  of  three  weeks  both  splints  should  be  removed,  and  the  ijatient 
should  carry  the  forearm  in  a  sling  for  a  few  weeks  longer  and  be  encour- 
aged to  use  the  hand. 

As  stiffness  of  the  wrist  and  the  fingers  is  very  apt  to  follow  this  fracture, 
it  is  important  that  the  fingers  should  be  moved  constantly  when  the  dress- 
ings are  changed,  the  wrist  gently  flexed  and  extended,  and,  while  the 


FRACTURES  OF  THE  ULNA. 


475 


fragments  are  fixed  with  one  hand,  the  motions  of  i>ronation  and  supination 
practised.  Ununited  fractures  of  the  lower  end  of  the  radius  are  extremelj' 
rare :  we  know  of  no  reported  case  of  non-union  in  Colles's  fracture. 

Reversed  Colles's  Fracture. — This  term  is  applied  to  a  rare  fracture 
of  the  lower  end  of  the  radius  in  which  the  lower  fragment  is  displaced 
forward  instead  of  backward,  the  deformity  being  the  reverse  of  that  seen 
in  Colles's  fracture.  This  fracture  results  from  a  fall  upon  the  back  of  the 
flexed  hand  ;  the  line  of  fracture  may  be  transverse  or  oblique. 

Symptoms. — There  is  prominence  on  the  back  of  the  wrist  due  to  the 
end  of  the  upper  fragment  of  the  fractiired  radius  and  the  styloid  process 
of  the  ulna;  in  front  of  this  is  a  furrow  marking  the  normal  position  of  the 
end  of  the  radius,  and  upon  the  palmar  surface  of  the  wrist  the  lower  frag- 
ment can  be  felt  to  project  underlying  the  flexor  tendons.  There  may  be 
marked  deviation  of  the  hand  to  the  radial  side  accompanying  a  similar 
deviation  of  the  lower  fragment. 

Treatment. — This  consists  in  the  reduction  of  the  deformity,  the 
manipulation  being  made  in  the  opposite  direction  to  that  described  for  the 
reduction  of  Colles's  fracture,  and  the  same  dressings  may  be  applied  as  for 
Colles's  fracture,  the  position  of  the  pads,  of  course,  being  reversed. 

Separation  of  the  Lower  Epiphysis  of  the  Radius. — This  acci- 
dent jjresents  more  or  less  the  deformity  of  the  ordinary  Colles's  fi-acture, 
and  is  quite  common  in  children,  the  greatest  number  of  cases  occurring 
between  the  twelfth  and  eighteenth  years. 

Symptoms. — The  deformity  consists  in  a  marked  angular  ]3rojection  on 
the  palmar  surface  of  the  forearm  above  the  wrist,  and  a  corresponding 
depression  upon  the  dorsal  sur- 
face. (Fig.  386.)  Deformity 
may,  however,  be  absent.  Crep- 
itus can  be  obtaiued  upon 
making  extension,  couuterex- 
tension,  and  manipulation,  but 
it  is  usually  softer  in  character 
than  that  occurring  in  fractures 
of  the  lower  end  of  the  radius. 
Gompoimd  separations  of  this 
epiphysis  are  not  uncommon. 

Treatment. — By  making  extension  and  counterextension  and  manipu- 
lation the  deformity  can  be  reduced,  and  when  once  corrected  the  tendency 
to  its  reproduction  is  not  so  marked  as  in  the  case  of  Colles's  fracture.  The 
treatment  is  similar  to  that  of  cases  of  fracture  of  the  lower  end  of  the 
radius.  The  results  following  epiphyseal  sepai-ation  of  the  lower  end  of  the 
radius  are  usually  very  satisfactory. 


Fig.  386. 


Separation  of  the  lower  epiphysis  of  the  radius. 


FRACTURES  OF  THE  ULNA. 


Fracture  of  the  Shaft  of  the  Ulna.— This  fracture  is  usually  pro- 
duced by  direct  force  from  blows  or  from  falls  upon  the  ulnar  side  of  the 
forearm.  Displacement  in  fracture  of  the  shaft  of  the  ulna  may  be  in  any 
direction,  often  being  determined  by  the  direction  of  the  force  which  jyxo- 


476  FRACTURE  OF  THE  OLECRANON  PROCESS. 

duced  the  fracture.     Fractures  of  tlie  ulna  may  be  oblique  or  transverse, 
and  if  the  radius  is  not  broken  there  will  be  no  overlapping. 

Prognosis. — In  these  fractures  union  generally  takes  place  without 
marked  deformity.  USTon-union  is  much  more  common  in  the  ulna  than  in 
the  radius.  We  have  seen  a  number  of  cases  of  ununited  fracture  of  the 
ulna  in  which  non-union  seemed  to  be  due  to  the  fact  that  the  fractures  were 
treated  with  a  single  short  anterior  splint  which  did  not  control  the  move- 
ment of  the  fingers. 

Treatment. — Displacement  of  the  fragments  should  be  reduced  by 
manipulation  with  the  fingers,  and  care  should  be  taken,  if  the  fragments 
are  displaced  towards  the  radius,  to  bring  them  into  their  natural  position, 
so  as  to  prevent  subsequent  loss  of  pronation  and  supination.  After 
reducing  the  deformity  the  hand  and  forearm  should  be  placed  in  the  supine 
position,  and  a  well-padded  splint  applied  to  the  anterior  surface  of  the 
forearm  from  the  bend  of  the  elbow  to  the  tips  of  the  fingers ;  a  shorter 
l^added  splint,  extending  from  the  olecranon  to  the  wrist  or  a  little  beyond, 
should  be  placed  uj)on  the  posterior  surface  of  the  forearm,  and  the  two 
splints  should  be  held  in  position  by  the  turns  of  a  roller  bandage.  (Fig. 
377.)  The  position  of  the  splints  may  be  reversed,  the  long  splint  being 
applied  to  the  posterior  surface.  Some  surgeons  prefer  to  treat  fractures  of 
the  shaft  of  the  ulna  with  the  forearm  in  the  position  between  pronation 
and  supination.  The  dressings  should  be  changed  at  intervals  of  two  or 
three  days,  and  at  the  end  of  four  or  five  weeks  the  splints  may  be  perma- 
nently removed.  A  plaster-of-Paris  dressing  or  Bavarian  splint  on  the 
internal  border  of  the  forearm  from  the  knuckles  to  the  elbow  may  also  be 
employed. 

Fracture  of  the  Olecranon  Process  of  the  Ulna. — This  fracture 
is  seldom  seen  in  children,  but  is  not  infrequent  in  adults.  The  line  of 
fracture  may  separate  the  tip,  or  pass  through  the  base  or  the  middle  of  the 
olecranon  process.     (Fig.  387.) 

Fig.  387. 


Fracture  of  thi.'  nlc(r;ni.iii  process  of  the  ulna. 


Symptoms. — These  are  pain  at  the  back  of  the  elbow,  more  or  less 
loss  of  power  of  extending  the  forearm,  and  a  i^rominence  above  the  normal 
position  of  the  olecranon  process,  the  fragment  being  drawn  up  by  the 
action  of  the  triceps  muscle.  Crepitus  may  also  be  felt,  and  lateral  motion 
of  the  fragment  can  be  obtained  by  manij)ulation  with  the  fingers.  Upon 
flexion  of  the  arm  a  marked  gajj,  into  which  the  fingers  can  be  pressed,  will 
be  seen  behind  the  joint. 

Prognosis. — In  these  fractures  fibrous  union  usually  is  obtained.  This 
probably  results  from  difficulty  in  bringing  about  jDerfect  ai^position  of  the 
fragments  and  from  the  presence  of  synovial  fluid  in  the  fissure  between 
them.  We  had  recently  under  our  care  an  oblique  fi-acture  of  the  upper 
portion  of  the  ulna  which  separated  the  olecranon  process,  and  in  this  case 


FEACTUEE  OF  THE  OLECEANON  PEOCESS. 


477 


non-union  resulted.     Upon  exposing  the  parts  by  incision  the  synovial  fluid 
escaped  from  the  fissure  in  the  bone,  and  the  surfaces  were  lined  with  a 
smooth    membrane    resem- 
bling synovial    membrane.  Fig.  388. 
In  this  case  firm  bony  union 
was  obtained  by  freshening 
the  surfaces  and  introducing 
heavy  wire  sutures. 

Treatment. — The  arm  ottuse-angied  spimt. 

should  be  extended  and  a 

primary  roller  applied  from  the  tips  of  the  fingers  to  a  point  just  below  the 
elbow.  A  well-padded  straight  or  obtuse-angled  splint  (Fig.  388),  extending 
from  the  shoulder  to  the  tips  of  the  fingers,  should  be  applied  upon  the  anterior 
surface  of  the  arm  and  forearm  ;  a  compress  of  lint  should  next  be  placed  just 
above  the  upper  fragment  and  held  in  place  by  one  or  two  strips  of  adhesive 

Fig.  389. 


fracture  of  the  olecranon  process. 


plaster,  applied  obliquely  (Fig.  389)  from  above  downward,  and  fastened  to 
the  splint,  and  the  siilint  should  be  secured  by  a  bandage.  (Fig.  390. )  This 
dressing  should  be  changed  at  intervals  of  two  or  three  days,  and  the  splint 
should  not  be  permanently  discarded  until  about  six  weeks  after  the  injury. 

Fig.  390. 


Dressing  for  fracture  of  the  olecranon  process  of  the  ulna 


This  fracture  may  also  be  treated  by  means  of  a  plaster-of- Paris  bandage. 
Passive  motion  should  not  be  practised  until  two  or  three  weeks  have 
elapsed.  In  making  passive  motion  the  fragments  should  be  held  firmly 
with  the  fingers  while  i^ronation  and  supination  of  the  forearm  and  slight 
extension  and  flexion  are  practised.     As  the  union  in  this  fracture  is  usually 


478  FEACTUEE   OF  THE  STYLOID  PEOCESS. 

fibrous,  it  is  importaBt  that  as  close  apposition  as  possible  of  the  fragments 
be  obtained,  as  a  long  fibrous  union  interferes  very  markedly  with  exten- 
sion of  the  forearm.  In  spite  of  fibrous  union  in  cases  of  fractures  of  the 
olecranon,  although  there  may  be  a  certain  amount  of  disability  immedi- 
ately following  the  repair  of  the  fracture,  in  a  short  time  the  function  of  the 
arm  is  usually  satisfactorily  regained. 

Fracture  of  the  Coronoid  Process  of  the  Ulna.— This  fracture 

is  a  rare  one.  In  one  hundred  and  thirty  cases  of  fracture  of  the  ulna 
admitted  to  the  Pennsylvania  Hospital  three  fractures  of  the  coronoid 
process  were  recorded.  We  have  seen  recently  a  case  in  which  this  frac- 
ture unquestionably  existed.   '  (Pig.   391.)     It  is  produced  by  tails  upon 


j& 


Fracture  of  the  coronoid  proc 


the  hand,  which  drive  the  process  against  the  articular  surface  of  the 
humerus,  or  may  result  from  posterior  dislocation  of  the  elbow,  or  from 
violent  muscular  action. 

Symptoms. — These  may  be  a  slight  posterior  displacement  of  the  bones 
of  the  forearm  and  a  prominence  of  the  detached  process  in  front  of  the 
elbow.  This  displacement  may  be  reduced  by  extension,  but  upon  relaxing 
the  extending  force  the  bones  will  tend  to  slip  backward.  The  diagnosis 
may  be  very  difficult,  but  the  use  of  the  X-rays  will  reveal  the  presence 
of  this  fracture. 

Treatment. — The  arm  should  be  flexed  to  a  right  angle  and  a  compress 
and  a  well-padded  anterior  angular  splint  applied  to  the  anterior  surface  of 
the  arm  and  forearm  and  secured  by  a  bandage. 

Fracture  of  the  Styloid  Process  of  the  Ulna. — Fracture  of  this 
process  may  result  from  direct  force  or  may  be  associated  with  fractures  of 
the  lower  end  of  the  radius,  and  is  j)robably  due  in  the  latter  case  to  extreme 
tension  upon  the  internal  lateral  ligament. 

Symptoms. — The  usual  signs  of  this  fracture  are  pain,  swelling,  and 
deformity  at  the  inner  part  of  the  wrist ;  when  the  hand  is  abducted  the 
process  may  be  seen  and  felt  to  leave  the  lower  end  of  the  bone,  and  crepitus 
may  be  obtained. 

Treatment. — In  this  fracture  a  Bond  splint  may  be  emj)loyed,  which 
carries  the  hand  to  the  ulnar  side  of  the  ax-m  and  relaxes  the  internal  lateral 
ligament,  and  favors  the  restoration  of  the  process  to  its  normal  position. 
After  applying  the  splint,  a  comj)ress  should  be  applied  over  the  process, 
and  the  splint  and  compress  held  in  ijosition  bj^  a  roller  bandage. 

Separation  of  the  LoWer  Epiphysis  of  the  Ulna. — This  may  be 
separated  by  direct  force  or  indirectly  in  fracture  of  the  lower  end  of  the 
radius.  The  symptoms  are  pain,  mobility  and  displacement.  The  treatment 
consists  in  reduction  of  the  displacement  and  the  use  of  a  compress  over  the 
fragment  and  a  palmar  splint.  As  the  ulna  grows  largely  from  the  lower 
epiphysis,  arrest  of  growth  may  follow  this  injury. 


FRACTURES  OF  THE  METACARPAL  BONES. 


479 


Fracture  of  the  Carpal  Bones. — The  carpal  bones,  from  their  shape, 
being  short  and  irregular  and  compactly  bound  together  by  jjowerful  liga- 
ments, do  not  often  jpresent  examples  of  simple  fracture.  Fractures  in  these 
bones  are  readily  overlooked.  In  doubtful  cases  an  X-ray  examination 
should  be  made. 

Treatment. — This  consists  in  reduction  of  any  displacement  by  manipu- 
lation and  the  application  of  a  palmar  splint.  More  or  less  stiffness  of  the 
wrist  may  follow  this  fracture. 

Fractures  of  the  Metacarpal  Bones. — Fractures  of  the  metacarpal 
bones  are  not  uncommon.  The  metacarpal  bones  most  frequently  broken 
are  those  of  the  index,  ring,  and  little  fingers.  These  fractures  may  result 
from  crushing  force  which  does  extensive  damage  to  the  soft  jjarts  and 
breaks  several  bones  at  the  same  time.  The  bones  are  also  sometimes  broken 
by  force  transmitted  from  the  knuckles  when  blows  are  struck  with  the 
clinched  fist,  as  in  boxing. 

Syraptoms. — These  are  pain,  preternatural  mobility,  and  crepitus,  with 
a  prominence  on  the  back  of  the  hand.  The  usual  displacement  is  projec- 
tion of  the  proximal  fragment  upon  the  dorsum  of  the  hand,  but  there  may 
be  a  concavity  on  the  dorsum.  It  is  often  difficult  to  elicit  mobility  and 
crepitus,  biit  they  may  sometimes  be  obtained  by  placing  one  finger  upon 
the  knuckle  and  another  over  the  suxjposed  seat  of  fracture,  and  manipu- 
lating the  parts. 

Treatment. — After  reducing  the  deformity  by  pressure,  a  pad  should 
be  i)laced  under  the  palm  of  the  hand,  and  a  well-padded  straight  splint 
applied  to  the  palmar  surface  of  the  hand  and  forearm  (Fig.  392),  extending 


press  applied  for  fracture  of  the  metacarpal  bones. 


from  the  tips  of  the  fingers  half-way  up  the  forearm.  A  comi^ress  of  lint 
should  be  applied  over  the  seat  of  fracture,  and  the  splint  and  compress 
held  in  position  by  the  turns  of  a  bandage.  The  clinched  fist  may  also  be 
bandaged  over  a  roller  bandage  held  in  the  hand. 

Compound  Fractures  of  the  Carpal  and  Metacarpal  Bones. — 
These  fractm-es  result  from  crushing  forces  and  gunshot  injury,  and  are  fre- 
quently seen  in  machinery  and  railway  accidents.  In  many  cases  of  com- 
pound fractures  of  the  carpal  and  metacarpal  bones  the  injury  to  the  tissues 
of  the  hand  is  so  extensive  that  amputation  of  the  hand  may  be  required, 
although  with  the  modern  methods  of  wound  treatment  conservative  treat- 
ment should  be  attempted.  By  thorough  sterilization  of  the  parts  and  the 
removal  of  detached  fragments  it  is  possible  for  recovery  to  occur,  witli  a 


480  FEACTURES  OF  THE  PELVIS. 

more  or  less  useful  hand,  even  where  there  have  been  extensive  comminu- 
tion and  destruction  of  the  bones. 

Fractures  of  the  Phalanges  of  the  Fingers. — Fractures  of  the 
phalanges  of  the  fingers  may  involve  the  phalanges  of  a  single  finger  or  of 
several  fingers. 

Symptoms. — ^The  symptoms  of  these  fractures  are  preternatural  mo- 
bility and  crepitus.  As  a  rule,  the  deformity  is  not  very  marked  and  is 
easily  reduced. 

Treatment. — After  reducing  the  deformity  by  manipulation,  a  narrow 
padded  splint  is  applied  to  the  palmar  surface  of  the  hand  and  of  the 

injured  finger ;  a  posterior 
Fig.  393.  short  splint,  extending  fi'om 

the  knuckle  to  the  tip  of 
the  finger,  may  also  be  ap- 
plied, the  splints  being  held 
in  position  by  the  turns  of 
a  narrow  bandage.  (Fig. 
393.)  If  there  is  lateral 
displacement,  short  lateral 

Splints  applied  to  fracture  of  the  phalanx.  SpliutS     may    alSO     be     em- 

ployed in  conjunction  with 
the  palmar  and  dorsal  splints.  A  A^ery  satisfactory  method  of  treating  these 
fractures  consists  in  moulding  a  piece  of  binder's  board  into  the  form  of  a 
gutter,  or  using  an  aluminum  plate  or  wire  splint,  which  is  jjadded  with 
cotton  and  applied  to  the  palmar  or  dorsal  surface  of  the  finger,  and  held  in 
position  by  the  turns  of  a  narrow  bandage  or  by  strips  of  adhesive  plaster. 

Separation  of  the  Epiphyses  of  the  Metacarpal  Bones  and.  the 
Phalanges  of  the  Fingers. — These  separations  may  occur  up  to  the  twen- 
tieth year.  The  symptoms  are  those  of  fracture  of  the  corresponding  bones. 
Treatment. — This,  after  reduction  of  the  displacement,  is  similar  to  that 
of  fractui-es  of  these  bones. 

FEACTURES   OP   THE   PELVIS. 

Fractures  of  the  pelvis  are  not  very  common  injuries.  They  usually 
result  from  falls,  from  the  application  of  dii-ect  force,  or  from  the  pelvis 
being  caught  between  heavy  bodies  and  crushed.  The  gravity  of  these 
injuries  depends  largely  upon  whether  the  pelvic  girdle  is  broken,  and  upon 
the  presence  of  injury  of  the  important  pelvic  viscera.  The  most  serious 
class  of  injuries  of  the  pelvis  are  those  which  break  the  pelvic  girdle ;  the 
less  serious  are  those  which  involve  the  crest  or  spine  of  the  ilium,  the 
margin  of  the  acetabulum,  or  the  tuber  ischii,  and  transverse  fractures 
involving  the  lower  portion  of  the  sacrum.  Shock  is  usually  a  prominent 
symptom  in  fracture  of  the  pelvis. 

Vertical  fractures  of  the  pelvis  occur  in  two  forms,  being  either  single 
or  double.  Single  vertical  fractures  usually  pass  through  the  horizontal 
ramus  of  the  pubis  in  front  of  the  ilio-pectineal  eminence  and  through  the 
descending  ramus  near  its  junction  with  the  ischium.  Double  vertical 
fractures  may  present  a  line  of  fracture  passing  through  the  pubic  bone  or 


FRACTURES   OF  THE  SACRUM. 


481 


acetabulum  and  a  second  fracture  through  the  ilium  behind  the  acetabulum 
or  through  the  sacrum.     (Fig.  394.) 

Fig.  394. 


Double  vertical  fracture  o£  the  pelvis.    (After  Dennis. ) 

Separations  'of  the  pelvic  bones  at  their  junctions  may  also  occur  inde- 
pendently or  combined  with  fractures ;  such  lesions  have  been  observed  at 
the  pubic  symphysis  and  the  sacro-iliac  synchondrosis  ;  the  os  innominatum 
has  been  completely  separated  from  the  other  bones  of  the  pelvis. 

Complications  in  Fractures  of  the  Pelvis. — The  most  serious  com- 
plications resulting  from  fractures  of  the  pelvis  are  injury  of  the  pelvic 
viscera,  such  as  rujpture  of  the  bladder  or  of  the  membranous  portion  of  the 
urethra  from  displaced  fragments  of  the  pubic  arch.  Laceration  of  the  rec- 
tum may  also  result  from  fractures  of  the  sacrum  or  the  ischium,  and  the  iliac 
vessels  have  been  torn  in  these  injuries.  In  fractures  of  the  bones  of  the 
pelvis  the  condition  of  the  pelvic  viscera  should  be  carefully  investigated. 
The  vagina  and  rectum  should  be  examined  with  the  finger  :  if  a  laceration 
of  either  of  these  organs  is  present  it  may  be  located,  and  blood  will  usually 
be  found  in  their  cavities,  and  at  the  same  time  the  position  of  the  fragments 
may  be  recognized.  The  treatment  of  these  complications  is  considered 
under  injuries  of  the  special  organs. 

Fractures  of  the  Sacrura.— These  are  uncommon  injuries  unless 
associated  with  fractures  of  other  bones  of  the  pelvis.  The  lower  portion  is 
that  most  liable  to  fracture,  as  it  is  the  most  exposed  portion  of  the  bone. 
They  usually  result  from  concentrated  force  applied  directly  to  the  part,  as 
in  falls  from  a  distance  where  the  patient  alights  upon  the  sacrum,  or  where 
a  heavy  body  comes  in  contact  with  this  bone.  The  line  of  fracture  is  usu- 
ally transverse.  The  displacement  consists  in  an  anterior  projection  of  the 
lower  fragment.  Vertical  fissures  occur  only  with  fissure  through  the  pelvic 
girdle  at  another  point. 

Symptoms. — These  are  pain,  which  is  much  increased  by  movements 
calculated  to  disturb  the  fragments,  by  straining  efforts  at  defecation  from 
the  action  of  the  levator  aui  muscle,  or  by  urination,  coughing,  or  sneezing  ; 
crepitus  may  be  obtained  by  manipulation  of  the  fragments ;  and  by  the 

31 


482  FEACTURES   OF  THE  ILIUM. 

introduction  of  the  finger  into  the  rectum  it  is  often  possible  to  feel  the 
anterior  projection  of  the  fragment. 

Complications. — The  most  serious  complications  in  fractures  of  the 
sacrum  are  injury  to  the  sacral  plexus  or  laceration  of  the  rectum,  and  infec- 
tion of  the  wound  followed  by  suppuration  and  necrosis.  A  force  which  is 
sufficient  to  fracture  the  sacrum  often  iiroduces  extensive  damage  to  the 
pelvic  organs,  aside  from  the  direct  contact  of  the  organs  with  the  fractm-ed 
bone. 

Treatment. — The  patient  should  be  placed  in  bed,  the  thighs  being 
flexed  and  supported  upon  a  pillow ;  the  rectum  should  be  examined,  to 
ascertain  whether  it  has  sustained  any  injury,  and  the  urine  drawn,  to  ascer- 
tain whether  the  bladder  has  escaped  injury.  The  pelvis  should  next  be 
sirrrounded  with  a  stout  musliu  binder,  or  broad  strips  of  adhesive  plaster 
should  be  applied  over  the  ilium  on  each  side,  across  the  sacrum,  to  produce 
fixation  of  the  fragments.  If  the  pain  is  severe,  opiates  should  be  admin- 
istered, and  it  is  well  to  keej)  the  bowels  confined  for  a  few  days  by  their 
use  ;  at  the  end  of  this  time  they  should  be  moved  by  an  enema,  and  after 
they  have  been  freely  moved  they  may  be  kept  quiet  again  by  the  same 
means.  In  uncomplicated  cases  the  patient  should  be  kept  in  bed  for  four 
weeks.  In  compound  and  complicated  fractures  of  the  sacrum  a  much 
longer  period  of  rest  in  bed  will  be  required. 

Fractlire  of  the  Coccyx. — This  fracture  is  not  a  common  one,  and 
results  from  the  ajiplication  of  direct  force  to  the  coccyx  from  kicks,  blows, 
or  falls.  The  displacement  is  usually  forward,  and  the  principal  complica- 
tion is  a  neuralgic  affection  of  the  coccyx  known  as  coccygodynia. 

Treatment. — This  consists  in  placing  the  patient  in  the  recumbent 
posture,  so  that  no  pressure  shall  be  brought  to  bear  upon  the  coccyx  :  ante- 
rior projection  of  the  fragment  may  sometimes  be  relieved  by  introducing 
the  finger  into  the  rectum  and  pushing  the  fragment  backward.  In  spite  of 
treatment  a  certain  amount  of  anterior  projection  of  the  fragment  always 
results  after  fractui-e  of  the  coccyx.  Union  is  usually  sufficiently  firm  in 
three  weeks  to  allow  the  patient  to  pursue  his  ordinary  occupations. 

Fractures  of  the  Ilium.— In  fractures 
^°"  of  the  ilium  the  line  of  fracture  may  separate 

the  crest  or  the  anterior  superior  spinous  pro- 
cess (Fig.  395),  or  it  may  extend  through  the 
body  of  the  bone  from  the  great  sacro-sciatic 
notch  forward.  Fractures  of  the  ilium  are 
usually  produced  by  falls,  or  by  the  pelvis  being- 
caught  between  heavy  bodies  and  crushed. 

Symptoms. — The  prominent  symptom  is 
Ijain  on  motion  ;  the  patient  is  unable  to  stand 
Fracture  of  the  ilium.  ^r  Walk,  and  Crepitus  may  be  elicited  by  grasp- 

ing the  anterior  superior  spinous  process  of  the 
ilium  and  making  lateral  motion.  Where  the  crest  of  the  bone  alone  is 
broken,  the  detached  fragment  may  be  found  drawn  away  from  the  body  of 
the  bone  by  the  action  of  the  abdominal  muscles.  Where  the  anterior  supe- 
rior spinous  process  is  broken,  it  may  be  drawn  downward  by  the  sartorius 


FRACTURES   OF  THE  ISCHIUM. 


483 


Fig.  396. 


muscle.     In  extensive  fractures  of  the  ilium  the  abdominal  viscera  may  be 

injured. 

Treatment. — The  patient  should  be  placed  in  bed  upon  his  back,  and 

the  lower  extremities  flexed  by  ijlacing  pillows  under  them,  the  head  and 

shoulders  also  being  sup]3orted  on  pillows 

to  relax  the  abdominal  muscles.      The 

pelvis  should  be  siu-rounded  by  a  stout 

binder  of  muslin  firmly  secured  by  pins, 

or  broad  strips  of  adhesive  plaster  should 

be  passed  around  the  pelvis,  liroducing 

fixation  of  the  fragments.     The  dressings 

should  be  retained  for  six  weeks. 

Fractures  of  the    Os  Pubis. — 

These  fractures  result  from  the  same  class 

of  injuries  that  produce  fractures  of  the 

other  pelvic  bones,  and  may  involve  the 

horizontal  ramus  (Fig.  396),  the  descend- 
ing ramus,  or  the  body  ;  single  vertical 

fractures  are  not  uncommon  in  this  bone. 

A  diastasis  of  the  os  pubis  at  the  symphysis 

may  also  result.     Fractures  of  the  pubis 

are  often  complicated  by  injuries  of  the 

bladder  and  m-ethra. 

Symptoms. — These  are  severe  pain, 

increased  by  attempts  at  motion  or  by 

pressure  on  the  body  of  the  bone,  inability 

to  walk  or  stand,  and  a  feeling  on  the  jjart  of  the  patient  as  though  he  were 

falling  apart.     Crepitus  and  mobility  may  also  sometimes  be  obtained. 

Treatment. — The  patient  should  be  placed  in  bed  upon  his  back,  with 

the  thighs  flexed,  and  the  pelvis  should  be  suj)ported  by  a  binder  of  strong 
muslin,  or  by  broad  strips  of  adhesive  plaster, 
three  inches  in  width,  extending  entirely  around 
the  pelvis.  In  cases  of  fi-acture  of  the  pubis  the 
patient  should  be  kept  in  bed  and  the  di-essings 
retained  for  six  weeks. 

Fractures  of  the  Ischium.— These  are 
not  so  common  as  those  of  the  other  i)elvic  bones, 
though  they  sometimes  occur  in  connection  with 
similar  injuries  of  the  other  bones  where  great 
force  has  been  applied.  (Fig.  397.)  The  ischium 
may  be  fractured  in  the  ascending  ramus,  through 
the  tuberosity,  or  near  the  acetabulum.  These 
fractures  are  especially  liable  to  occur  in  falls 
from  a  distance,  where  the  weight  of  the  body 

is  received  upon  the  buttocks,  and  are  often  complicated  by  iujm-ies  of  the 

urethra,  bladder,  or  rectum. 

Symptoms. — The  patient  is  unable  to  stand  or  walk,  and  pain  is  a 

prominent  symptom.     By  firmly  grasping  the  tuberosity  of  the  bone  mobil- 


Fracture  of  the  os  pubis.    (After  Agne 


Fig.  397. 


Fracture  of  the  ramus  of  the  ischium 
(Agnew.) 


484  FRACTUEES  OF  THE  FEMUR. 

ity  and  crepitus  may  be  obtained,  and  rectal  or  vaginal  examination  will 
often  disclose  the  seat  of  fracture. 

Treatment. — The  ijatient  should  be  placed  iipon  his  back  or  side,  with 
the  limbs  moderately  flexed  over  pillows,  and  should  be  kept  in  bed  for  six 
weeks. 

Fractures  of  the  Acetabulum. — These  fractures  may  consist  in  a 
single  fissure  or  a  number  of  fissures ;  the  lip  of  the  acetabulum  may  be 
detached,  and  in  some  cases  the  head  of  the  femur  has  been  driven  through 
the  acetabulum  into  the  pelvis.  When  the  lip  of  the  acetabulum  is  broken, 
the  head  of  the  femur  may  slip  out  of  the  acetabulum  when  the  thigh  is 
rotated.  These  fractures  result  from  violence  applied  to  the  sides  of  the 
pelvis,  or  from  force  transmitted  through  the  femur. 

Symptoms. — These  are  often  very  obscure,  and  they  may  be  confounded 
with  those  of  fractures  of  the  neck  of  the  femur  or  dislocations  of  the  head 
of  the  bone.  A  digital  examination  of  the  inner  surface  of  the  pelvis  oppo- 
site the  acetabulum  should  be  made  by  the  rectum.  Fracture  of  the 
posterior  lip  of  the  acetabulum,  permitting  displacement  of  the  head  of  the 
femur  backward  and  ujiward,  is  especially  liable  to  be  confounded  with 
posterior  dislocation  of  the  femur. 

Treatment. — The  patient  should  be  placed  upon  a  firm  bed,  and  an 
extension  apparatus  similar  to  that  employed  in  the  treatment  of  fractures 
of  the  femur  should  be  applied  to  the  limb  of  the  injured  side.  This  often 
relieves  the  patient's  discomfort,  and  the  extension  should  be  continued  for 
at  least  four  or  five  weeks.  Where  it  is  found  that  the  edge  of  the  acetabu- 
lum is  fractured,  the  addition  of  a  compress  above  the  fragment,  held  firmly 
in  place  by  broad  strips  of  adhesive  plaster,  will  give  additional  fixation. 

Compound.  Fractures  of  the  Pelvis.^ — These  are  grave  injuries  on 
account  of  the  risk  of  infection  of  the  wound  and  visceral  injuries.  The 
treatment  consists  in  careful  sterilization  of  the  wound  and  the  use  of 
copious  sterilized  dressings  in  addition  to  the  dressings  applied  in  simple 
fractures  of  the  pelvic  bones.  Wiring  the  fragments  in  compound  fracture 
of  the  pelvis  may  be  required  where  it  is  found  impossible  to  keep  the 
fragments  in  position. 

FRACTURES  OF  THE  FEMUR. 

Fractures  of  the  femur  are  common  injuries,  and  constitute  about  six  per 
cent,  of  all  fractures.  They  occur  at  all  ages,  but  fractures  of  certain 
portions  of  the  bone  are  met  with  at  different  periods  of  life.  Fractures  of 
the  shaft  of  the  bone  are  common  in  children  and  adults,  of  the  lower 
extremity  in  adults,  and  of  the  neck  in  the  aged.  Fractures  of  the  femur 
may  involve  the  upper  extremity,  the  shaft,  or  the  lower  extremity. 

Fractures  of  the  Upper  Extremity  of  the  Fem.ur.— These 
include  separatiou  of  the  upper  epiphysis,  fi-actures  of  the  head  and  the 
neck,  and  fracture  of  the  great  trochanter.  Fracture  of  the  head  of  the  femur 
is  so  rare  an  injury  that  it  need  not  be  considered. 

Separation  of  the  Upper  Epiphysis  of  the  Femur. — This  is  com- 
paratively a  rare  injury,  and  results  from  direct  or  indirect  force,  and  may 
occur  up  to  the  twentieth  year,  but  has  most  frequently  been  observed 


FRACTURES  OF  THE  FEMUR. 


485 


Fig.  .398. 


between  tlie  foiirteentli  and  eighteenth  years.  (Fig.  398.)  It  is  possible 
that  the  injury  is  more  frequent  than  is  generally  supposed,  and  that  in 
many  cases  in  which  the  deformity  was  not  marked  the 
injury  has  been  overlooked.  It  is  also  probable  that  many 
of  the  cases  of  coxa  vara,  which  have  recently  attracted 
considerable  attention,  have  resulted  from  separation  of  the 
upper  epiphysis  of  the  femur.  Symptoms. — These  are 
pain,  shortening  of  the  limb,  eversion  of  the  foot,  some- 
times inversion,  elevation  of  the  great  trochanter,  and 
moist  crepitus.  Diagnosis. — This  injury  is  likely  to  be 
confounded  with  dislocation  of  the  head  of  the  femur  on 
the  dorsum  ilii  and  fracture  of  the  neck  of  the  femur. 
Prom  dislocation,  which  is  rare  in  childhood,  the  diagnosis 
is  made  by  observing  the  absence  of  fixation  and  inversion 
of  the  limb  and  feeling  the  head  of  the  bone  in  an  abnormal 
position.  From  fracture  of  the  neck  of  the  femur,  of  which 
a  few  cases  have  been  observed  in  children,  the  diagnosis 
is  diiflcult,  as  both  lesions  present  shortening,  eversion, 
pain,  loss  of  function,  and  crepitus,  but  the  latter  is  rough 
and  bony  in  fracture  and  soft  or  muffled  in  ej)iphyseal 
separation.  Treatment. — This  consists  in  the  reduction 
of  the  deformity  if  present  by  manipulation  and  extension, 
and  fixation  of  the  limb  by  similar  apparatus  to  that  which 
is  employed  in  fracture  of  the  femur. 

Separation  of  the  Epiphysis  of  the  Great  Tro- 
chanter of  the  Femur. — This  may  result  from  direct 
violence  or  muscular  action,  and  has  been  observed  in  a  few  cases,  and  has 
been  most  frequently  seen  from  the  thirteenth  to  the  sixteenth  years. 
Symptoms. — These  are  pain,  swelling,  muffled  crepitus,  and  in  some  cases 
displacement  of  the  fragment.  Prognosis. — In  this  injury  the  prognosis 
is  grave,  for  in  many  of  the  cases  suppuration  and  pytemia  occurred  with 
a  fatal  result.  Fibrous  union  may  result  if  the  separation  is  great.  Treat- 
ment.— This  consists  in  fixation  of  the  joint  by  a  long  splint  applied  to  the 
body  and  limb  with  a  compress  at  the  seat  of  separation,  or  the  use  of  a 
plaster-of-Paris  dressing. 

Separation  of  the  Epiphysis  of  the  Lesser  Trochanter. — This  may 
occur  as  the  result  of  muscular  action  from  the  thirteenth  to  the  eighteenth 
year.  The  symptoms  are  outward  rotation  of  the  limb,  pain,  swelling, 
and  inability  to  move  the  limb.  Suppuration  may  occur  and  lead  to  a  fatal 
result.  Treatment. — This  consists  in  fixation  of  the  limb  by  splints  or  a 
plaster-of-Paris  dressing. 

Fractures  of  the  Neck  of  the  Femur. — Fractures  of  the  neck  of 
the  femur  may  occur  through  the  narrow  portion  of  the  neck  of  the  bone 
near  the  head  or  through  the  base  of  the  neck  of  the  bone,  and  the  line  of 
fracture  may  be  within  the  insertion  of  the  capsule  of  the  joint.  The  line 
of  fracture  may  also  be  entirely  external  to  the  cai^sule,  or  may  be  partly 
within  and  partly  without  the  capsule,  constituting  what  are  known  as 
"mixed  fractures"  in  contradistinction  to  those  occurring  within  the  cap- 


Epiphyses  of  femur. 
(After  Poland.) 


486 


FRACTURES   OF  THE  NECK  OF  THE  FEMUR. 


sule,  wMcli  are  described  as  intracapsular  fractures.  These  fractures  are 
most  common  in  advanced  age,  but  may  occur  in  young  subjects,  and  are 
most  frequent  in  females,  and  constitute  the  large  majority  of  fractures  of 
the  femur  seen  after  iifty  years  of  age.  They  often  occur  as  the  result  of 
the  application  of  a  trivial  amount  of  force,  and  are  peculiar  from  the  fact 
that  bony  union  is  not  common.     (Fig.  399. )     The  great  frequency  of  frac- 


FiG   399. 


Skiagraph  of  fracture  of  the  neck  of  the  femur. 


Impacted  fracture  of  tin 


ture  of  the  narrow  part  of  the  neck  of  the  femur  in  advanced  age  from 
slight  violence  is  probably  due  to  the  weakening  of  the  cancellous  tissue  of 
the  femoral  neck  from  senile  atrophy  or  from  fatty  degeneration.  It  is 
questionable  whether  there  is  a  marked  change  in  the  angular  relation  of 
the  head  and  neck  of  the  bone  to  the  shaft  in  advanced  life. 

These  fractures  may  result  from  severe  force  applied  to  the  hij)  or  knee  ; 
slight  falls  upon  the  trochanter  or  the  knee,  or  twisting  of  the  thigh,  in 
persons  of  advanced  age  are  often  followed  by  a  fracture  of  the  neck  of  the 
bone.  They  may  be  oblique,  so  that  the  line  of  fracture  extends  through 
the  bone  outside  of  the  joint,  or  there  jnay  be  impaction  of  the  fragments, 
so  that  the  lower  fragment  is  driven  into  and  fixed  in  the  substance  of  the 
neck  or  head  of  the  bone.  (Fig.  400.)  In  fracture  of  the  neck  of  the 
femur,  as  before  stated,  bony  union  is  not  common,  but  fibrous  union  often 
takes  place,  or  union  may  be  entirely  absent,  and  there  is  often  more  or  less 
absorption  of  the  neck  of  the  bone.     (Fig.  401.) 

Symptoms. — These  are  pain,  loss  of  power  of  the  limb,  mobility, 
deformity,  and  crepitus.  Pain,  if  impaction  has  not  occurred,  is  acute,  is 
aggravated  by  muscular  spasm,  and  is  relieved  by  extension  made  upon  the 
injured  limb.  The  loss  of  function  is  marked ;  occasionally,  however, 
patients  are  able  to  perform  certain  motions  at  the  hiij-joiut  when  a  frac- 
ture is  present,  which  probably  results  from  impaction  of  the  fragments. 
Mobility  in  cases  of  fracture  of  the  neck  of  the  femur  is  usually  increased. 


FRACTURES  OF  THE  NECK  OF  THE  FEMUR. 


487 


Shorten  iug,  which  is  caused  by  the  fragments  being  driven  past  each  other, 
varies  from  half  an  inch  to  an  inch,  but  may  be  progressive  and  increase 
gradually  for  some  weeks  after  the  injury.  Shortening  when  the  fracture 
involves  the  narrow  portion  of  the  neck  is  less  than  in  fractures  involving 
the  base  of  the  neck,  as  the  fi-agments  are  held  by  the  capsular  attachments. 

Crepitus  cannot  be  obtained  when  there 
Fig.  401.  is  firm  impaction  of  the  fragments,  but  can 

be  obtained  by  rotating  the  thigh  when  the 
fragments  are  loose. 

Fig.  402. 


Absorption  of  the  neck  of  the  femur  after 
fracture. 


Displacement  in  fracture  of  the  neck  of  the  femur. 
(Hines.) 


Eversion  of  the  foot  is  usually  present,  except  in  cases  of  impaction, 
when  instead  of  eversion  there  may  be  inversion  of  the  foot. 

Deformity. — The  displacement  in  fracture  of  the  neck  of  the  femur  is 
due  to  the  action  of  the  glutei  muscles,  the  pectineus,  and  the  adductors,  as 
well  as  of  the  psoas,  iliacus  iuternus,  and  obturator  externus  muscles.  The 
displacement  is  shown  in  Pig.  402.  Another  marked  deformity  is  eversion 
of  the  foot,  from  external  rotation  of  the  limb.  This  is  due  to  the  action  of 
the  external  rotator  muscles,  to  the  absence  of  resistance  of  the  ligamentum 
teres,  and  to  the  action  of  gravity,  as  the  centre  of  gravity  of  the  leg  and 
thigh  lies  outside  of  the  centre  of  figure  of  the  limb.  Crepitus  may  be 
elicited  in  the  majority  of  cases  of  unimpacted  fracture,  by  making  exten- 
sion upon  the  leg,  iiesing  the  thigh  at  right  angles  with  the  pelvis,  and 
rotating  the  limb.  If  other  symptoms  of  fracture  of  the  femur  are  present, 
it  is  not  advisable  to  make  forcible  prolonged  efforts  to  obtain  crepitus,  as 
by  so  doing  the  periosteum  may  be  torn,  or  an  impacted  ft-acture  may  be 
liberated  and  greater  deformity  result. 

Prognosis. — In  cases  of  fracture  of  the  neck  of  the  femur,  as  they  usu- 
ally occur  in  aged  persons,  the  prognosis  is  generally  grave,  and  many  patients 
suffering  from  this  fracture  die  from  exhaustion  following  the  confinement 
to  bed  and  the  occurrence  of  bed-sores.  In  these  fractures  union  may  be 
absent,  or  there  may  be  bony  union,  or  fibrous  union  may  occur.      The 


488 


FEACTUEES  OF  THE  NECK  OF  THE  FEMUR. 


Fig.  403. 


Excessive  callus  after  fracture  of 
the  neck  of  the  femur.   (Agnew. ) 


causes  of  non-union  are  probably  deficient  vascularity,  the  presence  of  syno- 
vial fluid  in  contact  with  the  reparative  material,  and  the  imperfect  coap- 
tation of  the  fragments.  The  most  satisfactory  results  occur  in  those  cases 
in  which  the  line  of  fracture  not  only  involves  the  neck  of  the  bone,  but 
extends  to  the  bone  outside  of  the  neck.  In  these 
cases  there  is  enough  reparative  material  deposited 
outside  of  the  capsule  to  give  a  certain  amount  of 
fixation.  In  some  fractures  of  the  neck  of  the 
femur,  more  or  less  comminution  occurs,  and  in 
these  fractures  an  excessive  amount  of  callus  may 
be  produced.  (Pig.  403.)  There  are,  however, 
occasionally  seen  cases  in  which  patients  recover 
with  fairly  useful  limbs  in  spite  of  considerable 
shortening. 

Diagnosis. — The  injury  which  is  most  likely 
to  be  confounded  with  fracture  of  the  neck  of  the 
femur  is  posterior  dislocation  of  the  femur.  Frac- 
ture is  usually  produced  by  trival  force  or  by  force 
applied  directly  to  the  trochanter.  Posterior  dis- 
location usually  results  from  great  force  applied  to 
the  knee  while  the  thigh  is  adducted.  Fracture  occurs  most  commonly 
after  fifty  years  of  age  and  most  frequently  in  females  ;  dislocation  is  more 
likely  to  occur  in  adult  males  before  fifty  years  of  age.  In  fracture  the 
limb  is  markedly  everted,  unless  there  be  impaction,  and  in  dislocation 
inversion  and  adduction  of  the  thigh  are  present.  The  shortening  in  frac- 
ture is  at  first  trivial,  and  may  be  from  one  inch  to  two  inches.  The  short- 
ening is  ascertained  by  measuring  with  a  steel  tape  from  the  anterior  supe- 
rior spinous  process  of  the  ilium  to  the  inner  malleolus  on  the  sound  side 
and  on  the  injured  side  and  noting  the  difference.  In  posterior  dislocation 
the  shortening  is  often  three  or  four  inches.  In  fracture  the  shortening  can 
be  reduced  by  extension,  but  recurs  on  the  removal  of  the  extending  force. 
In  dislocation,  when  the  short- 
ening is  reduced  by  replacing 
the  bone,  on  the  removal  of  the 
extending  force  it  does  not 
recur.  In  fracture  there  is 
great  mobility,  while  in  disloca- 
tion the  limb  is  rigid.  Crepitus 
may  often  be  obtained  in  frac- 
ture ;  in  dislocation  there  is  no 
true  crepitus.  Another  method 
of  recognizing  shortening  and 
measuring  its  extent  is  Bryant's 

ilio-femoral  triangle  (Fig.  404) :  a  vertical  line,  a,  e,  is  drawn  from  the  anterior 
superior  spinous  process,  another  line,  h,  c,  is  drawn  from  the  tip  of  the  great 
trochanter,  measurements  are  made  oa  both  sides,  and  if  shortening  exists 
the  line  6,  c  is  shorter  on  the  injured  side  than  on  the  uninjured  side. 

Nelaton's  line  is  also  employed,  and  consists  in  passing  a  cord  from  the 


Fig.  404. 


,  c,  Bryant's  ilio-femoral  triangle  ;  a,  d,  N^laton's  line. 


FRACTURES  OF  THE  NECK  OF  THE  FEMUR. 


489 


anterior  superior  spinous  process  of  the  ilium  to  the  tuberosity  of  the 
ischium,  which  when  no  shortening  is  present  should  pass  over  the  top  of 
the  great  trochanter  when  the  thigh  is  slightly  flexed  on  the  pelvis.  (Fig.  404. ) 

AUis  has  called  attention  to  a  sign  of  fracture  of  the  neck  of  the  femur, 
which  consists  in  a  relaxed  condition  of  the  fascia  lata  between  the  crest  of 
the  ilium  and  the  trochanter  major  on  the  Injured  side,  due  to  the  loss  of 
resistance  which  is  normally  furnished  by  the  unbroken  neck  of  the  bone. 
This  is  a  valuable  diagnostic  sign  in  this  fracture. 

Eotation  of  the  trochanter  on  a  shorter  axis  than  on  the  normal  side  and 
fulness  in  Scarpa's  triangle  are  also  important  in  the  diagnosis. 

Treatment. — As  it  is  impossible  in  any  case  of  fracture  of  the  neck  of 
the  femiu-  to  say  that  the  fracture  is  entirely  within  the  capsule,  it  is  wise 
to  treat  the  patient  as  though  there  were  a  prospect  of  bony  union.  But  as 
these  fractures  occur  in  patients  well  advanced  in  years,  and  as  such  cases 
frequently  do  not  bear  the  application  of  retentive  apparatus  well,  the 
surgeon  has  often  to  consider  the  patient's  constitutional  condition  more 
than  the  local  injury,  and  has  practically  to  disregard  the  treatment  of  the 
fracture  and  get  the  patient  up  and  about  as  a  means  of  improving  his  gen- 
eral condition.  We  have  seen  very  excellent  results  in  cases  of  fracture  of 
the  neck  of  the  femur  in  which  the  patient  was  allowed  to  remain  in  bed, 
changing  the  position  as  often  as  was  desired,  for  three  or  four  weeks,  no 
retentive  dressings  being  applied. 


Application  of  adhesive  plaster  extension  apparatus. 


The  dressing  which  we  would  recommend  in  cases  of  fracture  of  the  neck 
of  the  femur  Is  an  extension  apparatus,  which  is  made  by  taking  a  strip  of 
adhesive  plaster  two  and  a  half  inches  in  width  and  long  enough  to  extend 
from  the  knee-joint  or  the  middle  of  the  thigh  down  the  leg  to  two  or  three 
inches  below  the  heel,  forming  a  loop  ;  it  is  then  carried  up  the  other  side 
of  the  limb  to  a  point  opposite  the  point  of  starting.     (Fig  405.)     Some 


490 


FEA-CTUEES   OF  THE  NECK  OF  THE   FEMUE. 


surgeons  prefer  to  cai'ry  the  extension  strips  of  plaster  well  up  on  the  thigh, 
fearing  that  if  they  extended  only  to  the  knee-joint  the  ligaments  would  be 
injured,  but  in  using  the  strips  only  to  the  knee  in  a  large  number  of  cases 
the  writer  has  never  found  any  damage  to  result.  A  block  of  wood  about 
five  inches  in  length  and  three  inches  in  width  is  fastened  to  the  middle  of 
this  strip  of  i)laster,  and  is  secui-ed  in  position  by  a  short  strip  of  plaster  of 
the  same  width,  about  twelve  inches  in  length.  This  block  is  secured  by 
wrapping  it  with  a  few  strips  of  plaster.  The  strip  of  plaster,  being  heated, 
is  attached  to  the  outer  and  inner  sides  of  the  leg  from  the  knee  to  just 
above  the  malleoli.  It  is  secured  by  three  bands  of  plaster  carried  around 
the  leg,  one  applied  just  above  the  malleoli,  the  second  about  the  middle 
of  the  leg,  and  the  third  just  below  the  knee.  A  bandage  is  applied  to  the 
foot  and  leg,  to  give  additional  fixation  to  the  plaster.  A  piece  of  cord 
is  next  secured  in  a  perforation  in  the  block  below  the  foot.  The  patient 
being  placed  in  the  recumbent  position  in  bed  upon  a  firm  mattress, 
lateral  support  is  given  to  the  limb  by  means  of  a  short  internal  sand-bag 
extending  from  the  perineum  to  the  sole  of  the  foot,  and  a  long  external 
sand-bag  extending  from  the  axilla  to  the  external  malleolus.  Eversion  of 
the  foot  is  corrected  by  rotating  the  thigh  inward,  and  the  corrected  posi- 
tion is  maintained  by  apposition  of  the  external  sand-bag.  A  weight  of 
from  five  to  eight  pounds  is  attached  to  the  cord  and  secured  to  the  block 
in  the  extension  apparatus.     (Fig.  -106. )     If  this  dressing  is  well  borne,  it 


Fig.  406, 


Dressing  for  fracture  of  the  neck  of  the  femur. 


should  be  kept  in  position  for  from  eight  to  ten  weeks  ;  the  patient  should 
then  be  allowed  to  sit  up  in  bed,  and  finally  to  get  out  of  bed  and  use 
crutches,  bearing  at  first  very  little  weight  upon  the  injured  limb.  If,  how- 
ever, the  recumbent  posture  and  the  confinement  in  bed  affect  the  patient 
unfavorably  before  this  period,  it  may  be  necessary  to  abandon  all  treat- 
ment and  to  allow  him  to  sit  in  a  chair  or  to  use  crutches,  the  trea.tment  of 
the  fracture  for  the  time  being  disregarded.  It  is  remarkable  in  some  cases, 
even  of  persons  far  advanced  in  years,  how  much  use  of  the  limb  the  patient 
may  regain  after  this  fracture. 

Fracture  of  the  Great  Trochanter. — This  consists  in  a  separation 
of  the  great  trochanter  from  the  sliaft  of  the  femur,  and  usually  results  from 


FEACTUEES  OF  THE  UPPEE  THIED  OF  THE  FEMUR. 


491 


direct  violence,  such  as  falls  upon  this  portion  of  the  bone.  In  patients 
under  eighteen  years  of  age  the  injury  may  consist  in  a  separation  of  the 
epiphysis.     Suppuration  and  necrosis  not  infrequently  follow  this  injury. 

Symptoms. — These  are  swelling  in  the  region  of  the  trochanter,  pain, 
tenderness,  and  mobility  of  the  fragments  elicited  by  manij)ulation  ;  crepitus 
also  may  be  obtained.  There  will  be  no  shortening  of  the  thigh,  and  move- 
ments of  the  hip  may  be  but  slightly  impaired. 

Treatment. — This  consists  in  fixation  of  the  limb  by  the  use  of  sand- 
bags ;  if  there  is  pain  fi'om  contusion  of  the  joint  produced  at  the  time  of 
the  injury,  this  may  be  relieved  by  the  application  of  the  extension  appa- 
ratus, such  as  is  employed  in  cases  of  fracture  of  the  neck  of  the  femur. 

Fractures  of  the  Upper  Third  of  the  Femur.— These  fractures 
are  often  accompanied  bj'  marked  deformity,  and  their  treatment  is  difficult, 
owing  to  the  fact  that  the  upper  fragment  is  often 
Fin.  407.  displaced  upward  and  inward  by  the  action  of  the 

psoas  and  iliacus  internus  muscles,  or  outward  by 
the  action  of  the  gluteus  minimus,  obturator  inter- 
nus, and  quadratus  fern  oris  muscles.  (Fig.  407.) 
The  greatest  difficulty  experienced  in  the  treatment 
of  these  fractures  arises  from  this  displacement  of 
the  upper  fragment,  which  may  lead  to  marked  short- 
ening, angular  deformity,  and  consequent  impair- 
ment of  the  use  of  the  limb. 

Treatment. — In  these  fractures,  in  the  majority 
of  cases  the  dressing  which  will  be  described  for  frac- 
tures of  the  shaft  may  be  employed  with  satisfac- 


Displacement  in  fracture  of  Smith's  anterior  wire  splint, 

the.  upper  third  of  the  femur. 
(Agnew.) 

tory  results,  bnt  occasionally  cases  are  met  with  in  which  the  upward  and 
inward  tilting  of  the  upper  fragment  is  so  marked  that  a  different  kind 
of  dressing  has  to  be  resorted  to.  In  such  cases,  where  it  is  impossible  to 
bring  the  upper  fragment  in  contact  with  the  lower  one,  the  surgeon  may 
find  it  advisable  to  apply  a  dressing  which  will  bring  the  lower  fragment  in 
the  line  of  the  upper  fragment.  This  may  be  accomplished  by  using  the 
anterior  wire  splint  of  Professor  N.  E.  Smith  (Pig.  408),  or  by  placing  the 
leg  and  thigh  upon  a  double  inclined  plane  and  applying  an  extension  appa- 
ratus to  the  thigh  from  the  knee  to  a  point  a  little  below  the  seat  of  fracture, 


492 


FRACTURES   OF  THE  SHAFT  OF  THE  FEMUR. 


extension  being  made  by  a  weight  and  pulley,  as  shown  in  Pig.  409,  and  lateral 
support  supplied  either  by  the  use  of  short  rhoulded  splints  or  by  movable 
sides  attached  to  the  double  inclined  splint. 


Fig 


ll!|l'1lillllll|llll|il1ll'illlllllllillll!l'lfFFii''ii^--^  "  -I  'I'll, 

Double intlmed  plane.     (At,iie-«.) 

Fractures  of  the  Shaft  of  the  Femur.— Fractures  of  the  shaft  ot 
the  femur  are  common  injuries,  and  are  most  frequent  under  ten  years  of 
age.  The  line  of  fracture  may  be  transverse  or  oblique.  Transverse  frac- 
tures of  the  femur  are  most  common  in  children,  oblique  fractures  in  adults. 
They  may  occur  from  direct  violence,  as  the  result  of 
the  passage  of  heavy  bodies  over  the  thigh,  or  may 
result  from  indirect  violence,  from  force  transmitted 
through  the  foot  and  leg.  Muscular  action  may  also 
produce  fracture  of  the  shaft  of  the  femur. 

Symptoms. — These  are  pain,  increased  by  move- 
ments or  by  muscular  contraction ;  mobility,  which 
may  be  demonstrated  by  raising  the  leg  or  thigh,  and 
by  adduction  or  abduction  ;  and  deformity,  which 
consists  in  shortening,  with  a  prominence  upon  the 
anterior  portion  of  the  thigh  (Fig.  410),  or  may  con- 
sist of  marked  angular  displacement  of  the  fragments 
and  eversion  of  the  foot.  The  shortening  may  not  be 
marked  in  transverse  fractures,  or  in  indented  frac- 
tures in  which  the  irregular  projections  of  the  frag- 
ments are  interlocked.  Crepitus  may  be  elicited  by 
rotating  the  thigh.  In  fracture  of  the  shaft  of  the 
femur  the  disability  is  marked,  the  patient  usually 
being  unable  to  move  the  limb. 
Deformity  in  fracture  of  Prognosls. — In  cases  of  Simple  fracturc,  without 
the  shaft  of  the  femur.  (Ag-  complications,  a  good  result  generally  follows.  The 
results  of  this  fracture  in  children  are  usually  favor- 
able as  regards  recovery  with  very  little  shortening.  In  adults,  however, 
a  certain  amount  of  shortening  always  occurs,  varying  from  a  quarter  of  an 
inch  to  an  inch  and  a  half.  Agnew  held  that  in  this  fracture  of  the  femur, 
except  in  cases  of  children,  an  appreciable  shortening  always  resulted. 

Treatment. — The  patient  should  be  placed  in  bed  upon  a  firm  mattress  ; 
an  extension  apparatus  of  adhesive  plaster  is  applied,   and  a  weight  is 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUE. 


493 


attached  to  this,  as  previously  described  uuder  fractures  of  the  neck  of  the 
femur.  Lateral  support  is  given  to  the  limb  by  the  application  of  two 
wooden  splints,  the  outer  or  longer  one  extending  from  the  axilla  to  the  foot, 
the  inner  or  shorter  one  extending  from  the  perineum  to  the  foot.  The 
upper  extremity  of  each  should  be  about  sis  inches  in  width,  and  the  lower 
extremity  about  three  and  a  half  inches.  The  splints  should  be  wrapped  in 
a  splint-cloth  which  extends  from  the  foot  to  the  groin,  and  after  this  has 
been  placed  under  the  limb  they  are  fixed  in  their  positions,  the  short  one 
to  the  inner  side,  the  long  one  to  the  outer  side,  of  the  limb.  Between  the 
limb  and  the  splints  bran-bags,  or  bags  filled  with  cotton,  should  be  inter- 
posed ;  the  outer  one  should  be  long  enough  to  extend  from  the  axilla  to  the 
foot,  and  the  inner  one  from  the  groin  to  the  foot.  The  splints  and  bran- 
bags  should  next  be  held  in  i^osition  by  five  or  six  strips  of  bandage  passed 


Dressing  for  fracture  of  the  shaft  of  the  femur. 

at  intervals  under  the  limb  and  body  and  around  the  splints  and  bran-bags. 
(Fig.  411.)    The  heel  is  saved  from  pressure  by  placing  a  pad  of  oakum  or 
cotton  under  the  tendo  Achillis,  and  after  the  splints  have  been  brought 
into  place  the  strips  of  bandage  are  firmly  tied,  and  a  weight  of  ten  or 
twelve   pounds  is  at- 
tached to  the  extend-  Fig.  412. 
ing  cord.     The  foot  of 
the  bed  is  raised,  to 
prevent    the    patient 
from    slipping    down- 
ward, and  to  allow  the 
weight  of  the  body  to 
act  as  a  counterextend- 
ing  force.  Volkmann's 
slide,  which  raises  the 
heel  and  leg  and  pre- 
vents them  from  bur- 
rowing into  the  mattress,  may  be  employed  to  hold  the  foot  in  place  and  to 
make  the  extension  more  effective.   (Pig.  412.)   After  the  application  of  the 
dressing  the  thigh  should  be  slightly  abducted.     During  the  after-ti-eatment  of 
fractures  of  the  shaft  of  the  femur  the  surgeon  should  see  that  the  splints  and 


Volkmann's  sliding  foot-piece. 


494 


FEACTUEES   OF  THE  SHAFT  OF   THE  FEMUE. 


Fig.  ^IS. 


brau-bags  are  kept  firmly  in  place  and  that  the  foot  does  not  roll  outward. 
This  is  accomplished  by  untying  the  strips  and  readjusting  the  bags,'  and 
then  bringing  up  the  splints  and  securing  them  in  position  by  fastening  the 
strips.  The  extension  apparatus  does  not  require  renewal  during  the  course 
of  treatment.  The  extension  apparatus  and  splints  are  kept  in  position  for 
from  six  to  eight  weeks  in  an  adult.  At  the  end  of  this  time  union  at  the 
seat  of  fracture  is  usually  quite  firm,  so  that  they  may  be  removed,  and  the 
fracture  may  then  be  supported  by  moulded  pasteboard  splints,  or  by  the 
application  of  a  plaster-of- Paris  splint,  for  several  weeks  longer.  At  the 
end  of  eight  weeks  it  is  safe  to  allow  the  patient  to  be  up  and  about  on 
crutches.  Lateral  support  in  fractures  of  the  shaft  of  the  femur  may  also 
be  supplied  by  the  use  of  a  long  external  sand-bag  and  a  short  internal  one, 
in  place  of  the  corresponding  long  and  short  splints  and  bran-bags.  If  care 
is  taken  that  the  sand-bags  are  kept  accurately  in  contact 
with  the  limb  and  body,  excellent  results  may  be  obtained 
by  this  form  of  dressing.  After  considerable  experience 
with  different  methods  of  furnishing  lateral  support  in 
fracture  of  the  shaft  of  the  femur,  we  are  satisfied  that 
angular  deformity  is  less  likely  to  result  where  the  sijlints 
and  bran-bags  are  employed.  The  plaster-of-Paris  dress- 
ing, including  the  foot,  leg,  thigh,  and  pelvis,  is  employed 
by  some  surgeons  in  this  fracture,  the  limb  being  kept  well 
extended  until  the  plaster  is  thoroughly  diy.  This  dress- ' 
ing  is  also  applied  in  the  ambulant  method  of  treatment, 
which  will  be  described  later. 

Fracture  of  the  Shaft  of  the  Femur  in  Chil- 
dren.— These  fractures  in  young  children  are  often  in- 
complete or  "greenstick"  fractures,  and  even  when  com- 
plete the  shortening  is  usually  not  marked,  as  the  line  of 
fracture  is  likely  to  be  transverse,  and  the  periosteum 
often,  not  being  comj)letely  ru^jtured,  tends  to  hold  the 
fragments  in  position.  In  cases,  however,  in  which  the 
periosteum  is  extensively  torn,  marked  displacement  and 
shortening  may  occur,  as  is  shown  in  the  specimen,  taken 
from  a  child  eighteen  months  of  age,  two  weeks  after  a 
fracture  which  had  not  been  treated.  (Fig.  413. )  In  in- 
complete fractures  with  deformity,  the  latter  should  be 
reduced  by  manipulation,  even  if  it  is  necessarj-  to  convert  the  incomplete 
fracture  into  a  complete  one  to  accomplish  this  object. 

Treatment. — The  treatment  of  these  fractures  in  young  children  by 
extension  and  lateral  splints  is  sometimes  troublesome,  on  account  of  the 
difficulty  in  keeping  the  patient  quiet  upon  his  back  and  from  the  soiling  of 
the  dressing  by  fteces  and  urine.  In  children  two  years  of  age  and  over  we 
have  never  found  much  trouble  in  employing  extension  and  lateral  support 
by  splints  and  bran-bags  or  sand-bags,  and  have  used  this  method  in  younger 
children,  but  in  these  cases  we  make  additional  fixation  at  the  seat  of  frac- 
ture, and  guard  against  displacement  of  the  fragments  by  the  child's  sitting 
up  in  bed  when  not  carefully  watched,  by  moulding  and  applying  well- 


Fractured  femur  of 
a  child  of  eighteen 
months,  two  weeks 
after  injury. 


SEPARATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  FEMUR.         495 

padded  internal  and  external  pasteboard  or  binder's  board  splints  to  the 
thigh  and  holding  them  in  place  by  the  turns  of  a  bandage.  These  fractures 
may  also  be  dressed  according  to  Bryant's  method,  by  suspending  both  legs 
from  a  gallows  over  the  bed  so  as  just  to  lift  the  sacrum  from  the  bed,  or  a 
plaster-of- Paris  bandage  from  the  foot  to  the  waist  may  be  employed.  In 
cases  of  fracture  of  the  femur  in  children  eighteen  months  of  age  or  under, 
it  is  often  difficult  to  keep  them  in  a  fixed  position,  or  they  may  have  to  be 
moved  to  give  nourishment  if  they  are  taking  the  breast.  In  such  cases  the 
dressing  which  we  have  found  most  satisfactory  consists  in  applying  a  roller 
bandage  from  the  foot  to  the  groin,  and  then  moulding  to  the  outer  half  of 
the  foot,  leg,  thigh,  and  pelvis  a  binder's  board  splint,  applied  wet  and 
allowed  to  dry  and  harden,  which  is  well  padded  with  cotton  and  held  in 
position  by  the  turns  of  a  bandage  carried  from  the  foot  to  the  pelvis  and 
finished  with  circular  turns  about  the  latter.  This  splint  should  be  fitted  so 
as  to  include  a  little  more  than  one-half  the  circumference  of  the  thigh  and 
leg.  If  the  splint  becomes  soiled  it  is  easily  rei^laced  by  a  fresh  one,  and  its 
removal  and  renewal  are  much  easier  than  is  the  case  with  the  plaster-of- 
Paris  dressing. 

Supracondyloid  Fractures  of  the  Femur. — These  may  occur 
immediately  or  a  short  distance  above  the  condyles.  The  treatment  of  supra- 
condyloid fractures  is  similar  to  that  employed  in  cases  of  fracture  of  the 
shaft  of  the  femur. 

Separation  of  the  Lower  Epiphysis  of  the  Femur. — This  acci- 
dent occurs  in  children  or  in  j)atients  under  twenty  years  of  age,  as  the 
result  of  direct  or  indirect  violence  ;  in  a  large  number 
of  the  cases  the  separation  was  due  to  a  forcible  twisting 
of  the  leg  by  being  caught  between  the  spokes  of  a  moving 
wheel.  The  separation  may  be  compound  or  simple.  A 
simple  separation  of  the  lower  epiphysis  of  the  femur 
may  be  confounded  with  a  dislocation  of  the  knee-joint, 
but  a  careful  examination  will  show  that  the  articular 
surface  of  the  femur  is  still  in  contact  with  the  articular 
surface  of  the  tibia.  The  deformity  generally  consists  in 
the  epij)hysis  being  carried  forward  and  the  end  of  the 
shaft  of  the  femur  being  forced  backward  into  the  pop- 
liteal space,  where  it  may  injure  the  vessels  and  nerves. 
(Pig.  ■414.)  The  cases  of  separation  of  the  lower  epiph- 
ysis of  the  femur  which  have  come  under  our  observation 
have  occurred  from  the  leg  being  thrust  between  the  separation  oi  the  lower 
spokes  of  a  moving  wheel,  and  have  usually  been  cases  ?Hamiuon°)  "^'^  '^^"'^ 
of  compound  separation  of  the  epiphysis. 

Treatment. — The  treatment  of  simple  separation  of  the  lower  epiphysis 
of  the  femur  consists  in  reduction  of  the  deformity  by  manipulation  and  the 
aijplication  of  an  extension  apparatus  to  the  leg,  with  lateral  supijort  to  the 
leg  and  thigh  by  the  use  of  padded  splints  or  sand-bags,  or  in  the  application 
of  a  plaster-of- Paris  bandage.  In  compound  separation,  if  the  vessels  and 
nerves  are  not  injured,  the  wound  should  be  sterilized  and  the  displacement 
reduced ;  if  the  vessels  are  injured,  j)rimary  amputation  may  be  required. 


496  FRACTURES   OF  THE  CONDYLES   OF  THE  FEMUR. 

Fractures  of  the  Condyles  of  the  Femur. — These  fractures  are 
usually  produced  by  blows  or  falls  upon  the  knee.  The  line  of  fracture  may 
pass  between  the  condyles,  separating  one  condyle  from  the  shaft  (Fig.  415), 
or  both  condyles  may  be  separated,  and  the  shaft  of  the  bone  may  occupy  a 
position  in  front  of  them. .  In  condyloid  fracture  the  most  serious  complica- 
tions are  involvement  of  the  knee-joint  and  injury  to  the 
Fig.  415.  vessels  and  nerves  in  the  popliteal  space. 

Treatment. — Seduction  is  effected  by  flexing  the  leg 
upon  the  thigh,  at  the  same  time  making  extension,  carefully 
avoiding  all  rough  movements  for  fear  of  the  displaced  frag- 
ments injuring  the  j)opliteal  nerves  or  vessels.  After  the 
deformity  has  been  reduced  the  extension  apparatus  should 
be  applied  to  the  leg,  and  lateral  supi^ort  should  be  furnished 
by  means  of  splints  and  bran-bags  or  by  sand-bags.  If  one 
condyle  only  is  separated,  the  uninjured  condyle  prevents 
shortening,  and  the  extension  apparatus  is  not  required. 
The  leg  and  thigh  may  then  be  placed  in  a  long  fracture-box, 
Fracture  of  the  and  a  compress  placed  over  the  injured  condyle  to  hold  it 
external  condyle  of    jjj  position,  Or  a  plaster-of- Paris  bandage,  including  the  foot, 

the     femur.       (Ag-  j-  i  j.  o   ;  o  j 

new.)  leg)  and  thigh,  may  be  employed  in  the  place  of  the  latter 

dressing.  In  a  case  recently  under  our  care  extension  of  the 
knee-joint  was  found  impossible  by  reason  of  the  displaced  fragment,  and 
incision  exposed  the  separated  condyle  reversed  with  its  articular  surface 
presenting  against  the  fractured  surface  of  the  femur.  Excision  of  the  sepa- 
rated condyle  was  practised,  and  recovery  followed  with  good  function 
in  the  knee-joint.  The  results  following  fi-actures  of  the  condyles  of  the 
femur  are  usually  not  satisfactory  ;  the  involvement  of  the  knee-joint  is  apt 
to  lead  to  permanent  stiffness  or  ankylosis  of  the  joint,  and  it  is,  therefore, 
important  that  the  limb  should  be  kept  as  nearly  as  possible  in  the  extended 
position  in  case  this  complication  should  follow. 

The  Ambulant  Treatment  in  Fractures  of  the  Femur. — This 
treatment  has  recently  been  recommended,  and  consists  in  applying  a 
plaster- of-Paris  splint  to  the  foot,  leg,  and  thigh,  extending  from  the  meta- 
tarsal bones  to  the  tuber  ischii.  In  applying  this  dressing  the  foot  is  placed 
at  a  right  angle  to  the  leg  and  is  well  padded  with  a  number  of  layers  of 
cotton ;  the  plaster-of- Paris  bandage  is  then  apijlied  from  the  metatarsal 
bones  to  the  knee,  five  or  six  thicknesses  of  bandage  being  employed  ;  this 
is  allowed  to  become  partially  firm ;  the  i^atient  is  then  placed  with  the 
pelvis  elevated,  and  extension  is  made  from  the  plaster  cast  and  by  pulling 
upon  the  chest  from  above.  When  the  deformity  has  been  corrected  and  the 
legs  are  of  equal  length,  a  plaster-of- Paris  dressing  is  applied  from  the  knee 
to  the  tuber  ischii  and  the  gluteal  folds,  and  turns  of  the  bandage  are  made, 
so  as  to  include  the  thigh  and  extend  as  far  as  the  anterior  superior  spine 
of  the  ilium.  Oblique  turns  of  the  bandage  are  made  from  the  thigh  over 
the  lower  portion  of  the  abdomen  and  back  again  to  the  thigh,  and  the 
plaster  bandage  may  be  strengthened  by  narrow  strips  of  veneer  or  bass- 
wood  splinting  incorporated  with  the  layers  of  plaster.  The  extension  is 
maintained  upon  the  limb  until  the  plaster  bandage  has  firmly  set.     The 


COMPOUND  FRACTUBES  OF  THE  FEMUR.  497 

patient  is  allowed  to  get  up  on  the  following  clay,  and  to  walk,  first  witli 
crutches,  then  with  a  cane,  and  finally  without  either  of  these  appliances, 
placing  his  weight  upon  the  foot  of  the  injured  leg.  This  method  of  treat- 
ment has  not  been  widely  employed,  and  we  are  of  the  opinion  that  in  any 
case  where  the  ambulant  method  is  desirable,  the  application  of  a  Thomas's 
hip-splint  will  be  more  satisfactory. 

Compound  Fractures  of  the  Femur. — Compound  fractures, 
involving  any  portion  of  the  femur,  are  serious  injuries,  and  in  cases  where 
the  main  blood-vessels  are  injured,  or  where  there  is  much  comminution  of 
the  bone  or  involvement  of  the  knee-joint,  primary  amputation  or  excision 
may  be  required.  However,  if  the  main  blood-vessels  have  escaped  injury, 
and  the  wound  is  carefully  sterilized  and  good  fixation  of  the  fragments  can 
be  secured,  many  cases  recover  with  useful  limbs.  If  it  is  found  that  there  is 
marked  comminution  of  the  bone,  and  there  are  present  in  the  wound  loose 
fragments,  these  should  be  removed.  We  had  recently  under  our  care  a 
compound  comminuted  fracture  of  the  femur  in  which  a  fragment  an  inch 
and  a  half  in  length  was  entirely  sei^arated.  This  was  removed,  and  the 
patient  made  a  good  recovery,  with  a  proportionate  amount  of  shortening. 
In  cases  where  amputation  is  not  considered,  the  patient  should  be  anaes- 
thetized, and,  after  carefully  sterilizing  the  wound  and  reducing  the 
displacement  by  extension  and  manipulation,  primary  fixation  of  the  frag- 
ments should  be  made  by  drilling  the  bone  and  securing  the  fragments  in 
position  by  heavy  silver  wire  sutures,  or  by  the  use  of  x>erforated  silver 
splints  secured  by  screws.  The  wound  should  then  be  drained  and  closed. 
A  copious  antiseptic  dressing  should  be  ajjiilied,  and  fixation  of  the  frag- 
ments at  the  seat  of  fracture,  as  well  as  of  the  leg,  the  knee-joint,  and  the 
hip-joint,  secured  by  the  aijplication  of  a  plaster-of- Paris  dressing  extending 
from  the  foot  to  the  pelvis.  If  for  any  reason  this  dressing  is  not  considered 
advisable  after  the  dressing  of  the  wound,  a  dressing  similar  to  that  employed 
in  simple  fractures  of  the  shaft  of  the  femur,  consisting 
of  extension  and  lateral  support  by  means  of  bran-bags  Fi«-  -W^. 

and  splints,  or  sand-bags,  may  be  applied. 

FRACTURES  OF  THE  PATELLA. 

Fractures  of  the  patella  are  rarely  seen  in  patients 
under  twenty  years,  and  are  not  common  after  fifty  years 
of  age.  They  may  be  simple,  compound,  or  comminuted, 
and  result  from  direct  violence  and  muscular  action.  The 
direction  of  the  fracture  may  be  transverse,  vertical,  or 
oblique.  Comminuted  fractures  of  the  patella  usually  re-  DispiacLmmt  of  the 
suit  from  force  directly  applied  to  the  front  of  the  knee,  as    f™s™ents  m  fracture 

•^      ^^  '  of  the  patella.     (Ag- 

from  falls,  or  from  the  kick  of  a  horse.  new.) 

Symptoms. — These  are  pain,  loss  of  power  of  extend- 
ing the  leg,  a  considerable  amount  of  swelling  about  the  knee-joint,  and  an 
upward  displacement  of  the  upper  fragment  by  the  action  of  the  quadratus 
muscle,  and  often  a  marked  depression  can  be  felt  with  the  finger  between 
the  fragments.  (Fig.  416.)  Hutchinson  holds  that  displacement  of  the 
fragments  is  as  much  due  to  the  pressure  of  the  effusion  into  the  knee-joint 

32 


498 


FEACTURES  OF  THE  PATELLA. 


Fig.  417. 


as  to  muscular  action.  The  separation  of  the  fragments  may  vary  from  the 
fraction  of  an  inch  to  several  inches.  Patients  suffering  from  fracture  of 
the  patella  are  not  always  incapacitated  from  using  the  limb.  Crepitus 
can  usually  be  obtained  by  drawing  the  upper  fragment  downward  in  con- 
tact with  the  lower  fragment  and  making  lateral  motion. 
Marked  swelling  of  the  knee  occurs  rapidly  after  this 
fracture,  as  the  joint  becomes  distended  with  synovial 
fluid  and  blood.     (Fig.  417.) 

Prognosis. — In  fracture  of  the  patella  union  is  usually 
ligamentous,  although  cases  have  been  recorded  in  which 
bony  union  has  resulted.  The  bond  of  union  may  be  short 
or  long ;  a  ligamentous  bond  of  three  or  foiu-  inches  has 
been  noted.  The  fnnction  of  the  limb  is  generally  more 
or  less  impaired  as  the  result  of  this  fracture.     Eigidity 

Fig.  418, 


Deformity  in  fracture 
of  tlie  patella. 


Skiagraph  of  fractu 


ragnient  was  separated  twelve 

cture. 


of  the  joint  is  often  marked  and  may  persist,  and  union  by  a  long  fibrous 
band  may  interfere  seriously  with  the  extension  of  the  leg.  In  other  cases 
the  patient  may  have  a  fair  functional  result  in  spite  of  union  by  a  long 
fibrous  band.  In  most  cases  rigidity  of  the  joint  or  weakness  of  the  knee 
is  present.  The  results  as  regards  function  depend  largely  upon  the  extent 
of  the  rupture  of  the  tendinous  expansion  of  the  quadriceps,  the  amount 
of  effusion  of  blood  into  the  joint,  and  the  interposition  of  the  capsular 
tissues  between  the  fragments.  After  fracture  of  the  patella  refracture  or 
separation  of  the  bond  is  very  frequent,  and  the  subject  seems  more  liable  to 
fi'acture  of  the  other  patella.  In  three  cases  of  fracture  of  the  patella  with 
fibrous  union  we  have  seen  a  subsequent  fracture  of  the  same  bone  at  a 
different  position.     (Fig.  418.) 

Treatment. — The  limb  should  be  placed  in  the  extended  jDOsition,  and 
a  roller  bandage  applied  from  the  toes  to  a  point  jiist  below  the  knee-joint. 
A  posterior  padded  wooden  splint,  extending  from  the  middle  of  the  thigh 
to  the  middle  of  the  leg,  should  then  be  placed  under  the  limb,  and  a  com- 


FEACTURES  OF  THE  PATELLA. 


499 


press  placed  just  above  the  upper  fragmeut,  and  over  this  should  be  applied, 
obliquely,  one  or  two  straps  of  adhesive  or  rubber  plaster,  which  are  carried 
downward  and  attached  to  the  posterior  splint  some  distance  below  the 
position  of  the  upper  fragment ;  the  lower  fragment  should  also  be  fixed  by 
a  compress,  and  oblique  strips  of  plaster  applied  in  the  opposite  direction 
and  secured  to  the  splint  above.     (Fig.  419.)   A  bandage  should  then  be 


Application  of  splint,  compresses,  and  strips  m  fracture  of  the  patella. 

applied  to  fix  the  splint  firmly  to  the  leg  and  thigh,  being  carried  over  the 
knee  and  to  the  upper  end  of  the  splint  (Fig.  420) ;  or  an  Agnew's  splint, 
which  consists  of  a  posterior  splint  with  pegs,  around  which  the  ends  of 
the  adhesive  plaster  applied  above  and  below  the  ends  of  the  fragment  are 

Fig.  420. 


Dressing  for  fracture  of  the  patella. 

fastened,  may  be  employed.  After  the  application  of  the  splint  and  bandage 
the  limb  should  be  elevated  and  placed  upon  an  inclined  plane  or  in  a 
fracture-box,  the  lower  end  of  which  has  been  elevated,  in  order  to  relax  the 
rectus  muscle.  After  the  second  week  the  dressings  should  be  removed 
daily  and  massage  practised,  and  after  the  fourth  week  passive  motion 
should  be  practised  as  far  as  can  be  done  without  making  the  tendon  of  the 
quadriceps  muscle  tense.  This  dressing  is  usually  retained  for  from  four  to 
six  weeks,  at  the  end  of  which  time  there  is  generally  firm  fibrous  union  at 
the  seat  of  fracture.  The  splint  should  then  be  removed,  and  a  plaster-of- 
Paris  bandage  applied,  extending  from  the  middle  of  the  leg  to  the  middle 
of  the  thigh,  and  retained  for  several  weeks,  or  a  posterior  splint  which  can 
be  removed  for  massage  or  at  night. 

Operative  Treatment. — This  consists  in  exposing  the  fragments  by  am 
incision  with  full  antiseptic  precautions,  removing  blood-clots,  and  intro- 
ducing heavy  silver  wire  sutures  to  secure  apposition  of  the  fragments,  or  in 
the  employment  of  Stimson's  method,  in  which  the  capsule  and  the  periosteum 
are  sutiu-ed  with  catgut  so  as  to  hold  the  bone  surfaces  in  contact.     These 


500  COMPOUND  FRACTURES   OF  THE  PATELLA. 

methods  have  been  practised  with  success,  and  in  some  cases  bony  union  has 
been  secured.  The  indications  for  operative  treatment  are  :  1,  wide  separa- 
tion of  the  fragments ;  2,  great  hemarthrosis ;  3,  evident  interposition  of 
the  soft  parts.  The  results  obtained  by  the  more  conservative  methods  of 
treatment  are  usually  reasonably  satisfactory,  and  it  is  to  be  remembered 
that  there  is  a  definite  amount  of  risk  iu  exposing  the  patella  and  opening 
the  joint.  No  one  is  justified  in  suturing  a  fractured  patella  unless  he  is  in 
a  position  to  do  an  operation  in  which  every  aseptic  detail  can  be  carried 
out.  The  after-treatment  is  the  same  as  in  the  non-operative  method,  except 
that  passive  motion  can  be  more  vigorous  and  be  begun  earlier. 

Malgaigne's  Hooks. — This  method  of  treatment  was  revived  with  the 
introduction  of  antiseptic  methods  in  surgery,  but  has  the  disadvantage  that 

the  skin  wound  is  liable  to  infection. 
Fi<5-  ^21.  Ill  applying  this  treatment  the  skin 

iu  the  neighborhood  of  the  knee 
should  be  thoroughly  sterilized ; 
punctures  are  made  down  to  the 
fragments  with  a  tenotome,  the  hooks 
(Fig.  421),  previously  sterilized,  are 
gaigue's  hooks.  ~        .    placed  in  position  in  the  lower  and 

upper  fragments,  and  the  fragments 
are  then  brought  together  by  turning  the  screw  which  approximates  the 
hooks.  An  antiseptic  dressing  is  applied  over  the  hooks,  and  they  are 
allowed  to  stay  in  position  for  two  or  three  weeks ;  at  the  end  of  this  time 
they  are  removed,  and  the  leg  is  dressed  with  a  plaster-of- Paris  dressing, 
which  is  retained  for  from  four  to  six  weeks. 

Circumpatellar  Suture. — ^Another  method  of  treatment  which  has 
been  employed  is  the  circumiDatellar  subcutaneous  suture,  recommended  by 
Mr.  Barker,  which  consists  in  making  a  puncture  through  the  ligamentum 
patellae  with  a  tenotome  and  passing  through  this  puncture  a  heavy  curved 
needle  with  an  eye  near  its  point,  wh,ich  is  passed  under  the  patella,  trans- 
fixing the  tendon  of  the  quadriceps,  and  is  then  brought  out  through  the 
skin  ;  this  is  threaded  with  a  heavy  silk  or  silver  wire  suture  and  is  with- 
drawn ;  the  needle  is  again  passed  through  the  same  puncture  and  passed 
over  the  patella,  and  its  point  is  made  to  emerge  through  the  original  punc- 
ture in  the  skin  below  the  patella.  The  other  end  of  the  ligature  is  then 
threaded  into  the  needle,  and  it  is  withdrawn  ;  the  ends  of  the  suture  are 
then  securely  tied  by  several  knots,  which  are  buried  in  the  wound,  the  ends 
being  cut  off.  The  small  wounds  are  closed  by  compresses  of  antiseptic 
gauze,  and  the  limb  is  placed  upon  a  posterior  splint  or  in  a  plaster-of- Paris 
dressing.  In  this  operation  it  is  essential  that  all  aseptic  details  should  be 
most  carefully  observed.  This  method  leaves  a  foreign  body  in  the  joint 
cavity  and  does  not  permit  of  the  removal  of  blood  from  the  joint  or  soft 
tissues  from  between  the  fragments,  and  is  not  as  safe  or  satisfactory  as  the 
open  operation. 

Compound  Fractures  of  the  Patella.— These  are  serious  injuries, 
and  should  be  treated  by  first  thoroughly  sterilizing  the  wound  and  removing 
all  loose  fragments,  then  introducing  heavy  wire  sutures  to  secure  the  frag- 


FRACTURES  OF  THE  TIBIA  AND   FIBULA. 


501 


Fig.  422. 


ments  in  apposition,  and  following  this  procedure  by  suture  of  tlie  capsular 
structures  with  catgut  and  the  introduction  of  a  drainage-tube.  The  wound 
should  be  closed  and  dressed  with  a  copious  antiseptic  dressing,  and  fixation 
of  the  leg  in  the  extended  position  should  be  maintained  by  the  application 
of  a  posterior  splint  or  by  a  plaster-of- Paris  dressing. 

FEACTUEES  OF  BOTH  BONES  OP  THE  LEG. 

Fractures  of  the  Tibia  and  Pibiila. — These  are  common  accidents, 
and  may  result  from  force  directly  applied,  as  in  the  case  of  heavy  bodies 
falling  upon  the  leg,  the  kicks  of  horses,  and  the  passage  of  wheels  over  the 
leg  ;  or  from  indirect  injury,  as  falls 
from  a  height,  where  the  violence  is 
applied  to  the  foot.  When  produced 
by  direct  force  the  fracture  occurs  at 
the  seat  of  application  of  the  violence, 
and  the  line  of  fracture  is  likely  to  be 
more  or  less  transverse.  Fractures 
produced  by  indirect  force  are  usually 
oblique,  and  the  two  bones  are  seldom 
broken  at  the  same  level.     (Fig.  422.) 

Symptoms. — These  are  pain,  de- 
formity, mobility,  and  crepitus.  The 
deformity  depends  upon  the  degree 
of  displacement  of  the  fragments,  and 
may  consist  in  an  anterior  projection 
of  the  upper  end  of  the  lower  fragment, 
in  lateral  displacement,  or  in  overlap- 
ping of  the  fragments.  When  the  force 
producing  the  fracture  is  applied  to 
the  front  of  the  leg,  the  line  of  separa- 
tion may  be  from  below  upward  and 
from  before  backward,  in  which  case 
the  lower  fragment  will  assume  a  posi- 
tion behind  the  ujjper  one. 

Treatment. — In  the  treatment  of  fractures  of  both  bones  of  the  leg, 
extension  and  counterextension  and  manipulation  should  be  made  to  correct 
the  deformity.  Where  there  is  marked  upward  displacement  of  the  upper 
end  of  the  lower  fragment  and  the  deformity  persists  in  spite  of  extension 
and  manipulation,  or  recurs  after  correction,  it  may  be  necessary  to  make  a 
subcutaneous  section  of  the  tendo  Achillis  to  correct  the  deformity.  The 
leg  is  then  placed  in  a  fracture-box  padded  with  a  soft  pillow,  the  foot  being 
kept  at  a  right  angle  to  the  leg,  and  brought  in  contact  with  the  bottom  of  the 
box  and  secured  to  the  foot-board  by  a  strip  of  bandage ;  a  compress  should 
be  placed  under  the  tendo  Achillis,  and  the  sides  of  the  box  brought  uj)  and 
secured  by  strips  of  bandage.  The  principal  objection  to  the  use  of  the 
fracture-box  is  that  in  the  case  of  a  restless  patient  the  movements  of  the 
body  may  cause  the  foot  to  press  against  the  foot-board  and  thus  produce 
overlapping  of  the  fragments.     We  have  found  that  the  swinging  of  the  box 


Skiagraph  of  fracture  of  tibia  and  iibula. 


502 


FRACTURES   OF  THE  TIBIA  AND   FIBULA. 


by  a  frame  over  the  bed  will  prevent  this  complication  and  allow  the  patient 
to  change  his  position  slightly,  and  will  at  the  same  time  be  a  most  comfort- 


Swmging  the  fractuie  bos.    (AgneAV. ) 

able  dressing.  (Fig.  423.)  These  fractui'es  may  also  be  treated  by  the  use 
of  Volkmann's  splint  (Fig.  424)  for  one  or  two  weeks  until  the  swelling  has 
subsided,  followed  by  the  application  of  a  plaster-of- Paris  dressing.  Many 
surgeons  prefer  to  treat  fractures  of  both  bones  of  the  leg  by  the  immediate 


Volkmann's  splint. 


application  of  a  plaster- of- Paris  dressing.  This  can  be  done  with  perfect 
safety  if  the  patient  can  be  kept  under  observation  ;  but  if  there  is  a  great 
amount  of  swelling  when  the  plaster-of- Paris  dressing  is  applied,  the  dress- 


FRACTURES   OF  THE  TIBIA. 


503 


ing  should  be  removed  at  the  end  of  a  week  or  ten  days  and  a  fresh  one 
applied.     We  usually  employ  the  fracture-box  or  splint  in  the  treatment  of 


Plaster-of-Paris  dressing  for  fracture  of  both  bones  of  the  leg. 

fracture  of  both  bones  ot  the  leg  for  ten  days  or  two  weeks,  and  at  the  end 
of  this  time  apply  a  plaster-of- Paris  bandage,  including  the  foot  and  leg  and 
extending  a  short  distance  above  the  knee-joint. 
(Fig.  425.)  At  the  end  of  six  weeks  union  is  gen- 
erally quite  firm ;  but  the  patient  should  not  be 
allowed  to  support  his  weight  upon  the  injured 
leg  until  at  least  eight  weeks  have  elapsed  after 
the  injury. 

Fractures  of  the  Tibia. — These  include 
separation  of  the  upper  or  lower  epiphysis  and 
fractures  involving  the  head  and  shaft  of  the 
bone.  (Fig.  426.)  Fractures  of  the  head  of  the 
tibia  may  involve  the  knee-joint,  those  of  the 
lower  portion  may  involve  the  ankle-joint,  and 
both  are  produced  by  force  directly  applied,  or 
by  indirect  force,  the  violence  being  transmitted 
through  the  foot. 

Symptoms. — In  fractures  of  the  head  or  shaft 
of  the  tibia  tliere  is  usually  very  little  displace- 
ment, the  fibula  acting  as  a  sj)lint  to  prevent 
shortening,  but  some  little  displacement  may  often 
be  discovered  by  passing  the  finger  along  the  spine 
of  the  bone.  Crepitus  can  usually  be  elicited 
by  grasiDing  the  tibia  above  and  below  the  seat 
of  fracture  and  making  motion.  Fractures  of 
the  upper  portion  of  the  bone  which  involve 
the  knee-joint  are  followed  by  effusion  into  the 
joint. 

Treatment. — These  fractures  may  be  treated  by  the  use  of  the  fracture- 
box,  as  described  in  the  treatment  of  fractures  of  both  bones  of  the  leg, 
with  Volkmann's  splint,  or  by  the  application  of  a  plaster-of- Paris  dressing. 
The  results  following  the  treatment  of  these  fractures  are  usually  very  satis- 
factory, as  little  shortening  occurs,  from  the  fact  that  the  fibula  prevents 


Fractures  of  the  shaft  and  lower 
end  of  the  tibia. 


504 


FRACTURES   OF  THE  TIBIA. 


overlapping  of  the  bone.  Where  the  fracture  involves  the  knee-joint,  great 
care  should  be  taken  to  reduce  the  fragments  as  completely  as  possible  and  to 
secure  fixation  of  the  parts  above  and  below  the  seat  of  fracture.  In  such 
cases  a  certain  amount  of  ankylosis  of  the  knee-joint  may  result,  and  after 
three  or  four  weeks  jjassive  motion  should  be  instituted  to  preserve  mobility 
of  the  joint. 

Separation  of  the  Upper  Epiphysis  of  the  Tibia. — This  lesion  may 

result  from  direct  violence  or  torsion  of  the  leg  in  subjects  under  twenty 

years  of  age.     (Fig.  427.)    The  greatest  number  of 

Fig.  427.  cases  have  been  observed  between  the  third  and 

ninth  years.      The  separation  may  be  simple  or 

compound. 

Symptoms. — These  ai-e  mobility,  soft  crepitus, 
loss  of  function,  and  effusion  into  the  knee-joint, 
and  in  some  cases  marked  deformity.  Diagnosis. 
— This  injury  is  most  likely  to  be  confounded  with 
fracture  of  the  head  of  the  tibia  or  dislocation  of 
the  knee-joint ;  from  the  former  the  diagnosis  is 
made  by  observing  that  the  line  of  separation  is 
transverse,  and  bony  crepitus  is  wanting ;  from  dis- 
location, which  is  extremely  rare  in  childhood,  the 
diagnosis  may  be  made  by  observing  that  in  epi- 
physeal separation  the  motions  of  the  knee-joint 
are  not  interfered  with.  Prognosis. — In  simple 
separation  bony  imion  may  result,  but  the  sub- 
sequent growth  of  the  tibia  may  be  interfered 
with,  or  more  or  less  ankylosis  of  the  knee-joint 
may  follow.  In  compound  separations  suppuration,  necrosis,  or  gangrene 
may  occur.  Treatment. — In  simple  separations,  if  displacement  is 
present,  it  should  be  corrected  by  manipulation,  and  fixation  should  be 
made  by  the  application  of  a  splint  or  plaster-of- Paris  bandage.  In  com- 
pound separations  the  treatment  is  the  same  as  that  for  compound  fi-acture  of 
the  tibia,  and  in  exceptional  cases  amputation  may  be  required. 

Separation  of  the  Epiphysis  of  the  Tubercle  of  the  Tibia.— This 
lesion  is  rare,  but  has  been  most  frequently  observed  from  the  sixteenth  to 
the  eighteenth  year  as  the  result  of  muscular  action.  The  symptoms  are 
similar  to  those  of  rupture  of  the  ligameutum  patellae.  The  treatment  con- 
sists in  reducing  any  deformity  which  is  pi-esent,  and  in  applying  a  fixation 
splint  or  plaster-of- Paris  dressing. 

Fractures  of  the  Lower  End  of  the  Tibia.— These  may  consist 
in  separation  of  the  lower  epiphysis  of  the  tibia,  fracture  of  the  internal 
malleolus  or  a  bimalleolar  fracture  in  which  the  external  malleolus  is  also 
involved  in  the  line  of  fracture. 

Separation  of  the  Lower  Epiphysis  of  the  Tibia.— This  lesion  may 
result  from  the  application  of  indirect  force,  such  as  violent  flexion  or 
extension  of  the  leg  while  the  foot  is  fixed,  or  from  forcible  torsion  of  the 
foot.  The  greatest  number  of  cases  have  occurred  between  the  ninth  and 
nineteenth  years.     The  separation  may  be  simple  or  compound. 


Upper  epiphysis  of  tlie  tibia. 
(After  Poland.) 


FRACTURES   OF  THE  TIBIA.  505 

Symptoms. — These  are  mobility,  swelling,  largely  due  to  effusion  into 
the  ankle-joint,  moist  crepitus,  and  deformity, — usually  backward  displace- 
ment of  the  fragment  with  the  foot.  Diagnosis.— This  injury  is  most  apt 
to  be  confounded  with  dislocation  of  the  ankle,  but  may  be  differentiated 
from  the  latter  by  observing  that  the  internal  malleolus  preserves  its  natural 
relation  with  the  foot,  but  not  with  the  rest  of  the  leg  and  the  external 
malleolus.  Prognosis. — This  in  simple  separation  is  good  as  regards  union, 
but  suppuration  or  necrosis  may  occur,  with  subsequent  arrest  of  the  growth 
of  the  tibia.  Treatment. — In  simple  separations  the  displacement  should 
be  reduced  and  the  foot  iixed  at  a  right  angle  to  the  leg  by  moulded  splints,  or 
by  a  plaster-of-Paris  dressing  ;  in  compound  separations  the  same  treatment 
should  be  practised  ;  amputation  may  be  required  in  exceptional  cases. 

Fracture  of  the  Lower  Extremity  of  the  Tibia.— The  internal 
malleolus  may  be  seijarated  from  the  tibia,  or  the  line  of  fracture  may  pass 
through  the  bone  just  above  the  articular  surface,  and  oblique  lines  of  frac- 
ture may  also  occur ;  the  ankle-joint  may  be  involved  in  this  fracture. 
Bimalleolar  fractures  may  also  exist.  These  fractures  usually  result  from 
forcible  eversion  or  inversion  of  the  foot.  Symptoms. — These  are  pain, 
deformity,  crepitus,  and  loss  of  function.  Treatment. — The  deformity 
should  be  reduced  by  extension  and  manij)ulation,  and  moulded  binder's 
board  splints  or  a  plast€r-of-Paris  dressing  should  be  employed.  As  the 
ankle-joint  is  often  involved  in  these  fractures,  great  care  should  be  taken 
to  reduce  the  fragments,  and  passive  motion  should  be  practised  at  an 
early  ijeriod  to  prevent  ankylosis  of  the  joint. 

Arabulant  Treatment  of  Fractures  of  the  Bones  of  the  Leg. 
— In  employing  this  method,  the  leg  having  first  been  thoroughlj'-  washed 
with  soap  and  water,  extension  should  be  made  to  reduce  the  deformity, 
and  the  foot  placed  at  a  right  angle  to  the  leg ;  a  flannel  bandage  should 
next  be  apijlied  from  the  toes  to  a  short  distance  above  the  knee.  Cotton 
wadding  should  be  freely  applied  around  the  foot  and  the  malleoli,  and  a 
plaster-of-Paris  bandage  carried  from  the  base  of  the  toes  to  a  point  a  short 
distance  above  the  knee-joint,  being  made  especially  firm  just  below  the 
knee  and  at  the  sole  of  the  foot  and  the  ankle.  The  sole  should  also  be 
strengthened  by  a  number  of  longitudinal  layers  of  the  bandage,  extension 
being  kept  up  upon  the  leg  until  the  plaster-of-Paris  bandage  has  completely 
set.  The  patient  is  permitted  to  get  up  as  soon  as  the  plaster  is  firm,  and 
allowed  to  walk,  first  with  crutches,  then  with  a  cane,  and  finally  supporting 
his  weight  ujion  the  injured  limb.  The  theory  upon  which  this  dressing 
is  used  in  fractures  of  the  bones  of  the  leg  is  that  the  limb  is  suspended  in 
the  plaster  cast,  and  that  really  no  weight  is  brought  to  bear  ujaon  it ;  the 
weight  is  transmitted  to  the  plaster  cast,  and  the  points  of  pressure  are  just 
below  the  head  of  the  tibia  and  the  condyles  of  the  femur.  The  advantages 
claimed  are  that  the  patient  can  soon  be  about,  and  that  there  is  little 
swelling,  as  the  fragments  are  thoroughly  immobilized.  Excellent  results 
have  followed  this  method  of  treatment,  but  it  should  be  employed  only 
where  the  surgeon  has  the  ijatient  under  continuous  observation. 

Compound  Fractures  of  the  Bones  of  the  Leg.— These  are 
common  injuries,  and  the  line  of  fracture  may  be  similar  to  that  seen  in 


506  FRACTURES   OF  THE  FIBULA. 

simple  fractures.  The  greatest  danger  is  from  infection  of  the  wound,  and 
the  risk  of  infection  is  greater  if  the  wound  is  made  from  without  than  if 
made  by  the  fragments  from  within. 

Treatment. — This  consists,  first,  in  the  sterilization  of  the  skin  sur- 
rounding the  wound  and  of  the  wound  itself;  loose  fragments  of  bone  or 
foreign  bodies  should  be  removed,  and  it  is  wise  in  all  cases,  except  those  in 
which  only  a  small  punctured  wound  exists  and  in  which  there  is  no  com- 
minution of  the  bones,  to  fix  the  fragments  by  the  application  of  heavy 
silver  wire  sutures ;  the  wound  should  then  be  drained,  a  few  superficial 
sutures  introduced,  and  a  copious  antiseptic  dressing  applied.  The  ankle- 
joint  and  the  knee-joint  should  be  fixed  by  the  use  of  a  fracture-box,  or  by 
the  application  of  moulded  pasteboard  splints  extending  from  the  sole  of  the 
foot  to  a  point  a  little  above  the  knee-joint.  A  plaster-of- Paris  dressing 
may  be  a]3plied  in  these  cases,  provision  being  made  at  the  time  of  its  appli- 
cation for  fenestrating  the  bandage  over  the  seat  of  fracture,  if  it  should 
become  necessary  to  expose  the  wound.  The  time  required  for  union  in 
cases  of  compound  fractures  of  the  bones  of  the  leg  is  considerably  longer 
than  that  required  in  simple  fractures,  being  from  twelve  to  sixteen  weeks. 

Fractures  of  the  Fibula. — These  may  occur  at  the  upper  extremity, 
in  the  shaft,  or  at  the  lower  extremity  of  the  bone  ;  the  most  common  seat 
of  fracture  is  in  the  lower  third.  Separation  of  the  upper  or  lower  epiph- 
ysis of  the  fibula  may  also  occur.  These  fractures  are  produced  by  direct 
or  by  indirect  force.  "When  produced  by  direct  force,  such  as  a  blow,  the 
wheel  of  a  wagon,  or  the  kick  of  a  horse,  the  fracture  will  usually  be  found 
to  occur  at  the  point  where  the  force  is  applied.  When  i^roduced  by 
indirect  force,  the  bone  usually  gives  way  in  its  lower  third  within  two 
and  a  half  or  three  inches  of  the  inferior  extremity. 

Separation  of  the  Epiphyses  of  the  Fibula.— The  upper  or  lower 
epiphysis  of  the  fibula  may  be  separated  as  the  result  of  direct  violence  in 
subjects  under  twenty  years  of  age.  These  injuries  are  very  rare  and  may 
be  simple  or  compound.  The  diagnosis  from  fracture  is  made  largely  by 
the  character  of  the  crepitus.  Treatment. — If  displacement  is  present  it 
should  be  corrected  by  manipulation,  and  the  treatment  consists  in  the 
application  of  a  fixation  splint  or  a  plaster- of- Paris  bandage. 

Fracture  of  the  Upper  End  of  the  Fibula. — This  fracture  may 
be  caused  by  direct  force,  by  sudden  contraction  of  the  biceps  muscle,  or  by 
forcible  adduction  of  the  leg.  In  such  cases  the  fragments  are  usually  not 
much  displaced,  but  the  u^jper  one  may  be  drawn  slightly  upward  by  the 
biceps.  Fracture  of  the  upper  end  of  the  fibula  may  be  complicated  by 
injury  of  the  popliteal  nerve  with  paralysis  of  the  tibialis  anticus  and  foot 
drop,  or  later  impairment  of  the  function  of  this  nerve  from  its  implication 
in  the  callus.  Treatment. — ^This  consists  in  immobilization  of  the  leg  by 
the  use  of  a  fracture-box,  and  the  same  result  may  be  secured  by  the  appli- 
cation of  a  plaster- of- Paris  bandage,  which  fixes  the  ankle  and  the  knee. 
If  displacement  in  the  upper  fragment  is  marked,  from  contraction  of  the 
biceps  muscle,  flexion  of  the  knee  before  the  application  of  the  plaster-of- 
Paris  dressing  will  often  correct  this  deformity.  If  paralysis  exists,  the 
nerve  should  be  exposed  and  relieved  of  pressure  or  sutured  if  divided. 


FRACTURES  OF  THE  FIBULA. 


507 


Fig.  429. 


Fracture  of  the  Shaft  of  the  Fibula.— The  displacement  in  this 
fracture  usually  consists  in  a  tilting  forward  of  the  lower  end  of  the  upper 
fragment.  This  fracture  can  usually  be  recognized  by  the  presence  of  pain, 
mobility,  and  crepitus.  When  the  fracture  involves  the  upper  portion  of 
the  shaft  it  is  often  difficult  to  recognize.  Treatment. — In  the  treatment 
of  these  fractures  we  usually  employ  a  fracture-box  for  a  week,  and,  when 
the  swelling  has  subsided,  apply  a  plaster-of- Paris  bandage,  which  fixes  the 
ankle  and  the  knee-joint ;  if  little  displacement  is  present,  the  knee  need 
not  be  fixed. 

Fracture  of  the  Lower  End  of  the  Fibula. — This  is  the  most 
common  fracture  of  the  fibula  ;  it  is  usually  produced  by  indirect  force,  as 
by  falls,  and  by  twists  of  the  foot  causing  extreme  eversion  or  inversion, 
and  is  apt  to  lead  to  great  deformity  and  subsequent  disability.  It  is  often 
described  as  Pott's  fracture,  which  really  consists  in  a  fracture  occurring  in 
the  lower  fifth  of  the  fibula,  with  a  laceration  of  the 
internal  lateral  ligament  of  the  ankle-joint,  and  is  usually 
accompanied  by  marked  eversion  of  the  foot.  (Pig.  428.) 
With  the  fracture  of  the  lower  fifth  of  the  fibula  there 
may  be  associated  a  fracture  of  the  inner  edge  of  the  tibia 
and  rupture  of  the  tibio-fibular  ligament,  as  well  as  of  the 
internal  malleolus. 

Symptoms. — The    deformity    is  Fig.  428. 

very  characteristic,  consisting  in  an 
outward  displacement  of  the  foot  and 
increased  prominence  of  the  internal 
malleolus ;  the  ankle-joint  appears  to 
be  markedly  widened,  and  there  may 
be  more  or  less  displacement  of  the 
astragalus.  (Fig.  429.)  The  widening 
of  the  ankle  results  fi-om  separation  of 
the  malleoli,  and  occasionally  from 
the  astragalus  being  driven  upward 
between  the  tibia  and  the  fibula. 
There  is  often  a  marked  posterior  dis- 
placement of  the  lower  fragment  and 
foot  with  limited  dorsal  flexion  when 
union  occurs. 

Treatment. — The  most  important 
point  in  the  treatment  of  this  fracture  is  to  correct  the  displacement  and 
prevent  its  recurrence.  The  fragments  may  be  reduced  by  grasping  the 
leg  firmly  with  one  hand  and  the  foot  with  the  other  and  drawing  the  foot 
forward,  which  corrects  the  posterior  displacement,  and  pressing  it  inward 
at  the  same  time  until  the  astragalus  is  felt  to  press  against  the  internal 
malleolus.  After  the  deformity  is  corrected,  the  foot  should  be  placed  in  a 
fracture-box  padded  with  a  pillow,  a  compress  being  x^laced  above  the  internal 
malleolus  and  another  just  below  the  external  malleolus,  and  when  the 
sides  of  the  box  are  brought  up  the  foot  will  be  slightly  inverted.  This 
dressing  we  usually  emj)loy  for  a  week  or  ten  days,  if  it  satisfactorily  cor- 


Fraeture  of  the  lower 
fifth  of  the  fibula,  Pott's 
fracture. 


Pott's    fracture    with 
marked  deformity. 


508  FRACTURE  OF  THE  ASTRAGALUS. 

rects  the  deformity,  and  at  the  end  of  this  time  a  plaster-of-Paris  bandage 
is  applied  while  the  foot  is  held  in  its  corrected  position.  The  plaster-of- 
Paris  bandage  may  be  applied  as  a  primary  dressing.  After  a  week  or 
ten  days  the  plaster  splint  should  be  removed  and  one  applied  which  can 
be  removed  for  the  daily  employment  of  massage  and  gentle  passive  move- 
ments. The  Dupuytren  si)lint,  which  was  formerly  employed  in  the  treat- 
ment of  this  fracture,  we  have  found  usually  to  cause  the  patient  much 
pain,  and,  although  it  corrects  the  deformity  its  use  is  not  satisfactory. 

The  dressings  in  fractures  of  the  fibula  are  usually  retained  for  about 
four  weeks  ;  after  this  time  the  patient  should  be  allowed  to  get  about  on 
crutches.  At  the  end  of  six  weeks  he  may  with  safety  place  his  weight 
upon  the  limb.  It  is  extremely  rare  to  have  non-union  occur  in  the  fibula 
unless  it  is  associated  with  non-union  in  the  tibia  at  the  same  time. 

Fracture  of  the  External  Malleolus. — This  fracture  may  result 
from  sudden  and  forcible  adduction  of  the  foot,  by  which  the  astragalus  is 
forced  outward,  or  by  forced  invei-sion  of  the  foot.  Avulsion  of  the  external 
malleolus  may  occur  by  tension  upon  the  external  lateral  ligament.  It  is 
diagnosed  by  the  presence  of  pain,  mobility,  and  crepitus,  and  is  usually 
accompanied  by  marked  swelling  upon  the  outer  surface  of  the  ankle-joint. 

Treatment. — This  consists  in  the  correction  of  the  deformity  and  the 
application  of  the  plaster-of-Paris  dressing,  which  should  include  the  foot 
and  the  leg,  and  is  retained  for  four  weeks. 

FRACTURES   OF   THE   BOISTES   OF   THE   FOOT. 

Simple  fractures  of  the  bones  of  the  foot  are  not  common.  Palls  from  a 
distance,  when  the  patient  alights  on  his  feet,  are  more  apt  to  be  followed 
by  fracture  of  the  bones  of  the  leg  than  by  fracture  of  the  foot.  Practiu'es 
of  the  bones  of  the  foot  may  involve  the  tarsus,  the  metatarsus,  or  the 
phalanges.  The  diagnosis  is  often  difiicult  by  reason  of  the  great  swelling 
which  appears  early  ;  the  use  of  the  X-rays  is  very  satisfactory  in  these  cases. 

Separation  of  the  Epiphyses  of  the  Bones  of  the  Foot. — Separa- 
tion of  the  epiphyses  of  the  os  calcis,  astragalus,  and  metatarsal  bones  have 
occasionally  been  observed  in  subjects  under  twenty-one  years  of  age. 
The  treatment  of  these  injuries  is  similar  to  that  of  fractures  of  corre- 
sponding bones. 

Fracture  of  the  Astragalus. — Fracture  of  this  bone  is  rare ;  it 
usually  results  from  falls,  the  weight  of  the  body  striking  upon  one  foot. 

Symptoms. — The  strong  ligamentous  attachments  of  the  bone  usually 
prevent  much  displacement.  The  prominent  symptoms  are  persistent  pain, 
inability  to  bear  pressure  on  the  foot,  rapid  swelling,  and  crepitus  elicited 
by  flexing,  extending,  abducting,  or  adducting  the  foot.  Where  deformity 
is  marked  the  diagnosis  is  not  difflcult. 

Treatment. — If  there  is  displacement  of  the  fragments  in  this  fracture, 
the  leg  should  be  flexed  upon  the  thigh,  and  deformity  should  be  reduced 
by  extension,  counterextension,  and  manipulation,  the  foot  being  subse- 
quently fixed  in  an  extended  position  at  a  right  angle  to  the  leg.  We  had 
recently  under  our  care  a  woman  who  had  suffered  from  a  fracture  of  the 
astragalus  by  a  fall  from  a  step-ladder,  the  weight  of  her  body  striking  upon 


FRACTUKE  OF  THE   OS   CALCIS. 


509 


one  foot.  In  this  case  there  was  a  very  marked  projection  of  a  fragment  of 
the  astragalus  upon  the  anterior  surface  of  the  foot  below  the  ankle,  which 
was  reduced  by  pressure  under  anaesthesia. 

There  is  usually  marked  swelling  following  this  fi-acture,  so  that  the 
application  of  an  immovable  dressing  is  not  desirable  for  a  week  or  ten 
days ;  we  therefore  prefer  to  apply  as  a  primary  dressing  in  these  cases  a 
well-ijadded  moulded  binder's  board  splint,  which  is  retained  for  a  week  or 
ten  days,  a  jjlaster- of- Paris  dressing  being  then  applied  and  retained  for  five 
or  six  weeks,  or  a  removable  splint  may  be  used  so  that  massage  may  be 
employed.  More  or  less  imiDairment  in  the  motion  of  the  ankle-joint  is  apt 
to  result  from  this  fracture, 

and  the  surgeon  should  be  ^"^'-  '^■^'^• 

careful  that  the  foot  is  kept 
as  nearly  as  possible  at  a 
right  angle  to  the  leg,  for  in 
this  position  the  foot  will 
be  most  useful  if  ankylosis 
should  occur. 

Compound,  fractures  of  the 
astragalus  are  very  serious 
injuries,  and  generally  de- 
mand excision  or  amputa- 
tion.    (Fig.  430.) 

Fracture  of  the  Os  Calcis. — This  fracture  usually  results  from  falls 
upon  the  foot  or  from  force  directly  applied  to  the  plantar  surface  of  the 
foot.  Fractures  of  the  posterior  portion  of  the  os  calcis  also  occasionally 
result  from  violent  muscular  contraction.     (Figs.  431  and  432.) 

Syraptoms. — These  depend  somewhat  upon  the  position  in  which  the 
bone  is  broken :  if  the  posterior  portion  is  separated,  it  may  be  displaced 
upward  by  the  tendo  Achillis 
through  the  action  of  the  gas- 

FiG  431 


Compound  fracture  of  the  astragalus.    (After  Miller.) 


Fig.  432. 


Fracture  of  the  os  calcis. 


Skiagraph  of  fracture  of  the  os  calcis. 


trocnemius  and  soleus  muscles.  If  the  subastragaloid  portion  is  fractured, 
there  is  not  apt  to  be  much  displacement,  but  there  may  be  marked  swelling 
and  broadening  of  the  sole  of  the  foot. 


510 


COMPOUND  FRACTURES  OF  THE  BONES  OF  THE  FOOT. 


Fig.  433. 


Treatment. — In  cases  of  separation  of  the  posterior  portion  of  the  os 
calcis  the  deformity  can  best  be  reduced  if  the  leg  is  flexed  upon  the  thigh 
and  the  foot  is  fully  extended.  When  the  fragment  has  been  brought  into 
its  natural  position  a  well-padded  curved  splint  may  be  applied  to  the  ante- 
rior surface  of  the  foot  and  leg,  or  a  plaster-of- Paris  dressing  may  be  applied, 
holding  the  foot  and  leg  in  this  position.  In  cases  of  subastragaloid  frac- 
ture where  there  is  marked  deformity  it 
may  be  treated  in  a  fracture-box  or  by  the 
application  of  a  plaster-of- Paris  bandage, 
the  foot  being  fixed  at  a  right  angle  to  the 
bones  of  the  leg.  The  time  required  for 
union  in  fractures  of  the  calcaneum  is  from 
six  to  eight  weeks,  and  more  or  less  swell- 
ing, and  stiffness  of  the  ankle-joint  often 
"i^     A.    ■jfti       ^^m  persist  for  some  time, 

a  Jw*IP    ^^B|  Fracture     of    the     Metatarsal 

J^k.  tfli^BE     ^^^n        Bones. — Fractm-es  of  these  bones  usually 
^^  ^■^^w    ^^^Kk        result  from  direct  crushing  force,  and  are 
very  ai)t  to  be  comi^ouud.     The  first  and 
fifth    bones    are    those    most   frequently 
broken.     (Fig.  433.) 

Treatraent. — This  consists  in  the  ap- 
plication of  a  moulded  splint  of  binder's 
board  to  the  sole  of  the  foot  and  the  lower 
part  of  the  leg,  which  fixes  the  motion  of 
the  ankle-joint,  and  may  require  the  addi- 
tion of  a  compress  over  the  seat  of  fi-actm-e 
if  there  is  a  tendency  to  anterior  displace- 
ment of  the  fragments,  or  it  may  be  treated 
by  the  application  of  a  plaster- of- Paris 
bandage.  Union  in  fracture  of  the  meta- 
tarsal bones  is  usually  firm  enough  at  the  end  of  four  weeks  to  permit  of  the 
removal  of  the  dressings. 

Fractures  of  the  Phalanges  of  the  Toes. — Simple  fractures  of 
the  phalanges  of  the  toes  are  comparatively  rare  injuries ;  as  fractures  of 
these  bones  generally  result  from  crushing  force,  they  are  usually  compound. 
Treatment. — The  fragments  may  be  fixed  by  the  application  of  a 
moulded  binder's  board  splint  which  surrounds  the  injured  toe  and  extends 
some  distance  back  upon  the  plantar  surface  of  the  foot,  so  as  to  fix  the 
metatarso-phalangeal  joint.  A  light  wooden  splint  may  also  be  applied  in 
the  same  manner.     Union  is  usually  firm  at  the  end  of  three  weeks. 

Compound  Fractures  of  the  Bones  of  the  Foot. — These  frac- 
tures are  much  more  common  than  simple  fractures,  and  usually  result  from 
crushing  force  ajaplied  to  the  foot.  The  damage  to  the  blood-vessels  and 
soft  parts  is  often  so  extensive  that  primary  ami^utation  is  indicated.  In 
cases,  however,  of  compound  fracture  of  the  astragalus  or  calcaneum  or 
other  tarsal  bones  in  which  the  soft  parts  are  not  extensively  injured,  it  is 
often  possible  to  save  the  foot. 


Skiagraph  of  fracture  of  second  metatarsal 
bone. 


COMPOUND   FRACTURES.  511 

Treatment. — In  extensive  compound  fractures  of  the  tarsal  bones  it  may 
be  considered  a  safe  rule  of  practice  to  excise  the  injured  bones,  as  by  so 
doing  free  drainage  is  secured  and  the  risk  of  tension  is  diminished.  Com- 
pound fractures  of  the  metatarsal  bones  and  jahalanges  of  the  toes  are 
treated  by  sterilization  of  the  wound  and  fixation  of  the  parts  until  union 
has  been  secured.  Of  course  the  greatest  care  should  be  observed  to  steril- 
ize the  wound  and  the  surrounding  parts  and  to  prevent  its  subsequent 
infection.  Very  satisfactory  results  have  followed  excision  of  the  astraga- 
lus, as  well  as  of  the  calcaneum,  in  compound  fractures  of  these  bones.  We 
had  under  our  care  a  patient  who  had  sustained  a  compound  fracture  of  the 
astragalus  in  whom  an  excision  of  the  comminuted  astragalus  was  followed 
by  a  movable  ankle-joint.  In  a  case  of  compound  comminuted  fracture  of 
the  calcaneum  we  removed  the  calcaneum  entirely,  and  sutured  the  insertion 
of  the  tendo  Achillis,  which  had  been  torn  away  from  the  calcaneum,  to  the 
plantar  fascia,  the  patient  recovering  with  a  useful  foot. 

COMPOUND  PPvACTURES. 

Compound  fractures  may  be  produced  in  two  ways, — that  is,  from  without 
or  from  within.  In  the  former  variety  of  compound  fracture  the  force  which 
causes  the  fracture  lacerates  the  skin  and  tissue  covering  the  bone  at  the 
seat  of  fracture,  while  in  the  latter  variety  the  communication  of  the  frac- 
tured bone  with  the  air  is  caused  by  the  ends  of  the  bone  being  driven 
through  the  soft  parts  and  skin.  Comi^ound  fractures  produced  from  with- 
out are  usually  more  serious  injuries  than  those  produced  from  within,  for 
in  the  former  there  is  apt  to  be  a  larger  wound,  and  one  in  which  the  soft 
parts  are  more  or  less  lacerated  and  contused,  with  a  consequent  diminution 
of  their  vitality,  and  they  are  often  infected  ;  while  in  those  laroduced  by  the 
fractured  ends  of  the  bone  the  wound  is  usually  small,  and  unless  there  has 
been  damage  to  important  blood-vessels  or  nerves  or  subsequent  infection  of 
the  wound,  the  injury  is  not  so  serious.  Formerly  compound  fractures  were 
among  the  most  serious  injuries  that  came  under  the  care  of  the  surgeon, 
and  the  mortality  following  them  was  very  great,  many  patients  dying  of 
infective  processes,  such  as  pyaemia,  septicaemia,  erysipelas,  gangrene,  or 
tetanus,  or  from  exhaustion  following  profuse  suppuration  ;  it  was  usual  for 
extensive  necrosis  to  occur,  which  often  left  the  limb  useless,  so  that  ampu- 
tation subsequently  became  necessary.  In  view  of  these  facts,  it  was  the 
practice  to  resort  freely  to  amputation  in  compound  fractures  involving  the 
extremities.  Pew  compound  fractures  are  now  subjected  to  amputation,  for 
we  recognize  the  fact  that  if  the  wound  can  be  rendered  aseptic  and  kept  in 
this  condition  there  is  little  greater  risk  to  the  patient  in  this  variety  of 
fractures  than  in  corresponding  simple  fractures. 

Treatment. — The  early  treatment  of  a  compound  fracture  should  be 
directed  to  the  prevention  of  infection  of  the  wound.  When  it  occurs  at  a 
distance  from  the  place  where  the  subsequent  treatment  of  the  case  is  to 
take  place,  the  wound  should  be  irrigated  with  an  antiseptic  solution,  if 
possible,  or,  if  this  cannot  be  obtained,  with  boiled  water  or  pure  water, 
and  covered  with  towels  or  cloths  wrung  out  of  boiled  or  pure  water.  If 
these  precautions  are  taken,  a  compound  fracture  may  be  kept  aseptic  for 


512  TREATMENT  OF  COMPOUND  FEACTURES. 

some  time,  until  a  more  elaborate  dressing  is  applied.  If  the  wound  is 
small  and  the  skin  is  clean,  and  a  scab  of  blood  has  formed  over  it,  the 
wound  should  not  be  irrigated.  In  dressing  compound  fractures  the  greatest 
care  should  be  observed  to  prevent  infection  of  the  wound,  for  the  fate  of 
the  limb  or  of  the  patient  often  depends  upon  the  care  which  is  exercised 
in  this  respect. 

Dressing  of  Compound  Fractures. — The  skin  surrounding  the  wound 
should  be  first  rubbed  over  with  spirit  of  turpentine  and  then  thoroughly 
washed  with  Castile  soap  and  water,  the  surrounding  skin  and  the  wound 
being  irrigated  with  an  antiseptic  solution,  1  to  2000  bichloride  solution,  or 
with  sterilized  water  or  normal  salt  solution.  Foreign  bodies  should  be 
removed  with  forceps  or  washed  out ;  tissue  which  has  foreign  matter,  such 
as  grease,  sand,  or  dii't,  ground  into  it,  should  be  gently  cleaned  with  a 
gauze  pad  or  curette ;  loose  fragments  of  bone  should  be  removed,  fragments 
having  periosteal  attachments  being  allowed  to  remain.  The  question  of 
■**)  the  primary  fixation  of  the  fragments  should  always  be  considered  in  the 
case  of  compound  fi-actures.  We  are  inclined  to  think  that  one  reason  for 
the  satisfactory  results  following  compound  fractiu'es  at  the  present  day  is 
the  more  general  use  of  primary  fixation  of  the  fragments.  This  may  be 
accomplished  by  drilling  the  fragments  and  suturing  them  together  by 
heavy  silver  or  kangaroo  tendon  sutirres,  or  by  silver  splints  and  screws. 
After  fixation  of  the  fragments,  drainage  should  be  introduced  and  the 
external  wound  closed  with  sutui-es,  unless  there  has  been  much  laceration 
of  the  tissues,  in  which  case  it  is  better  to  introduce  no  sutures.  If  there  is 
any  question  of  the  escape  of  discharges,  the  deep  fascia  should  be  freely 
divided  to  secure  drainage,  and  sutures  should  not  be  used,  the  wound  being 
treated  as  an  open  one.  The  wound  and  surrounding  parts  should  next  be 
covered  with  a  copious  antiseptic  or  sterilized  gauze  dressing,  additional 
fixation  of  the  parts  being  made  by  the  application  of  splints  appropriate 
for  the  special  fracture,  or  by  the  use  of  a  plaster-of-Paris  dressing,  which 
may  be  fenestrated.  In  compound  fractures  of  the  bones  of  the  extremities, 
after  dressing  the  wound  we  usually  apply  moulded  splints  of  binder's 
board  for  a  few  days,  which  can  easily  .be  removed  to  dress  it  if  necessary, 
and  if  it  is  evident  that  the  wound  is  running  an  aseptic  course  we  discard 
these  and  apply  a  plaster-of-Pai-is  dressing.  In  compound  fractures,  Treves, 
after  sterilizing  the  skin  and  the  wound,  keeps  the  parts  dusted  with 
powdered  iodoform,  and  as  this  mixes  with  the  serum  and  blood  and  dries, 
an  antiseiJtic  scab  covering  the  wound  results.  If  in  a  case  of  compound 
fracture  the  wound  has  been  infected  before  it  comes  under  the  care  of  the 
surgeon,  and  if  in  spite  of  his  efforts  suppuration  occurs,  frequent  dressing 
of  the  fracture  may  be  necessary,  in  which  case  some  form  of  movable 
splints  will  be  found  very  satisfactory.  The  time  required  for  firm  union 
in  compound  fractiire,  if  the  wound  does  not  heal  promptly,  is  considerably 
longer  than  in  simple  fracture,  from  two  to  three  months  often  being  required. 
Amputation  or  Excision  in  Compound  Fractures.— Modern 
methods  of  wound  treatment  have  made  it  possible  to  save  many  compound 
fractures  which  would  otherwise  be  subjected  to  amputation  or  excision. 
The  surgeon  can  in  many  cases  now  give  the  patient  the  benefit  of  the  doubt 


DELAYED   UNION  IN   FRACTURE. 


513 


Fig.  434. 


without  subjecting  him  to  additional  risks.  In  doubtful  cases  the  wound 
should  be  carefully  sterilized  and  protected  from  infection,  and  if  in  a  few 
days  it  is  evident  that  the  parts  are  injured  beyond  the  i^ower  of  repair, 
amputation  or  excision  may  be  resorted  to  with  as  fair  a  prospect  of  success 
as  if  performed  as  a  primary  operation.  In  many  compound  fractures  with 
extensive  destruction  of  the  bones,  muscles,  vessels,  and  nerves,  such  as  is 
produced  in  railway  and  machinery  accidents,  primary  amputation  offers 
the  patient  the  best  chance  of  recovery.  In  compound  fractures  involving 
the  joints,  in  which  an  operation  is  indicated,  if  the  vessels  and  nerves  are 
uninjured,  excision  should  be  preferred  to  amputation. 

UNUNITED   FRACTURE,    OR   PSEUDARTHROSIS. 

Delayed.  Union. — A  fracture  in  which  the  bones  are  not  firmly  united 
and  mobility  is  present  after  the  lapse  of  the  time  when  it  is  usual  to  have 
firm  union,  is  described  as  one  of  delayed  union.  This  is  not  uncommon 
after  fractures,  and  results  from  constitutional  causes,  such  as  impaired 
vitality,  from  the  presence  of  various  diseases,  and 
from  shock  ;  also  from  local  causes,  such  as  im^Droper 
dressing,  or  insufficient  fixation  of  the  fragments.  The 
fact  that  union  is  delayed  in  a  fracture  does  not  imply 
that  it  will  ultimately  fail  to  unite.  We  have  often 
seen  cases  in  which  there  was  comparatively  little  union 
at  the  end  of  six  or  eight  weeks,  yet  in  which  after  a 
few  months,  by  improvement  in  the  patient's  constitu- 
tional condition  and  the  use  of  more  efScient  fixation 
apparatus,  firm  union  was  finally  obtained.  We  con- 
sider it  unwise  to  desist  from  treatment  in  cases  of 
delayed  union  for  at  least  six  months. 

Treatment. — This  consists  in  improvement  of  the 
patient's  constitutional  condition  and  the  employment 
of  dressings  which  will  produce  the  most  i)erfect  fixa- 
tion of  the  fragments  at  the  seat  of  fracture.  The 
administration  of  thyroid  extract  has  recently  been 
recommended  and  employed  in  a  number  of  these  cases 
with  encouraging  results.  Friction  of  the  ends  of  the 
bone  until  some  reaction  ensues,  with  or  without  an 
anaesthetic,  and  subsequent  fixation  of  the  fragments, 
are  most  eificient.  Fixation  of  the  joints  adjacent  to 
the  fracture  should  be  practised.  Plaster-of-Paris  skiagraph  of  immuted  fracture 
dressings,  changed  every  two  or  three  weeks,  we  have  °^  *^'''  "^'^' 

also  found  satisfactory.  Bier's  method  of  elastic  constriction  has  been 
em^Dloyed  with  good  results  to  stimulate  the  circulation. 

Ununited  Fracture.— This  is  not  a  frequent  complication  of  fractiu-es. 
Hamilton  estimates  that  about  one  case  occurs  in  five  hundred  fractures.  If 
union  in  a  fracture  has  failed  to  take  place  in  six  months,  the  case  may  be 
considered  one  of  ununited  fracture. 

Causes. — Ununited  fractures  may  result  from  constitutional  or  local 
causes.     Among  the  constitutional  causes  which  seem  to  predispose  to  non- 
33 


514 


UNUNITED   FRACTURE. 


union  are  fevers,  hemorrhage,  shock,  gestation,  and  lactation.  Advanced 
age,  syphilis,  and  paralysis  seem  to  have  little  eiiect  in  causing  non-union 
in  fractures.  I^on-union  is  most  frequently  observed  in  the  femur,  humerus, 
tibia,  and  ulna.     (Pigs.  434,  435,  and  436. ) 

Fig.  436. 
Fig  435 


Ununited  fracture  of  the  tones  of  the 
right  leg.    (Dr.  Robert  Ahbe. ) 


Skiagraph  oJ  ununited  fracture  of  the  femur. 
(Willard. ) 


Local  Causes. — These  include  imperfect  coaptation  of  the  fragments, 
such  as  marked  overlapping,  with  tlie  interposition  of  muscular  tissue  or 
fascia,  tendon,  or  nerve,  or  a  fragment  of  devitalized  bone,  between  the 
fragments,  imperfect  fixation  of  the  fragments,  which  permits  of  free  motion, 
and  too  tight  dressings,  interfering  with  the  vascular  supply  of  the  bone 
necessary  for  its  repair.  We  are,  however,  inclined  to  think  that  the  most 
frequent  cause  of  non-union  in  fractures  is  the  interposition  of  a  shred  of 
muscular  tissue  or  fascia  between  the  fragments,  and  that  improper  dressing, 
allowing  considerable  motion  at  the  seat  of  fracture,  is  not  a  frequent  cause 
of  non-union,  rather  tending  to  produce  an  excessive  amount  of  callus. 
When  one  considers  the  violence  done  to  the  bone  as  well  as  to  the  surround- 
ing tissues,  it  is  not  remarkable  that  tissues  should  be  interposed  between 
the  ends  of  the  fragments,  and  it  is  surprising  that  non-union  after  fracture 
is  not  more  common. 

In  view  of  the  greater  safety  with  which  operations  can  now  be  under- 
taken, we  think  the  time  is  not  far  distant  when  it  will  be  considered  the 
projDcr  treatment  in  simple  ii-actures  with  great  deformity,  or  in  those  in 
which  it  is  difficult  to  retain  the  parts  in  i^osition  after  reduction,  to  cut 
down  upon  the  fragments  and  secure  primary  fixation  by  the  use  of  sutures, 
as  by  such  a  procedure  accurate  apposition  of  the  fragments  may  be  secured 
and  retained,  and  the  risk  of  non-union  guarded  against  by  preventing  the 
interposition  of  tissues  between  the  fractured  ends  of  the  bone. 

Varieties  of  Ununited  Fractures. — Various  conditions  may  exist 
in  the  bone  at  the  seat  of  fracture  as  the  result  of  non-union.  (1)  The  ends 
of  the  bone,  being  subjected  to  more  or  less  motion  upon  each  other,  may 
become  rounded  and  covered  with  fibrous  tissue.     (Fig.  437. )     This  variety 


UNUNITED   FRACTURE. 


515 


of  non-union  often  results  where  there  has  been  a  considerable  loss  of  sub- 
stance in  the  bone,  and  is  followed  by  marked  disability  from  the  great 
mobility  at  the  seat  of  fracture.  (2)  The  ends  of  the  fragments  may  be 
united  to  each  other  by  a  more  or  less  firm  band  of  fibrous  tissue,  which 
allows  of  a  considerable  amount  of  mobility  between  the  ends  of  the  bone. 
(Fig.  438.)     This  is  by  far  the  most  common  variety  of  ununited  fracture. 


Fig.  437. 


FiCx.  -138. 


Fig.  439. 


Ununited  fracture 
with  rounding  of  the 
end3  of  the  bone. 
(After  Agnew.) 


Fibrous  union  be- 
tween the  ends  of  the 
fragments.  (After  Ag- 
new.) 


I     I 


False  joint  in  un- 
united fracture.  (Af- 
ter Agnew.) 


Pseudarthrosis. — Another  variety  of  ununited  fracture  which  is  occa- 
sionally seen  is  that  in  which  a  false  joint  is  formed  at  the  seat  of  fracture. 
The  new  joint  is  of  the  ball-and-socket  type,  one  fragment  being  rounded 
and  the  other  hollowed  out.  The  surfaces  of  the  bone  are  smooth  and 
covered  by  fibrous  tissue  or  fibrocartilage,  and  a  more  or  less  completely 
developed  capsule  is  formed  from  the  surrounding  soft  parts,  lined  with 
endothelium,  which  secretes  a  synovial  fluid.  This  variety  of  ununited  frac- 
ture probably  results  from  prolonged  motion  in  cases  of  transverse  fracture 
in  which  close  fibrous  union  was  originally  present.     (Fig.  439.) 

Treatment. — It  should  be  remembered  that  non-union  in  the  bones  of 
the  lower  extremity,  even  if  permitting  only  a  slight  degree  of  motion,  is 
followed  by  more  disability  than  results  from  non-union  in  the  bones  of  the 
uijper  extremity.  A  patient  with  a  moderate  amount  of  motion  in  an  u.n- 
united  fracture  of  the  shaft  of  the  humerus,  radius,  or  ulna  will  often  have 


516 


TREATMENT  OF  UNUNITED  FEACTURE. 


a  fairly  useful  arm,  while  a  correspondiug  amount  of  motion  iu  the  shaft  of 
the  femur  or  tibia  will  interfere  very  markedly  with  locomotion. 

Various  methods  of  operative  treatment  are  practised  for  the  relief  of 
ununited  fracture,  such  as  friction  of  the  ends  of  the  bone,  drilling  and 
subsequent  fixation,  the  use  of  mechanical  apparatus,  excision  of  the  ends 
of  the  bone,  and  fixation  with  sutures,  screws,  or  metal  splints. 

Friction. — This  may  be  employed  in  ununited  fractures,  an(l  is  often 
successful,  but  should  be  reserved  for  comparatively  recent  cases. 

Drilling. — Drilling  the  ends  of  the  fragments  through  a  small  puncture 
has  been  practised  with  success  iu  many  cases.  If  such  treatment  is  adopted, 
care  should  be  taken  that  the  skin  surrounding  the  seat  of  puncture  is  thor- 
oughly sterilized,  as  well  as  the  drill  with  which  the  ends  of  the  bone  are 
perforated.  The  ends  of  the  bone  may  also  be  freshened  with  an  osteotome 
introduced  through  a  small  wound.  This  j)rocedure  we  recently  practised 
with  a  satisfactory  result  iu  a  child  who  suffered  from  an  ununited  fracture 
of  the  femur.  Fixation  after  either  of  these  oj)erations  should  be  secured 
by  splints  or  by  the  plaster- of- Paris  bandage. 

Mechanical  Apparatus. — In  cases  where  an  operation  is  not  to  be 
recommended,  either  from  the  risk  that  it  entails  or  from  the  fact  that  the 
Vrn  4-in  patient  is  in  a  debilitated  condition  or  refuses  ojiera- 

tive  treatment,  mechanical  apiDaratus  may  be  em- 
ployed with  advantage.  In  ununited  fractvires  of  the 
humerus  a  moulded  leather  splint  or  a  splint  attached 


Fig.  4-12. 


Fig.  441. 


Partial  suture  of  the  bone. 


Complete  suture  of  the  bone. 


Apparatus  for  ununited  frac- 
ture of  the  femur, 

to  a  metal  brace  will  often  permit  the  patient  very  good  use  of  the  arm.  In 
ununited  fractures  of  the  tibia  and  fibula  a  brace  may  be  worn  with  comfort, 
and  union  may  follow.  In  ununited  fractures  of  the  femur,  where  operative 
treatment  is  always  attended  with  danger  from  shock  and  hemorrhage,  the 
application  of  a  brace,  as  is  seen  in  Pig.  440,  will  often  permit  the  patient 
to  have  good  use  of  the  part.  In  some  cases  after  wearing  such  an  appa- 
ratus for  a  time  union  has  finally  taken  j)lace. 


TREATMENT  OF  UNUNITED   FRACTURE. 


517 


Fig.  444. 


Excision  and  Fixation. — The  most  radical  oj)eration,  and  the  one  most 
likely  to  be  followed  by  a  satisfactory  result  in  ununited  fractures,  is  excision 
of  the  ends  of  the  bone,  with  fixation  of  the  fragments  by  metallic  sutures, 
screws,  metal  splints,  ivory  pegs,  or  a  bone  ferrule.  In  jjerforming  this 
operation  the  ends  of  the  bone  are  exposed  by  an  incision,  and  a  section  is 
sawed  off  each  end  so  as  to  get  a  good  bone  surface.  In  some  cases  of  oblique 
fracture  the  ends  of  the  bone  may  be  sawed  so  as  to  make  a  mortise.  The 
ends  being  drilled,  they  are  fixed  with  heavy  silver  wire  or  kangaroo  tendon 
sutures,  the  sutures  including  a  portion  or  the  whole  thickness  of  the  bone 
(Figs.  441  and  442),  by  a  silver  splint  secured  by  silver  screws  (Fig.  443),  or 
by  a  screw  (Fig.  444)  or  Parkhill's  clamp.  The  wound  is  then  closed,  and  the 
limb  is  put  up  in  a  plaster-of- Paris 
dressing.  The  greatest  care  should  be 
taken  to  keep  the  wound  aseptic,  for 
the  success  of  the  operation  depends 
largely  u^jon  avoiding  suppuration. 
The  wires  or  ]3lates,  if  supjpuration 
does  not  occur,  may  remain  perma- 
nently in  the  bone. 

In  cases  of  non-union  of  one  of  two 
parallel  bones  it  may  be  necessary  to 
resect  a  portion  of  the  sound  bone  in 
order  to  coaptate  satisfactorily  the  ends 
of  the  bone  in  which  union  has  not 
occurred.  In  such  cases  hohe-graft.ing 
— a  piece  of  fresh  bone  from  a  recentlj' 
killed  animal  being  fastened  bj'  sutures 
or  ivory  pegs  between  the  freshened 
ends  of  the  bone,  or  the  space  between 
the  freshened  ends  of  the  bone  being 
filled  in  with  bone  chips — has  been  practised  with  success, 
ures,  however,  often  fail,  and  a  plastic  operation  is  required, 
in  transplanting  a  portion  of  one  bone  into  the  other,  or  one  bone  may  be 
sutured  to  the  other,  as  has  been  done  with  success  in  cases  where  there  was 
a  marked  loss  of  substance  in  the  tibia,  the  fibula  being  divided  and  sutured 
to  the  tibia.  The  di-essings  should  be  retained  for  several  months,  and  the 
patient  restricted  in  the  use  of  the  part  for  some  months  afterwards. 

Deformed  Union. — This  complication  after  fractures  may  result  from 
imperfect  reduction  at  the  time  of  the  accident,  or  from  secondary  displace- 
ment caused  by  the  use  of  improper  dressings,  allowing  motion  at  the  seat 
of  fracture.  (Fig.  445.)  Faultj''  or  deformed  union  cannot  in  all  cases  be 
credited  to  the  surgeon,  for  where  there  is  great  swelling  it  may  be  impos- 
sible with  the  utmost  care  to  recognize  the  displacement  of  the  fragments, 
and  in  some  cases  the  bones  are  crushed  or  comminuted  so  extensively  that 
it  is  impossible  to  restore  their  shape,  or  the  obliquity  or  the  irregular  line 
of  the  fracture  may  prevent  the  restoration  of  the  shape  of  the  bone.  In 
fractures  complicated  with  flesh  wounds,  burns,  or  scalds,  it  may  be  im^ios- 
sible  to  apply  any  retentive  apparatus ;  the  patient  also  may  remove  or 


Fragments  secured  with  a 
Sliver  splint  and  screws. 


Fragments  secured 
with  a  screw. 

These  proced- 
This  consists 


518 


DEFORMED  UNION  IN   FRACTURE. 


interfere  with  the  dressings  and  splints,  or  suffer  from  mania  or  delirium 

tremens,  which  conditions  may  prevent  coaptation  of  the  fragments  or  lead 

to  secondary  displacement  and  result  in  deformed  union. 

Treatment. — The  deformity,  if  it  interferes  with  the  usefulness  of  the 

j)art,  may  be  corrected  by  refracturing  the  bone  or  by  bending  the  bone 
before  the  callus  has  become  firm.  After  the  correction 
of  the  deformity  the  part  should  be  fixed  by  the  appli- 
cation of  a  firm  dressing,  such  as  plaster- of- Paris.  In 
some  cases  where  the  deformity  is  marked  and  union  at 
the  seat  of  fracture  is  firm,  a  linear  or  cuneiform  oste- 
otomy may  be  em]3loyed  with  advantage.     In  a  case  of 

Fig.  440.  Fig.  447. 


Fig.  445. 


Deformed  union  after  frac-  Detormiti  alter  liacture  of  the  femur  corrected  by  osteotomy, 

ture  of  the  femur. 

deformity  after  fracture  of  the  femur  (Pig.  446)  we  resorted  to  osteotomy 
to  correct  the  deformity,  and  the  satisfactory  result  obtained  is  shown  in 
Pig.  447. 

AflEections  of  Callus. — Callus  thrown  out  in  the  repair  of  fractures 
may  undergo  various  changes  as  the  result  either  of  local  or  of  constitu- 
tional causes. 

Exuberant  Callus. — This  is  often  observed  after  a  comminuted  frac- 
ture, or  one  in  which  there  is  great  overlapping  ;  it  is  especially  noticed  in 
long  bones  in  fractures  near  the  joints,  and  is  frequently  observed  in  frac- 
tures of  the  femur  near  the  hip-joint.  The  mass  of  callus  may  be  so  exten- 
sive as  to  project  into  the  surrounding  tissues  and  cause  jiressure  upon  con- 
tiguous nerves.  (Pig.  448.)  In  the  case  of  "the  ulna  and  the  radius,  a 
bridge  of  bone  may  ignite  them,  interfering  with  the  motions  of  pronation 
and  supination.     (Pig.  449. ) 

Softening  and  Absorption  of  Callus.— Callus  may  undergo 
absorption  after  fracture  as  the  result  of  premature  motion  or  of  constitu- 
tional causes.     A  patient  with  a  fi'aoture  firmly  united  at  the  end  of  six  or 


COMPLICATIONS  AFTER  FRACTURE. 


519 


Fig.  448. 


fr- 


eight weeks,  as  the  result  of  a  depressed  constitutional  condition,  j)roduced 
by  typhoid  fever  or  other  adynamic  disease,  may  have  the  callus  soften  and 
motion  again  apiiear  at  the  seat  of  fracture.  This  is  not  uncommon  after 
osteotomy  for  rhachitic  deformity  if  the  disease  is  still  active.  In  such  cases, 
however,  when  the  disease  is  cured, 
it  is  not  unusual  for  the  union  again 
to  become  firm. 

Consecutive  Shortening. — 
This  usually  results  after  fracture 
from  the  patient's  beginning  to  use 
the  limb  before  the  callus  is  firm. 
It  is  most  frequently  observed  in 
fractures  of  the  lower  extremity. 
Here  the  shortening  is  probablj'  due 
to  condensation  of  the  not  yet  firm 
callus.  The  surgeon  should  bear  in 
mind  the  possibility  of  consecutive 
shortening,  and  discourage  the  use 
of  a  fractured  limb  until  it  is  quite 
clear  that  sufficient  time  has  elapsed 
for  the  callus  to  have  become  firmly 
consolidated. 

Fracture  of  Callus.— This  re- 
sults from  violence  apj)lied  to  a 
fractured  bone  before  the  callus  has 
become  thoroughly  consolidated,  and 
may  occur  from  the  application  of 
only  a  moderate  amount  of  force.  After  a  bone  has  firmly  united  it  is 
unusual  to  have  a  fracture  occur  at  the  seat  of  fracture,  even  upon  the  appli- 
cation of  great  force,  it  being  apt  to  give  way  at  another  point.  We  had 
under  our  care  a  short  time  ago  a  man  who,  after  the  removal  of  the  splint 
in  case  of  fracture  of  the  arm,  suffered  from  two  fractures  of  the  callus  at 
intervals  of  a  few  weeks  from  slight  falls.  It  is  often  observed  in  fractures 
of  the  lower  extremities  after  removal  of  the  splints  and  dressings,  when  the 
patient  receives  a  fall  from  the  unaccustomed  use  of  crutches ;  we  have  seen 
a  number  of  refractures  of  the  femur  xiroduced  in  this  manner.  The  repair 
of  fracture  of  callus  is  usually  very  prompt,  less  time  being  required  than 
in  the  case  of  piimary  fractures. 

Tumors  of  Callus. — Kew  growths  developing  in  the  callus  at  the  seat 
of  fracture  are  rare,  except  in  subjects  who  are  suffering  from  cancer  in 
other  parts  of  the  body ;  we  have  seen  a  woman  suffering  from  cancer  of 
the  breast,  who  sustained  a  fracture  of  the  femur,  develop  a  large  carcinom- 
atous mass  in  the  callus  at  the  seat  of  fracture.  Cases  of  euchondroma 
and  sarcoma  have,  however,  been  reported  as  developing  in  callus  after 
fracture  when  there  was  no  evidence  of  the  disease  in  other  parts  of  the 
body.  Separations  or  injuries  of  the  epiphyses  in  young  subjects  seem 
more  likely  to  be  followed  by  the  development  of  sarcomatous  growths  than 
are  fractures. 


Excessive  callus  in  fracture 
of  tlie  femur. 


Callus  uniting  the  ulna 
and  the  radius. 


520  COMPLICATIONS  AFTER  FRACTURE. 

Complications  after  Fracture.— Rupture  of  an  Artery.— This 
may  result  from  stretching  or  tearing  of  the  vessel  or  laceration  of  its  coats 
by  the  fragments  of  bone.  As  the  result  of  this  accident  a  traumatic  aneu- 
rism forms,  -vrhich  can  be  recognized  by  the  swelling,  change  in  the  color  of 
the  limb,  loss  of  pulsation  iu  the  injured  artery,  expansile  pulsation  and 
bruit,  or  thrill.  It  is  wise,  if  the  aneurism  is  not  increasing  in  size,  to  post- 
pone its  treatment  \intil  consolidation  has  occurred  at  the  seat  of  fracture. 

Embolism  and  Thrombosis. — A  thrombus  may  occur  from  injury  to 
the  veins,  and  an  embolus  may  be  detached  and  be  swept  into  the  heart  or 
the  pulmonary  artery,  causing  a  fatal  termination.  A  thrombus  may  result 
from  contusion  or  bruising  of  an  artery  at  the  seat  of  fracture  and  lead 
to  gangrene.  Fat  embolism  is  a  comj)aratively  rare  comxilication.  (See 
page  99.) 

Delirium  Tremens. — This  is  not  an  unusual  complication  of  fractures 
in  subjects  addicted  to  the  use  of  alcohol,  and  may  develop  soon  after  the 
occurrence  of  the  injury  or  some  weeks  afterwards.  Its  development  is 
usually  preceded  by  agitation  and  insomnia.     (See  page  97.) 

Gangrene. — This  is  an  occasional  complication  after  fracture,  and  occurs 
from  injury  of  the  soft  parts  at  the  time  of  fracture  or  subsec(ueutly  from 
compression  of  important  vessels  by  the  fi-agments  of  bone.  Traumatic 
spreading  gangrene  may  develop  after  com]3ound  fractui-es.  Tetanus,  septi- 
cwmia,  and  pycemia  are  complications  of  compound  fractures  which  are  rarely 
seen  when  aseptic  methods  of  treatment  have  been  carefully  practised. 

Paralysis. — This  may  occur  as  a  direct  result  of  injury  to  an  important 
nerve  at  the  time  of  fracture,  or  may  develop  later  from  the  pressure  of 
callus  upon  a  nerve.  Wrist-drop  is  sometimes  observed  after  fracture  of  the 
shaft  of  the  humerus  from  injury  of  or  pressure  upon  the  rausculo-spiral 
nerve,  and  foot-drop  is  sometimes  observed  after  fracture  of  the  fibula  or  the 
external  condyle  of  the  femur,  from  injury  6f  or  pressure  upon  the  external 
popliteal  nerve. 

Ankylosis. — Ankylosis  of  joints  is  a  later  complication  of  fractures, 
and  is  apt  to  occur  after  fracture  in  the  vicinity  of  joints,  or  one  in  which 
the  line  of  fracture  extends  into  the  joint,  producing  malposition  of  the 
articular  surface  of  the  bone.  Ankylosis  occurring  from  fracture  near  a 
joint  is  usually  due  to  thickening  of  the  tissues  about  the  joint  and  from 
disuse  of  the  joint,  and  is  not  apt  to  be  permanent.  On  the  other  hand, 
when  there  is  displacement  of  the  articular  surfaces  of  the  bones  making 
ix])  the  joint,  the  ankylosis  is  ai^t  to  be  permanent.  This  is  one  of  the  most 
troublesome  comijlications  in  fractures  involving  the  elbow-  and  knee-joints. 
In  ankylosis  of  a  joint  following  fracture,  massage  and  passive  motion  will 
do  much  to  overcome  the  stiffness  at  the  joint  and  restore  its  function,  being 
of  course  followed  by  better  results  in  case  of  ankylosis  from  disuse  and 
periarticular  thickening  than  where  there  has  been  absolute  involvement  of 
the  joint  iu  the  fracture. 

Muscular  Wasting. — This  condition  may  result  from  disuse  of  the 
muscles  consequent  upon  the  prolonged  use  of  fixation  apparatus,  or  from 
injury  of  or  pressure  upon  nerves  as  the  result  of  the  fracture.  In  the 
former  case,  when  the  splints  are  removed  and  union  at  the  seat  of  fracture 


DISEASES   OF  BONE. 


521 


is  firm,  the  use  of  massage  as  well  as  exercise  of  the  affected  muscles  will 
soon  restore  their  function.  Muscular  wasting  following  nerve  injury  or 
pressure  should  be  treated  by  galvanism  ;  if  this  fails  to  be  followed  by 
benefit  it  may  be  necessary  to  expose  the  nerve,  and  if  it  is  divided  to  imite 
it  by  sutures ;  excision  of  a  degenerated  portion  of  the  nerve,  or  the  removal 
of  callus  pressing  upon  it,  may  also  be  required. 

Restoration  of  Function  after  Fracture. — The  union  of  the  bone 
after  fracture  is  usuallj-  firm  in  from  six  to  eight  weeks,  but  the  restoration 
of  function  in  the  injured  part  is  sometimes  delayed  for  many  weeks  or 
months,  which  is  often  due  to  a  pi'olonged  immobilization  or  failure  to 
practise  passive  motion  during  the  course  of  treatment.  The  part,  after 
the  removal  of  the  splints  and  dressings,  is  painful,  and  swells  uj)on  being 
placed  iu  a  dependent  position,  from  loss  of  tone  in  the  blood-vessels,  and 
there  is  also  more  or  less  stiffness  of  the  joints  and  tendons.  The  restoration 
of  function  can  best  be  hastened  by  massage  and  rubbing  the  skin  with  soap 
liniment,  and  by  encouraging  the  patient  to  use  the  part 
carefully.  The  application  of  a  flannel  bandage,  which  pos- 
sesses some  elasticity,  may  be  followed  by  good  res'ults  in 
diminishing  the  amount  of  swelling.  The  swelling  is  most 
marked  after  fractures  of  the  lower  extremity,  and  patients 
should  not  allow  the  iiart  to  remain  in  a  dependent  position 
for  too  long  a  time,  but  should  constantly  change  its  position. 
Massage  and  passive  motion  are  the  two  most  valuable  means 
of  hastening  the  restoration  of  function  after  fractures. 


Frr,.  4.=;0. 


II 


DISEASES  OF  BONE. 

Bone  like  the  soft  tissues  of  the  body  may  be  the  seat  of 
atrophy  and  hypertrophy,  hypertemia,  and  inflammation,  the 
latter  either  simple,  suppurative,  or  specific ;  tubercle  and 
syphilis  being  the  types  of  specific  infections ;  tumors  also 
may  develop  in  bone. 

Hypertrophy  of  Bone. — True  hypertrophy  of  bone 
unassociated  with  osteoporosis  is  rarely  met  with,  but  occa- 
sionally cases  of  congenital  hyj)ertroj)hy  of  a  whole  limb  have 
been  observed,  in  which  the  bones  of  the  part  were  hyper- 
trophied.  In  very  muscular  subjects  the  bones  subjected  to 
excessive  use  may  show  increase  in  length  and  thickness,  as 
well  as  hypertrophy  of  the  ridges  for  muscular  attachments. 
In  parallel  bones,  when  one  bone  is  partially  destroyed  by 
disease,  hj'pertrophy  of  the  other  bone  is  often  observed.  The 
hyijertrophy  which  is  often  seen  in  the  skull  and  in  other 
bones  is  generally  due  to  chronic  osteomyelitis  and  osteoscle- 
rosis. (Fig.  -t50.)  The  term  osteoporosis  is  also  aijplied 
to  this  affection,  and  the  best  examples  of  this  disease  are 
observed  in  the  skull.  (Fig.  451.)  No  special  treatment  is  indicated  for 
this  condition. 

Leontiasis  Ossea. — This  is  an  affection  which  has  been  described  by 
Virchow,  characterized  by  hyperostosis  of  the  facial  and  cranial  bones. 


i 


C  t  U  1  lusis  of 
the  icrnui  ( \g 
new.) 


522 


ATROPHY  OF  BONE. 


Large  masses  of  bone  develop  from  the  facial  or  cranial  bones.  This  change 
in  the  bones  does  not  consist  in  a  simple  outgrowth,  but  the  whole  bone  is 
hypertrophiedor  involved  in  the  growth.  (Fig.  4.52.)  The  ijrincipal  symp- 
toms of  the  affection  are  pain,  great  deformity,  and  loss  of  function,  which 
is  caused  by  the  growths ;  the  eyes 
may  be  pushed  from  their  sockets, 
and  the   nerves  so   compressed  at 


Osteoporosis  of  the  skull.    (Agiiew.) 


Leontlasis  ossea.    (Ashhurst.) 


their  foramina  of  exit  as  to  have  their  function  arrested ;  loss  of  sight  is 
not  an  uncommon  complication  in  these  cases.  The  affection  runs  a  slow 
course,  and  it  may  be  years  before  the  deformity  or  pain  is  marked. 

Treatment. — In  unilateral  cases  where  there  is  distinct  evidence  of 
localized  nerve-pressui-e,  operative  treatment  may  be  undertaken,  but,  as  a 
rule,  where  the  disease  is  widely  distributed,  little  can  be  done  for  the 
patient's  relief  by  surgical  procedures. 

Acromegaly. — This  disease  consists  in  enlargement  of  the  hands  and 
forearms,  the  feet,  the  jaw,  and  sometimes  other  bones ;  the  bones  are  more 
porous  than  usual.  It  usually  appears  between  the  fifteenth  and  thirty-fifth 
years,  and  is  accompanied  by  mental  failure,  wasting  of  the  muscles,  exag- 
geration of  the  reflexes  and  gradually  increasing  weakness.  Ko  treatment 
has  any  influence  ux)ou  the  course  of  the  disease. 

Atrophy  of  Bone. — This  condition  is  much  more  common  than  hyper- 
trophy of  bone,  being  shown  by  diminished  solidity,  thickness,  and  length, 
and  usually  results  from  defective  nutrition.  The  bone  becomes  more  porous, 
the  medulla  and  cancellous  tissue  are  increased  in  size  and  filled  with  fat, 
and  the  cortical  portion  is  so  wasted  that  it  represents  but  a  fraction  of  its 
normal  thickness.  (Fig.  453.)  Atrophy  of  bone  may  result  from  many 
causes,  and  may  occur  at  any  period  of  life,  but  is  most  common  in  advanced 
age.  It  may  result  as  a  temporary  condition  after  fracture,  when  a  bone  has 
had  its  function  suspended  for  a  long  time,  or  may  be  observed  in  old  age, 
when  diminished  function  and  defective  nutrition  both  conduce  to  atrophy 
elsewhere  as  well  as  in  the  bone.     The  best  examples  of  atrophy  of  bone  are 


EXOSTOSIS. 


523 


seen  in  cases  of  infantile  paralysis,  wliere  the  bones  of  one  or  both  limbs 
remain  wasted,  while  other  bones  in  the  body  attain  their  normal  propor- 
tions. Malignant  disease  is  said  to  produce  ati'ophy  of  the  bone.  In  this 
disease  the  bones  often  become  weaker,  so  that  they  are  liable  to  fracture, 
but  we  know  of  no  observations  which  prove  that  there  results  actual 
atrophy  of  the  bones. 

Treatment. — In  atrophy  of  bones  occurring  in  old  age  little  can  be  done 

in  the  way  of  treatment,  but  in  atrophy  resulting  from  fracture  or  infantile 

paralysis  attempts  should  be  made  to  increase  the  nutrition  of  the  affected 

bones ;  this  may  be  done  by  the  use  of  passive  motion  and  massage,  and  in 

conjunction  with  this  treatment  Esmarch's  elastic  bandage  or 

Fig.  453.       constrictor  may  be  applied  at  frequent  intervals  for  a  limited 

time,  to  produce  temijorary  venous  hyj)er£emia  of  the  limb. 

Care  should  always  be  exercised  in  handling  bones  which 

present  evidences  of  atrophy,  as  they  are  more  susceptible 

to  fracture  than  normal  bones.      When  this  accident  occurs 

in  such  bones  union  usually  takes  place  satisfactorily. 

Exostosis. — This  consists 
of  a  bony  tumor  attached  to  the 
I  ^^^^^^^^K  external  surface  of  the  bone, 

which  occurs  in  two  forms,  the 
ivory  sessile  variety,  chiefly 
found  in  connection  with  the 

Fig.  455. 


Atrophy  of  the 
femur. 


I  of  an  exostosis  of  the  tibia. 
(Willard.) 


Subungual  exostosis. 


bones  of  the  skull  and  face,  and  the  spongy  pedunculated  form,  which  usu- 
ally occurs  in  the  region  of  the  epiphyses  of  the  long  bones.  These  growths 
are  often  observed  at  the  inner  surface  of  the  femur  just  above  the  condyle, 
over  the  head  of  the  tibia  (Fig.  4=54),  and  about  the  phalanges  of  the  fingers 
and  toes.  Subungual  exostosis  of  the  toes  is  a  common  affection.  (Fig. 
455.)  These  growths  are  composed  of  cancellated  tissue  covered  by  a  thin 
layer  of  compact  tissue.  Their  supposed  origin  from  adjacent  burste  has 
given  them  the  name  of  exostosis  bursata,  but  the  bursas  which  form  over 
these  growths  are  often  found  to  be  entirely  unconnected  with  adjacent 
bursas,  and  are  of  the  nature  of  the  adventitious  bursas  observed  in  other 
locations.  The  affection  possesses  no  hereditary  tendency,  and  there  is  no 
evidence  that  it  depends  upon  syj>hilis  or  rheumatism.    It  is  often  multiple, 


524  •  OSTEOMALACIA. 

and  if  the  growths  are  largely  developed  the  motion  of  adjacent  joints  may 
be  markedly  interfered  with. 

Treatment. — Operative  treatment  for  their  removal  should  be  under- 
taken only  when  the  growths  cause  great  deformity  or  interfere  with  the 
movements  of  the  adjacent  joints.  In  removing  exostoses  the  part  should 
be  rendered  bloodless  by  the  use  of  Esmarch'  s  bandage,  and  the  greatest 
care  should  be  observed  as  regards  asepsis.  The  bony  growth  should  be 
exposed  by  incision  and  the  soft  parts  carefully  separated,  to  expose  the 
base  of  the  tumor,  which  should  be  freely  separated  from  the  bone  by  a 
gouge  or  by  bone-forceps. 

The  removal  of  a  sirbungual  exostosis  is  accomplished  by  exposing  the 
bony  growth  by  incision  and  dividing  its  base  with  bone-forceps,  after  its 
removal  the  skin  incision  being  brought  together  by  sutures. 

Osteomalacia. — MoUities  Ossium. — This  disease  is  observed  in 
adults,  and  is  characterized  by  softening  of  the  bones,  which  renders  them 
very  liable  to  break  or  bend  upon  the  application  of  little  force.  The  con- 
dition is  seldom  seen  in  males,  occurring  with  much  greater  frequency  in 
females,  in  the  iiroportion  of  about  ten  to  one ;  pregnancy  and  lactation 
seem  to  be  the  principal  exciting  causes.  The  softening  of  the  bones  results 
from  absorption  of  the  earthy  matters ;  the  decalcified  osseous  tissue  is 
finally  converted  into  a  gelatinous  mass,  surrounded  by  a  thin  cortical  layer 
of  bone  beneath  the  periosteum. 

Symptoms. — The  premonitory  symptoms  are  failure  of  health  and 
wandering  pains  in  the  affected  bones  ;  the  urine  contains  an  abundance  of 
phosphate  of  lime.  In  pregnant  or  nursing  women  the  bones  of  the  pelvis 
are  first  involved,  but  later  other  bones  are  affected.  Bending  of  the  bones 
or  fracture  may  occur  upon  the  apiDlication  of  little  force,  such  as  turning  in 
bed  or  lifting  the  patient.  In  advanced  cases  multiple  fractures  are  common. 
Bending  or  distortion  of  the  bones  may  be  caused  by  muscular  action. 

Treatment. — General  tonic  treatment  is  indicated,  and  the  use  of  phos- 
phorus is  said  to  have  an  effect  in  arresting  the  development  of  the  disease. 
The  patient  should  be  placed  upon  an  air-  or  water-bed,  and  if  there  is  a 
tendency  to  deformity  of  the  bones  of  the  limbs,  light  splints  should  be 
applied  to  prevent  it.  If  the  disease  develops  during  lactation,  this  should 
be  arrested,  and  if  it  occurs  during  pregnancy,  the  induction  of  premature 
labor  should  be  j)ractised.  Eemoval  of  the  ovaries  in  the  non-pregnant 
state  has  been  employed  with  apparently  good  results  in  a  few  cases. 

Fragilitas  Ossium.  This  is  an  affection  of  bone  in  which  the  inor- 
ganic are  out  of  proportion  to  the  organic  constituents,  rendering  the  bone 
brittle  ;  there  is  an  apparent  increase  of  the  earthy  salts,  with  a  diminution 
of  the  vascularity  of  the  bone.  It  may  occur  as  a  result  of  malignant 
cachexia,  in  general  paralysis,  in  tabes,  and  in  the  early  stage  of  rhachitis, 
and  is  jarobably  due  to  defective  innervation.  There  are,  however,  persons 
presenting  excessive  brittleness  of  the  bones,  who  are  apparently  healthy  in 
other  respects  and  have  suffered  from  none  of  the  diseases  named.  Children 
and  young  jDcrsons  seem  to  suffer  most  from  fragilitas  ossium,  and  in  many 
instances  an  hereditary  tendency  can  be  traced.  Such  patients  suffer  from 
fracture  upon  the  slightest  provocation,  but  in  time  outgrow  the  tendency. 


HYPEE^MIA  OF  BONE. 


525 


There  seems  to  be  no  special  inclination  to  non-nnion  in  these  cases,  fractures 
uniting  pi-omptly,  even  when  several  have  occurred  in  different  bones  of 
the  skeleton  at  the  same  time. 

Osteitis  Deformans. — Tliis  disease  was  first  described  by  Paget, 
and  begins  in  middle  life  or  later ;  it  is  characterized  by  a  change  in  the 
size,  shape,  and  direction  of  the  diseased  bones,  the  genei'al  health  during 
the  development  of  the  osseous  lesions  being  only  slightly  affected.  The 
disease  commonlj^  affects  the  long  bones  of  the  lower  extremity  or  the  skull 
first,  but  in  time  the  bones  of  the  spine,  ribs,  pelvis,  and  upper  extremity 
are  involved.  The  bones  become  enlarged  and  softened,  gradually  present- 
ing marked  curving  and  deformity.  The  disease  appar- 
ently starts  as  a  rarefying  osteitis,  in  which  the  normal 
compact  tissue  becomes  porous  and  reticulated,  this  pro- 
cess involving  the  walls  of  the  shaft  as  well  as  those  of  the 
articular  ends  of  the  bone.  New  bone  is  formed  beneath 
the  periosteum,  and  in  time  undergoes  hypertrophic  and 
sclerotic  changes.  In  addition  to  the  deformity  and  change 
in  the  thickness  of  the  bone,  there  is  increase  in  length  or 
hypertrophy.     (Fig.  456.) 

Symptoms. — Patients  suffering  from  this  disease 
sometimes  complain  of  rheumatic  pain  in  the  lower  limbs 
and  spine,  but  the  general  health  is  usually  very  little 
affected.  The  decrease  of  stature,  stooping  figure,  and 
apparent  increase  of  length  in  the  arms  when  in  the  erect 
position  usually  attract  attention.  Bowing  of  the  spine 
and  loss  of  movement  of  the  ribs  in  respiratory  action  are 
marked  when  the  spine  is  involved ;  in  such  cases  the 
breathing  is  largely  diaphragmatic.  The  disease  does  not 
apparently  shorten  life;  one  of  Paget' s  original  cases 
lived  to  be  seventy  years  of  age.  We  have  had  under 
observation  Ashhurst's  case  of  osteitis  deformans  for  more  than  ten  years, 
and,  aside  from  increased  deformity  and  lessened  ability  to  take  exercise, 
the  patient's  condition  is  not  very  different  from  what  it  was  at  the  time  we 
first  saw  him.     Treatment  has  no  effect  upon  the  course  of  the  disease. 

Hypersemia  of  Bone. — HyperEemia  of  bone  may  result  from  injuries 
of  the  bone,  and  is  an  active  factor  in  the  repair  of  bone  after  wounds  and 
fractures  ;  it  may  be  accompanied  by  a  moderate  elevation  of  temperature, 
pain  or  tenderness,  and  swelling  of  the  ijeriosteum  and  overlying  soft  jjarts. 
During  the  period  of  growth  children  and  young  adults  often  complain  of 
intermittent  pains  in  the  long  bones  and  joints  which  are  po]3ularly  known 
as  growing  ixdns.  This  condition  is  most  frequently  observed  from  the  tenth 
to  the  sixteenth  year.  This  pain  is  usually  referred  to  the  region  of  the 
epiphyses,  the  portion  of  the  bone  in  which  the  circulation  is  most  active  by 
reason  of  the  increased  nutritive  changes  incidental  to  its  growth.  Pi'om  the 
position  of  the  pain  the  affection  may  be  confounded  with  early  disease  of 
the  joints ;  examination  will  show  that  the  joint  is  not  swollen,  that  the  pain 
is  in  the  shaft-  of  the  bone  near  the  joint  and  not  in  it,  and  that  the  pain 
will  usually  disapioear  under  rest  of  the  part  for  a  few  days. 


Osteitis  deformans. 
(Ashhurst.) 


526  NECROSIS  OF  BONE. 

Treatment. — In  the  majority  of  cases  no  special  treatment  is  required, 
but  in  severe  cases,  in  whicli  tiiere  is  a  question  of  diagnosis  between  this 
condition  and  beginning  joint  disease,  rest  in  bed  and  the  application  of  a 
splint  to  fix  the  part  may  be  followed  in  a  few  days  by  entire  relief  of  the 
condition. 

Tumors  of  Bone. — These  may  occur  as  primary  growths  or  secondary 
deposits  from  tumors  in  distant  parts,  or  from  extension  of  tumors,  origi- 
nating in  the  soft  parts  in  immediate  relation  to  the  bone.  The  primary 
tumors  of  bone  are  choudromata,  sarcomata,  and  exostoses ;  the  secondary 
tumors  are  sarcomata  or  carcinomata  resulting  either  from  metastasis  or 
fi-om  extension  from  neighboring  growths.     (See  pages  284  and  299.) 

Inflamraation  of  Bone. — Inflammatory  affections  of  bone  are  similar 
to  those  of  the  soft  parts,  and  are  modified  only  by  the  density  of  the  tissue 
in  which  they  occur.  The  term  osteitis  is  apj)lied  to  inflammatory  conditions 
of  bone  ;  when  the  process  involves  the  different  components  of  the  bone, 
the  periosteum,  cortical  portion,  or  the  medulla,  the  .affection  is  described 
as  periostitis,  cortical  osteitis,  and  medullary  osteitis  or  osteomyelitis.  It  is 
often  impossible  to  separate  these  conditions,  as  they  usually  exist  at  the  same 
time  ;  periostitis  is  usually  the  result  of  osteitis  or  osteomyelitis,  and  in  cases 
of  cortical  osteitis  and  osteomyelitis  a  certain  amount  of  periostitis  is  present. 
Inflammation  of  bone  may  be  acute,  chronic,  or  specific,  the  latter  form  being 
due  to  specific  infectious,  such  as  tubercle,  syphilis,  and  actinomycosis. 

Necrosis  of  Bone. — This  term  is  synonymous  with  mortification  or 
death  of  bone,  and  corresponds  to  gangrene  in  the  soft  parts.  In  this 
condition  a  considerable  portion  of  bone  has  lost  its  vitality  and  remains  in 
the  tissues  as  a  foreign  body  or  sequestrum.  Among  the  causes  producing 
necrosis  are  mechanical  violence,  which  may  completely  separate  a  portion 
of  bone  and  cirt  off  its  nutrition,  as  is  sometimes  seen  in  compound  and 
gunshot  fractures,  and  infective  or  specific  inflammations  of  bone.  Pyogenic 
infection  is  the  most  prolific  cause  of  necrosis  (see  Osteitis  and  Osteomye- 
litis), for  even  in  traumatic  separation  of  bone  the  detached  portion  may 
maintain  its  vitality  and  regain  attachments  to  the  living  bone  if  pyogenic 
infection  of  the  wound  does  not  take  place.  The  same  is  true  in  cases  of 
syphilitic  necrosis,  which  is  generally  due  to  pyogenic  infection  of  a  syphi- 
litic inflammation  of  bone.  Exposure  to  the  fumes  of  ijhosphorus  produces 
necrosis  of  the  jaws,  and  the  same  affection  is  often  seen  after  scarlet  fever 
and  measles.  It  is  probable,  however,  that  in  the  case  of  phosphorus  necrosis 
the  irritating  cause  is  the  fumes  of  phosphorous,  and  that  the  subsequent 
necrosis  results  from  an  infective  osteomyelitis  ;  while  in  the  case  of  necrosis 
following  scarlet  fever  and  measles,  there  is  little  doubt  that  the  death  of 
bone  results  from  osteomyelitis  caused  by  specific  and  pyogenic  organisms. 

Ssrmptoins. — The  condition  of  necrosis  is  preceded  by  the  symptoms 
of  inflammation  of  bone  :  when  the  bone  is  actually  dead  few  symptoms  are 
present.  The  devitalized  bone  usually  is  more  or  less  surrounded  by  a  case 
of  new  bone  which  has  developed  from  the  periosteum,  and  the  cavity  of 
which  communicates  with  one  or  more  sinuses  which  lead  to  openings  upon 
the  skin.  More  or  less  granulation-tissue  lines  the  cavity,  and  a  little  pus 
is  generally  discharged  from  the  sinuses.     The  presence  of  a  considerable 


PERIOSTITIS.  527 

portion  of  dead  bone  can  be  recognized  by  passing  a  probe  through  the 
sinus,  when  it  comes  in  contact  with  the  roughened  bone.  If  the  sequestrum 
is  loose,  it  can  be  moved  by  pressure  with  the  probe.  (Fig.  457.)  When 
this  condition  exists,  the  operation  for  the  removal  of  the  sequestrum — seques- 

FiG.  457. 


Necrosis  of  the  ulna,  with  exposed  sequestrum. 

trotomy  (see  page  534) — offers  the  best  means  of  securing  ijermanent  healing 
of  the  sinuses.  Where  a  small  sequestrum  exists,  it  may  be  loosened  by  the 
underlying  granulations  and  escape  through  a  sinus,  or  may  be  macerated 
and  broken  rip  and  escape  in  small  pieces.  This  spontaneous  extrusion  of  a 
sequestrum  is,  however,  not  likely  to  occur  except  in  the  case  of  a  very  small 
sequestrum,  and  a  period  of  years  is  often  required  for  its  accomplishment. 

PERIOSTITIS. 

This  consists  in  an  inflammation  of  the  periosteum,  but  as  this  condition 
rarely  exists  independent  of  that  of  the  underlying  bone,  the  affection  is 
often  described  as  osteoperiostitis.  It  may  be  either  acute  or  chronic,  and 
may  exist  as  simple  or  non-infective  j)eriostitis,  or  infective  periostitis  ;  the 
latter  includes  acute  suppurative,  tuberculous,  sj^philitic,  and  actinomycotic 
periostitis. 

Simple,  or  Non-Infective  Periostitis.— This  infection  may  arise 
from  contusions  and  non-infected  wounds  of  the  iseriosteum,  and  is  char- 
acterized by  pain  and  swelling  in  the  affected  region,  and  if  no  infection  of 
the  wound  occurs,  resolution  takes  place  promptly. 

Treatment. — As  the  tendency  of  this  affection  is  to  recovery,  active 
treatment  is  not  indicated.  The  part  should  be  put  at  rest  and  cold  applica- 
tions employed  ;  if  an  open  wound  communicates  with  the  wound  of  the  peri- 
osteum, it  should  be  closed  and  a  sterile  gauze  dressing  applied.  If  pain  is 
a  prominent  symj^tom,  anodyne  lotions  may  be  used  with  advantage. 

Acute  Suppurative  Periostitis. — This  affection,  which  results  from 
pyogenic  infection,  follows  injuries  and  wounds  of  bone ;  the  disease  if 
limited  in  extent  and  properly  treated  i.s  not  followed  by  extensive  necrosis. 
In  these  cases  the  periosteum  becomes  swollen  and  vascular  and  can  be 
easily  separated  from  the  bone ;  swelling  and  pain  occur  early,  and  j)us 
accumulates  between  the  periosteum  and  the  underlying  bone  ;  superficial 
necrosis  of  the  compact  layer  of  the  bone  may  occur.  The  majority  of 
cases  of  suppurative  or  infective  periostitis  do  not  occur  as  primary 
affections  following  injuries,  but  are  secondary  to  osteomyelitis,  and  are 
often  observed  as  the  result  of  infective  processes  following  dii-ect  or  indi- 
rect infection  from  pyogenic  or  specific  micro-organisms.     This  variety  of 


528  TUBERCULOUS  PERIOSTITIS. 

periostitis  is  characterized  by  marked  constitutional  disturbances  and 
extensive  necrosis  of  the  bone,  suppurative  arthritis,  and  often  i^ysemia,  and 
is  a  most  serious  affection.  In  certain  cases  the  infective  organisms  reach 
the  periosteum  by  a  direct  wound,  while  in  others,  where  the  skin  is 
unbroken,  the  organisms  reach  the  infected  district  by  way  of  the  circu- 
lation. A  contusion  of  the  periosteum  may  be  an  important  factor  in 
localizing  the  infecti-ve  inflammation  at  the  point  of  injury. 

Symptoms. — In  suppurative  or  infective  periostitis  the  region  involved 
becomes  swollen  and  painful ;  if  the  iieriosteal  inflammation  is  a  primary 
affection,  the  swelling  and  tenderness  appear  early,  whereas  if  it  is  secondary 
to  osteomyelitis  the  local  pain  and  swelling  appear  later.  The  patient  may 
have  a  chill  or  rigor,  followed  by  marked  elevation  of  temi^erature.  The 
skin  over  the  inflamed  area  becomes  cedematous  and  red,  and  sooner  or  later 
fluctuation  can  be  detected. 

Treatment. — In  suppurative  periostitis  prompt  treatment  is  indicated, 
and  consists  in  making  a  free  incision  through  the  tissues  and  periosteum. 
If  this  is  done  early  the  bone  may  be  found  little  affected,  and  recovery  may 
occur  without  necrosis,  or  with  only  the  development  of  a  superficial 
necrosis,  a  thin  shell  of  bone  finally  separating  before  the  wound  closes. 
Usually  as  the  result  of  free  incision,  the  pain  and  swelling,  as  well  as  the 
constitutional  symptoms,  disapjiear.  If,  however,  the  periostitis  is  secondarj;- 
to  osteomyelitis,  simple  incision  of  the  jjeriosteum  is  not  followed  by  relief 
of  the  symptoms,  and  a  more  radical  operation  is  required  ;  the  case  should 
then  be  treated  as  oue  of  osteomj^elitis.     (See  page  534.) 

Chronic  Suppurative  Periostitis. — In  this  affection  the  chronic 
inflaDimatory  process  is  rarely  confined  to  the  periosteum  alone.  It  may  be 
traumatic  in  origin  following  upon  an  acute  periostitis,  or  result  from  fre- 
quently repeated  traumatisms.  It  sometimes  results  from  the  infection  of 
an  overlying  chronic  ulcer.  This  affection  results  in  overgrowth,  thick- 
ening, and  condensation  of  ijeriosteum  and  bone.  Suppuration  is  usually 
followed  by  the  formation  of  sinuses  and  superficial  necrosis. 

Symptoms. — Dull,  aching  pain,  which  is  aggravated  at  night,  local- 
ized tenderness  on  pressure,  and  localized  thickening  of  the  bone  are  the 
most  prominent  symptoms. 

Treatment. — This  consists  in  applying  counterirritation,  and  if  the 
condition  is  not  relieved  the  diseased  periosteum  and  bone  should  be  exposed 
by  incision,  and  the  affected  tissues  freely  removed  with  the  gouge  or  chisel. 

Albuminous  Periostitis. — A  form  of  acute  non-suppni-ative  periostitis 
has  been  described  by  Oilier  as  albuminous  periostitis  or  periosteal  gan- 
glion, in  which  fluid  resembling  synovia  is  poured  out  beneath  the  peri- 
osteum, which  may  undergo  mucoid  degeneration  and  be  contained  in  a 
distinct  cyst.  It  is  a  rare  affection  and  one  which  can  only  be  diagnosed 
after  an  incision  has  been  made. 

Tuberculous  Periostitis. — This  is  comparatively  rare  as  a  primary 
affection,  but  is  very  common  in  connection  with  tuberculosis  of  the  under- 
lying bones ;  it  is  sometimes  seen  in  the  periosteum  over  the  ends  of  the 
long  bones,  but  is  more  frequent  in  the  carpal  and  tarsal  bones,  the  ribs,  the 
vertebrae,  the  cranium,  and  the  bones  of  the  face. 


OSTEITIS  AND  OSTEOMYELITIS.  529 

Symptoms. — Pain  and  tenderness  are  not  marked,  and  the  first  symp- 
tom which  attracts  the  patient's  attention  is  the  swelling.  The  i^atient  often 
shows  symptoms  of  failing  health  before  the  local  condition  becomes  marked. 
Softening  and  breaking  down  of  the  inflamed  tissues  in  tuberculous  peri- 
ostitis occur  earlier  than  in  syphilitic  periostitis,  and  pain  is  not  so  marked 
as  in  the  latter  affection,  but  the  diagnosis  from  osteoperiostitis  is  often 
impossible. 

Treatment. — This  is  similar  to  that  of  tuberculous  osteitis.  (See  page 
5-41.) 

Syphilitic  Periostitis. — This  is  one  of  the  later  manifestations  of 
syphilitic  infection,  which  may  be  seen  in  acquired  syphilis  or  in  hereditary 
syphilis.  The  most  common  seats  of  the  periosteal  inflammation  are  the 
shafts  of  the  long  bones ;  the  anterior  surface  of  the  tibia  is  a  favorite 
locality,  as  are  the  bones  of  the  cranium. 

Symptoms. — In  syphilitic  periostitis  the  pain  is  usually  severe,  and  is 
worse  at  night,  which  is  a  characteristic  symptom  of  this  affection,  and  at 
the  same  time  the  patient  may  exhibit  other  symptoms  of  syphilitic  infec- 
tion. It  is  most  likely  to  be  confounded  with  tubercular  periostitis,  but 
the  pain  in  the  latter  affection  is  usually  wanting,  and  other  evidences  of 
syiihilis  may  be  pi'esent  which  will  aid  in  making  the  diagnosis. 

Treatment. — This  is  similar  to  that  employed  in  syphilitic  osteitis  and 
osteomyelitis.     (See  page  543.) 

OSTEITIS  AND  OSTEOMYELITIS. 

These  may  be  acute,  chronic,  or  specific,  and  may  be  classified  as  acute 
nonsuppurative  osteitis,  or  osteomyelitis,  and  suppurative  osteitis  and  osteomyelitis, 
which  includes  acute  suppurative  osteitis  and  osteomyelitis,  and  this  includes 
traumatic  and  infective  osteomyelitis  and  epiphysitis.  Infective  osteitis  also 
includes  the  special  infections  of  bone  resulting  from  tubercle,  syphilis,  and 
actinomycosis. 

Acute  Non-Suppurative  Osteitis  and  Osteomyelitis.— It  is 

questionable  whether  this  affection  should  be  classed  as  an  inflammatory 
condition  of  bone,  as  it  is  rarely  seen  independently  of  injuries  or  fractures  of 
bone,  and  results  from  the  irritation  produced,  and  is  an  active  process  in 
their  repair.  As  the  result  of  this  irritation  there  may  result  thickening 
of  the  bone,  softening,  or  absorption.  Suppuration  does  not  occur  unless 
infective  organisms  reach  the  part.  The  symptoms  of  this  condition  are 
slight  pain,  swelling  of  the  bone  and  overlying  soft  parts  at  the  seat  of  the 
lesion,  and  loss  of  function.  Here  as  in  other  affections  of  bone  all  of  the 
components  are  affected  and  show  reaction  to  the  irritation.  Treatment. — 
No  special  treatment  is  ai^plicable  to  this  condition,  aside  from  rest  of  the 
affected  i^art  and  the  use  of  anodyne  lotions  if  j)ain  is  a  prominent  symptom. 
Acute  Suppurative  Osteitis  and  Osteomyelitis.— This  affection 
is  usually  described  as  acute  osteomyelitis,  and  is  essentially  a  septic  inflamma- 
tion of  the  medulla  and  other  components  of  the  bone,  which  is  caused  by 
infection  by  pyogenic  organisms,  resulting  in  suppuration  and  necrosis.  It  is 
accompanied  by  marked  constitutional  disturbance  and  may  lead  to  a  fatal 
termination  from  septicaemia  or  pyajmia,  or  from  exhaustion  following  the 

34 


530  TRAUMATIC  OSTEOMYELITIS. 

profuse  discharge.  Clinically  two  varieties  of  suppurative  osteomyelitis  are 
recognized, — traumatic  osteomyelitis  and  acute  infective  osteomyelitis,  the 
so-called  spontaneous  osteomyelitis. 

Traumatic  Osteomyelitis.^This  variety  of  osteomyelitis  was  formerly 
very  common,  and  was  recognized  as  one  of  the  most  serious  complications 
which  followed  compound  fractures  and  operations  upon  bone.  In  com- 
pound or  gunshot  fractures,  or  after  amputation  or  resection  of  bone,  if  the 
wound  is  infected  at  the  time  of  oi^eration  or  afterwards,  inflammation  occurs 
in  the  medullary  canal,  followed  by  suppuration  and  destruction  of  a  limited 
portion  or  the  whole  of  the  bone  ;  the  patient  at  the  same  time  may  develop 
symj)toms  of  septicaemia  or  pyaemia;  The  medullary  canal  being  exposed, 
the  infection  may  occur  primarily,  or  may  result  from  organisms  entering  it 
from  suppuration  in  the  surrounding  parts.  When  infection  has  once  taken 
place  it  may  involve  only  a  limited  amount  of  the  bone,  or  may  extend 
throughout  the  canal,  and,  the  products  of  inflammation  being  confined 
within  the  bony  walls  and  having  no  outlet,  thrombosis  and  arrest  of  circu- 
lation take  place,  and  necrosis  results.  The  condition  is  best  studied  in  an 
infected  scalp  wound.  Here  the  edges  of  the  wound  are  swollen  and  the 
tissues  of  the  scalp  are  cedematous,  a  thin  purulent  discharge  escapes  from 
the  wound,  the  surface  of  the  skull  at  the  base  of  the  wound  is  rough  to  the 
feel  and  is  white  or  dark  in  color,  and  a  line  of  demarcation  forms,  which 
marks  the  point  where  the  devitalized  bone  or  sequestrum  separates  slowly 
from  the  living  bone. 

In  osteomyelitis  after  amputation  the  medulla  becomes  inflamed,  suppu- 
ration occurs,  and,  if  the  constitutional  infection  does  not  cause  death,  the 
bone  becomes  necrosed  and  a  tubular  sequestrum  forms,  which  in  time 
separates  from  the  surrounding  healthy  bone.  In  compound  fractures  the 
infective  process  rapidly  involves  the  different  components  of  the  bone  and 
extensive  necrosis  results.  At  the  same  time  that  inflammatory  changes 
are  taking  place  in  the  bone,  the  patient  exhibits  more  or  less  elevation  of 
temperature  and  acceleration  of  the  pulse,  and  in  many  cases  develops  septi- 
caemia or  pyEemia. 

Treatment. — The  prophylactic  treatment  consists  in  thorough  steriliza- 
tion of  all  wounds  of  bone  and  in  the  exercise  of  the  greatest  care  to  prevent 
wound-infection  during  and  after  operations  upon  bone.  When  osteomye- 
litis has  developed  in  a  compound  fracture  or  an  amputation,  the  bone 
should  be  exposed  and  the  inflamed  medullary  canal  opened  and  scrai^ed  or 
curetted  and  irrigated  with  a  bichloride  solution  ;  after  drainage  by  gauze 
or  tubes  has  been  established,  the  wound  should  be  closed  ;  if  necrosed  bone 
is  present,  it  should  be  removed.  Under  this  treatment  the  disease  is  gen- 
erally arrested,  and  the  constitutional  symptoms  rapidly  disappear. 

Infective  Osteomyelitis. — The  so-called  spontaneous  osteomyelitis 
occurs  without  the  presence  of  a  wound  of  the  bone,  the  infection  being 
carried  by  pyogenic  organisms  which  reach  the  medulla  by  the  circulation. 
The  disease  generally  affects  the  long  bones,  and  is  seen  most  frequently  in 
children.  It  usually  starts  near  the  epiphyseal  line,  and  often  spreads  rap- 
idly, so  that  it  soon  involves  the  whole  shaft  of  the  bone.  The  bones  most 
frequently  affected  are  the  femur,  tibia,  humerus,  fibula,  and  radius.     The 


INFECTIVE  OSTEOMYELITIS. 


531 


Fig.  458. 


portion  of  the  bone  at  which  there  is  the  greatest  blood-snpply  is  usually 
the  point  of  infection,  consequently  the  disease  commonly  begins  at  or  near 
the  epiphyses. 

Causes. — Osteomyelitis  may  occur  either  as  an  acute  or  as  a  chronic 
affection,  and  in  either  variety  of  the  disease  the  essential  cause  is  the  pres- 
ence of  one  or  more  varieties  of  pyogenic  organisms ;  the  staphylococcus 
pyogenes  aureus  is  the  organism  oftenest  observed.  Infection  usually  occurs 
from  pyogenic  organisms  which  have  found  their  way  into  the  circulation 
from  an  infected  wound,  or  through  the  respiratory  or  intestinal  mucous 
membrane,  and  accumulate  in  the  medullary  tissue  in  the  region  of  the 
epiphyses,  this  localization  being  probably  due  to  the  increased  vascularity 
of  the  bone  in  these  positions.  Slight  traumatisms  in  the  region  of  the 
epii^hyses  of  the  long  bones  may  predispose  to  the  localization  of  the  pyo- 
genic organisms  at  these  points.  "VVe  are  disposed  to  think  that  slight  trau- 
matisms of  the  extremities  of  the  long  bones  are  important  in  the  localization 
and  development  of  the  disease.  Kocher  believes  that  the  extravasation  of 
blood  following  a  traumatism  plays  an  important  role  by  act- 
ing as  a  culture  medium  for  the  growth  of  micro-organisms. 
In  almost  all  the  cases  of  osteomyelitis  that  have  come  under 
our  observation  there  was  a  history  of  a  sprain  or  twist  which 
was  followed  by  the  development  of  the  infective  inflamma- 
tion. Experimentally  osteomyelitis  has  been  produced  in 
animals  suffering  from  fractures  by  the  injection  of  septic 
materials  into  the  circulation.  It  is  a  curious  fact,  however, 
that  slight  traumatisms,  siich  as  si^rains  and  twists  about  the 
epiphyses,  seem  much  more  likely  to  be  followed  by  osteo- 
myelitis than  serious  injuries,  such  as  extensive  comminuted 
fractures.  We  often  see  patients  suffering  with  one  or  more 
fractures  who  have  at  the  same  time  a  supj)urating  and  pre- 
sumably infected  wound,  and  yet  the  development  of  osteo- 
myelitis in  these  cases  is  a  very  rare  occurrence. 

Osteomyelitis  not  only  results  from  infection  by  staphylo- 
cocci and  streptococci,  but  may  be  caused  by  certain  specific 
organisms,  such  as  those  of  typhoid  fever,  scarlet  fever, 
measles,  variola,  and  diphtheria  ;  in  such  cases  the  infection 
is  probably  a  mixed  one.  The  not  inlxequent  occurrence  of 
osteomyelitis  and  necrosis  of  the  jaw  following  measles  and 
scarlet  fever  was  so  well  recognized  by  the  older  surgeons  that 
the  name  exanthematous  necrosis  was  a^jplied  to  this  affection. 
Osteomyelitis  and  subsequent  necrosis  are  also  occasionally  ^ 
seen  after  typhoid  fever,  diphtheria,  and  small- pox.  (Fig.  removed  from  a 
458.)     Bush  reported  a  case  of  abscess  of  the  tibia  with  a    ^'''**  °^  osteomye- 

^  ,,         .  -,■-,„  .  UMs  following   ty- 

sequestrum  following  typhoid  fever  ni  which  active  typhoid    phoid  fever. 
bacilli  were  present  in  the  pus  of  the  abscess  seven  years  after 
the  original  infection.    Exposure  to  cold  and  sudden  chilling  of  the  body  in 
children  are  considered  by  Senn  to  be  frequent  causes  of  osteomyelitis.     Pro- 
longed chilling  of  the  surface  of  the  body  produces  a  sudden  disturbance  in 
the  circulation  of  the  medullary  tissue  of  the  bone,  resulting  in  congestion, 


11 


532 


INFECTIVE  OSTEOMYELITIS. 


Fig.  4.59. 


implautatioB,  and  localization  of  the  pyogenic  organisms  which  may  be  pres- 
ent in  the  circulation.  Under  such  conditions  the  localization  is  apt  to  occur 
at  the  j)ointof  least  resistance,  the  medullary  tissue,  and  suppurative  iniiam- 
mation  develops.  In  many  cases  of  osteomyelitis  the  existence  of  a  distinct 
suppurating  lesion,  from  which  pyogenic  organisms  enter  the  circulation, 
cannot  be  clearly  demonstrated. 

Pathology. — The  inflammation  begins  in  the  capillaries  from  implanta- 
tion of  micro-organisms,  and  supj)uratiou  results.  The  veins  become  throm- 
bosed, micro-organisms  entering  them  cause  liquefaction  of  the  coagulated 
blood,  and  i^j'temia  in  certain  cases  results  from  fragments  of  infected  thrombi 
being  carried  to  distant  organs.  Thrombosis  of  the 
veins  is  also  one  of  the  immediate  causes  of  necrosis. 
Pus  may  extend  through  the  whole  medullary  canal  and 
infiltrate  the  sijongy  tissue  of  the  bone.  The  periosteum 
later  becomes  detached  by  the  accumulation  of  pus 
between  it  and  the  bone,  and  at  points  may  be  destroyed 
by  a  phlegmonous  inflammation  ;  the  pus  finds  its  way 
into  the  surrounding  structures,  and  the  resulting  abscess 
either  opens  spontaneously  or  is  opened  by  the  surgeon. 
If  the  staphylococcus  or  streptococcus  infection  is  very 
virulent,  small  or  extensive  abscesses  develop  ra]3idly, 
and,  the  products  of  inflammation  being  confined  within 
the  bony  walls,  arrest  of  the  circulation  occurs,  so  that 
necrosis  results.  A  layer  of  bone  is  developed  in  time 
from  the  periosteum,  which  is  known  as  the  involucrum, 
and  the  whole  or  a  portion  of  the  devitalized  shaft,  known 
as  a  sequestrum,  remains  in  its  new  bony  sheath,  usually 
communicating  with  the  skin  by  one  or  more  sinuses, 
which  open  into  the  involucrum,  the  openings  being- 
called  cloacce.  The  involucrum  is  usually  sufficient  in 
amount  and  firmness  to  maintain  the  stability  of  the 
bone  ;  occasionally,  however,  bending  or  fracture  occurs. 
The  size  of  the  sequestrum  resulting  varies  with  the  inten- 
sity of  the  infection  and  the  amount  of  venous  thrombosis 
occurring.  The  whole  shaft  of  a  long  bone  may  be 
destroyed  from  epiphysis  to  epiphysis  (Fig.  459),  or  a 
limited  portion  of  the  shaft  may  become  devitalized.  In 
other  cases  the  suppuration  may  be  circumscribed  and 
a  chronic  bone  abscess  results,  which  may  remain  latent 
for  months  or  years,  when  the  micro-organisms  may  again 
be  aroused  to  activity  by  some  exciting  cause,  producing  an  attack  of  acute 
osteomyelitis.  In  rare  cases  there  may  be  no  abscess,  extensive  necrosis 
taking  place,  with  a  minimum  amount  of  pus  which  is  absorbed. 

Symptoms. — The  disease  is  usually  ushered  in  by  a  chill  or  rigor,  which 
is  followed  by  high  fever,  and  the  local  symptoms  of  the  aifection  may  be 
accompanied  by  the  development  of  a  condition  of  profound  septic  intoxica- 
tion, the  patient  passing  into  a  typhoid  state,  with  stupor  and  delirium. 
Pain  is  an  early  and  persistent  symj)tom,  is  of  a  gnawing  or  boring  char- 


Necrosis  of  the  shaft 
of  the  tihia  from  infective 
osteomyelitis. 


INFECTIVE  OSTEOMYELITIS.  533 

acter,  and  is  usually  located  in  the  end  of  one  of  the  long  bones.  It  may  not 
be  distinctly  linaited  to  the  area  of  bone  involved,  but  may  extend  to  the 
shaft  of  the  bone  and  adjacent  joints.  It  is  usually  more  severe  at  night, 
increases  with  the  elevation  of  temperature  and  also  with  the  extent  of  the 
exudation,  and  very  materially  diminishes  if  ijerforation  of  the  bone  occurs 
and  the  inflammatory  exudations  escajje  into  the  surrounding  tissues. 

Tenderness  on  pressure,  which  is  probably  due  to  secondary  periostitis,  is 
most  marked  as  the  disease  approaches  the  surface  of  the  bone,  but  is  often 
present  early  in  the  disease  before  any  swelling  has  made  its  appearance. 
Tenderness  on  pressure  is  both  a  valuable  diagnostic  sign  and  an  important 
guide  to  the  surgeon  in  determining  the  ijosition'  at  which  the  medulla 
should  be  exposed  by  operation. 

Swelling. — From  the  fact  that  the  primary  inflammation  is  located  in  the 
interior  of  the  bone,  swelling  is  not  marked  until  the  periosteum  and  the 
connective  tissue  become  involved.  (Edema  of  the  connective  tissue  from 
thrombophlebitis  and  enlargement  of  superficial  veins  may  cause  the  earliest 
swelling  at  the  seat  of  disease,  but  when  the  bone  and  the  periosteum  have 
been  perforated  and  pus  escapes  into  the  connective  tissue  the  swelling 
becomes  marked,  and  fluctuation  can  be  elicited. 

Bedness. — This  is  not  present  in  the  early  stages  of  the  disease,  but 
appears  after  the  i^us  has  escaped  from  the  bone  and  approaches  the  surface. 

Loss  of  function  is  also  a  conspicuous  clinical  feature  of  this  affection; 
the  patient  is  unable  to  move  the  limb  or  the  adjacent  joint.  Spontaneous 
fracture  or  separation  of  the  epiphysis  from  the  diaphysis  may  occur,  or 
synovitis  of  an  adjacent  joint,  either  simple  or  suppurative,  may  be  present ; 
these  latter  symptoms  are  met  with  later  in  the  disease. 

Diagnosis. — The  diagnosis  of  infective  osteomyelitis  is  often  difficult  at 
the  beginning  of  the  disease  ;  if  the  infection  is  very  virulent,  the  symptoms 
of  profound  septic  intoxication  may  cause  the  case  to  resemble  one  of  typhoid 
fever,  but  the  sudden  appearance  and  severity  of  the  constitutional  symp- 
toms, with  the  continued  high  temperature,  and  the  absence  of  the  daily  rise 
common  in  the  early  history  of  typhoid  fever,  will  distinguish  it  from  that 
disease.  Owing  to  the  fact  that  the  disease  is  apt  to  start  about  the  epiphy- 
seal lines,  there  may  be  pain,  swelling,  and  loss  of  function  in  an  adjacent 
joint ;  the  disease  is  very  apt  to  be  confounded  with  acute  rheumatism,  but 
careful  examination  will  show  that  the  i3ain  is  near  but  not  in  the  joint,  and 
the  greatest  tenderness  uijon  pressure  will  be  noticed  over  the  bone  near  the 
epiphyseal  line,  which  would  not  be  the  case  in  acute  rheumatism ;  the 
boring,  gnawing  character  of  the  pain  in  osteomyelitis  will  also  serve  to 
distinguish  it  from  the  pain  of  the  former  affection.  We  believe  the  error 
of  confounding  osteomyelitis  with  acute  rheumatism  to  be  a  very  common 
one.  "We  have  seen  many  cases  of  osteomyelitis  in  which  this  mistake  was 
made,  and  the  error  was  discovered  only  when  an  abscess  had  formed  and 
the  presence  of  dead  bone  was  demonstrated  with  the  probe.  The  presence 
of  an  abscess  can  usually  be  ascertained  without  difficulty  after  the  pus  has 
escaped  from  the  bone  into  the  surrounding  soft  parts,  but  before  this  has 
occurred  a  marked  leucocytosis  would  point  to  the  presence  of  pvis  in  the 
medullary  cavity. 


534  SEQUESTEOTOMY. 

An  early  diagnosis  of  osteomyelitis  is  most  important,  for  prompt  recogni- 
tion and  treatment  of  the  disease  diminish  very  greatly  the  risk  to  the  patient, 
the  amount  of  destruction  of  the  bone,  and  the  subsequent  disability. 

Prognosis. — The  j)rognosis  in  infective  osteomyelitis  is  always  grave ; 
resolution  and  recovery  rarely  occur  ;  death  may  result  in  a  few  days  from 
septicaemia,  or  later  from  pysemia,  and  if  so  unfortunate  a  termination  does 
not  take  place,  the  j)atient  may  be  worn  out  by  the  pain  and  fever  which  are 
present  before  the  inflammatory  exudations  perforate  the  bone  and  appear 
at  the  surface.  The  prognosis  varies  also  with  the  virulence  of  the  infection, 
as  well  as  with  the  promptness  and  thoroughness  of  the  treatment  which  is 
instituted. 

Treatment. — N"o  surgical  affection  demands  more  prompt  operative 
treatment  than  acute  suppurative  osteomyelitis.  As  soon  as  it  is  evident  that 
this  disease  has  attacked  a  bone,  the  skin  over  the  affected  region  should  be 
carefully  sterilized,  and  an  incision  should  be  made  down  to  the  bone.  After 
the  periosteum  has  been  divided,  in  most  cases  serum  or  pus  will  escape,  and 
it  is  not  uncommon  to  find  at  the  epiphyseal  line  some  evidence  of  inflamma- 
tion or  necrosis  of  the  bone.  In  every  case  the  bone  should  be  trephined  or 
cut  away  with  a  gouge,  and  pus  is  usually  found  when  the  medullary  cavity 
is  exposed.  In  early  operations  there  may  be  merely  swelling  and  hypersemia 
of  the  medullary  tissues.  The  surgeon  should  not  hesitate  to  remove  the  bone 
freely,  cutting  away  one  surface  so  as  fully  to  expose  the  inflamed  and  sup- 
purating medullary  cavity ;  the  curette  should  also  be  used,  and,  after  all 
the  infected  medullary  tissue  has  been  removed,  the  wound  should  be  irri- 
gated with  a  solution  of  bichloride  of  mercury,  and  loosely  packed  with 
iodoform  or  sterilized  gauze.  A  gauze  dressing  should  next  be  applied,  and 
the  limb  should  be  placed  upon  a  splint.  Usually  after  such  treatment  the 
pain  and  constitutional  symptoms  disappear  rapidly,  and  in  a  few  days  the 
exposed  bone  is  covered  with  healthy  granulations,  but  a  limited  amount 
of  necrosis  may  result.  Healing  of  the  wound  takes  place  slowly,  and  a 
depressed  cicatrix  results.  To  hasten  the  healing  Schede's  method  of  having 
the  cavity  filled  with  a  blood-clot  has  been  employed.  Amputation  in  rare 
cases  may  be  required  as  the  only  means  of  completely  removing  the  infected 
tissues.  It  is  seldom  demanded  in  young  subjects,  but  may  be  required  in 
adults. 

In  cases  in  which  the  operation  is  not  done  for  weeks  or  months  after  the 
beginning  of  the  attack,  more  or  less  dead  bone  may  be  found  upon  making 
the  incision  ;  this  should  be  freely  removed,  even  at  the  expense  of  removing 
bone  which  is  not  devitalized. 

Sequestrotomy. — "When  a  sequestrum  exists,  healing  cannot  take  place 
until  this  is  removed.  The  region  of  operation  should  be  thoroughly  steril- 
ized, and  in  operating  upon  the  long  bones  the  use  of  Esmarch's  bandage 
to  render  the  parts  bloodless  will  be  found  most  satisfactory.  After  the 
circulation  has  been  controlled,  an  incision  should  be  made  down  to  the 
bone,  the  sinuses  being  used  as  guides  to  the  incision,  and,  when  it  is 
possible,  the  intermuscular  septa  being  followed,  to  avoid  transverse  divi- 
sion or  splitting  of  the  muscular  fibres.  When  the  bone  has  been  exposed, 
the  periosteum  should  be  separated  and  turned  aside,  and  the  involucrum 


SEQUESTROTOMY. 


535 


or  new  bone  surrounding  the  sequestrum  or  dead  bone  cut  away  with  a 
gouge.  When  this  has  been  sufficiently  removed,  the  sequestrum  should 
be  grasped  with  forceps  and  removed.  The  edges  of  the  involucrum  should 
next  be  cut  away  freely,  so  as  to  expose  the  cavity  fully  and  leave  it  with 
sloping  edges,  to  favor  the  falling  in  of  the  soft  parts  in  the  subsequent 
cicatrization.  (Fig.  463.)  The  cavity  should  then  be  thoroughly  cleared  of 
granulation-tissue  with  a  curette,  and,  after  being  irrigated  with  bichloride 
solution  or  sterilized  water,  should  be  dried  with  gauze  pads  and  loosely 
packed  with  iodoform  or  sterilized  gauze,  a  copious  antiseptic  dressing 
applied,  and  after  this  has  been  secured  with  a  firm  bandage  covering  the 
whole  limb,  the  elastic  tube  of  the  Esmarch  apparatus  should  be  removed, 
and  the  circulation  allowed  to  return  to  the  limb.  If  no  large  vessel  has 
been  injured,  troublesome  hemorrhage  is  not  likely  to  occur.  The  after- 
treatment  consists  in  the  removal  of  the  dressings  and  packing  at  the  end 
of  a  week,  and  the  introduction  of  a  loose  gauze  packing  and  a  gauze 
dressing  aj)plied  in  the  same  manner.  If  the  cavity  is  a  large  one,  a 
considerable  time  is  required  for  the 

healing,  which  leaves  a  depressed  scar,  Fig.  460. 

the  tissues  being  drawn  into  the  cavity 
in  the  healing. 

To  shorten  the  time  occupied  in 
healing  and  to  diminish  the  scar  re- 
sulting, various  procedures  have  been 
adopted.  Neuber  made  flaps  from  the 
skin,  which  were  turned  in  and  fast- 
ened to  the  floor  of  the  cavity  by  steril- 
ized tacks.  Senn  has  recommended  the 
filling  of  the  cavity  with  decalcified 
bone  chips,  the  soft  parts  being  subse- 
quently closed  over  the  cavity  with 
sutures.  Schede's  method  of  allow- 
ing the  cavity  to  fill  with  blood-clot, 
which  becomes  oi-gauized,  has  also 
been  employed.  Sponge-grafting  has 
been  used  in  these  cases.  Bier  has 
practised  an  osteoplastic  resection  of 
the  involucrum,  in  which  a  portion  of 
the  involucrum  attached  to  the  soft 
parts  is  turned  aside  (Fig.  460),  and 
when  the  cavity  is  cleared  of  the  se- 
questrum and  granulations  it  is  al- 
lowed to  fall  back  over  the  cavity, 
and  is  secured  in  j)osition  by  sutures 
or  sterilized  nails. 

There  is  no  doubt  that  by  some  of  these  various  methods  the  time  of  heal- 
ing and  the  resulting  scar  are  diminished,  but  for  success  to  follow  in  such 
cases  it  is  essential  that  the  wound  should  be  aseptic;  if  suppuration 
occurs,  the  materials  introduced  are  apt  to  act  as  foreign  bodies,  and  are 


Osteoplastic  resection  for  the  rei 
trum,    (Bier.) 


val  of  sequcs- 


536 


ACUTE   EPIPHYSITIS. 


thrown  off,  or  have  to  be  removed,  and  faUuie  as  regards  prompt  healing- 
results. 

We  have  employed  bone  chips  in  some  cases  with  advantage ;  but  in 
the  majority  of  cases  the  method  of  after-treatment,  which  consists  in  loose 
packing  of  the  wound  with  gauze,  is  the  most  satisfactory.  If  care  is  exer- 
cised to  see  that  a  cavity  is  left,  with  sloping  edges  of  bone,  so  that  the  soft 
parts  can  be  drawn  in  during  the  healing,  repair  is  usually  satisfactory, 
and  the  resulting  scar,  if  it  is  on  the  part  of  the  body  covered  by  the  clothing, 
is  a  matter  of  little  consequence.  In  cases  where  the  involucrum  is  poorly 
developed,  or  has  to  be  so  freely  removed  as  to  weaken  the  bone  materially, 
or  where  the  sequestrum  is  removed  from  an  exposed  portion  of  the  body, 
and  the  resulting  scar  would  caiise  marked  deformity,  some  of  the  methods 
which  have  been  described  may  be  employed. 

Acute  Epiphysitis. — This  is  a  disease  frequently  seen  in  infants  and 
young  children,  which  arises  from  infection  of  the  long  bones  in  the  region 
of  the  epiphysis  by  pyogenic  organisms,  and  is  a  variety  of  acute  infective 
osteomyelitis;  its  tendency,  however,  is  to  involve  the  adjacent  joint,  setting 
up  an  ac^^te  suppurative  arthritis,  i-ather  than  to  extend  to  the  shaft  of  the 
bone,  as  is  the  case  in  the  latter  affection.  Prom  its  tendency  to  involve  the 
joints  it  has  also  been  described  as  Acute  Arthritis  of  Infants.  The  cases 
described  by  Mr.  Thomas  Smith  under  this  name  were  probably  cases  of 
acute  epiphysitis.  The  infection  in  young  infants  probably  arises  from 
sloughing  of  the  umbilical  cord,  and  the  localization  of  the  pyogenic  organ- 
isms may  be  determined  by  slight  traumatisms  received  during  labor.  In 
older  children  the  infection  may  arise  from  an  acute 
tonsillitis  or  the  throat  complications  of  dijDhtheria  or 
scarlet  fever,  or  it  may  be  imijossible  to  trace  the  source 
of  the  infection,  as  is  often  the  case  in  acute  infective 
osteomyelitis,  the  pathology  of  which  aifectiou  is  sim- 
ilar. In  acute  ei^iphysitis  the  jjus  may  make  its  way 
directly  through  the  articular  end  of  the  bone  and 
open  into  the  joint,  or  may  .open  laterally  through  the 
periosteum  and  come  to  the  surface,  the  joint  escaping 
infection. 

Symptoms. — In  a  typical  case  of  acute  epiphysitis 
the  tissues  over  au  epiphysis  of  a  long  bone  become 
swollen  and  painful,  and  the  limb  is  kept  quiet ;  the 
child  at  the  same  time  is  feverish  and  restless  and  soon 
presents  the  constitutional  symptoms  of  septic  infec- 
tion, and  in  a  short  time  the  joint  becomes  swollen  and 
presents  all  the  symptoms  of  acute  sui^purative  arthri- 
tis, or  the  abscess  may  point  upon  the  limb  near  the 
joint.  If  the  abscess  has  opened  into  the  joint,  rapid 
absorption  of  the  cartilages  occurs,  and  the  pus  soon 
makes  its  way  through  the  capsule  of  the  joint,  and  the  abscess  may  open 
spontaneously  through  the  skin.  After  this  occurs  the  inflammation  sub- 
sides, and  recovery  takes  place  often  with  very  little  impairment  of  the  joint 
motion,  but  the  subsequent  growth  of  the  bone  may  be  retarded.    (Fig.  461.) 


Fig.  461. 


Deformity  following  ar- 
rested growth  of  the  radius 
from  acute  epiphysitis. 
(Aslihurst.) 


CHRONIC  OSTEITIS  AND   OSTEOMYELITIS. 


537 


Treatment. — If  the  case  be  seen  early,  before  the  abscess  has  opened 
into  the  joint,  an  incision  should  be  made  over  the  inflamed  epiphysis  with 
full  aseijtic  precautions,  the  pus  evacuated,  and  the  wound  irrigated  and 
drained  and  an  antiseptic  dressing  aijplied.  If,  however,  the  joint  has  been 
involved  before  the  case  comes  under  the  surgeon's  care,  he  should  open  the 
joint  by  an  incision,  evacuate  the  pus,  and,  after  irrigating  it,  introduce 
drainage  and  apply  an  antiseptic  or  sterilized  gauze  dressing  and  immobilize 
the  joint  by  a  splint.  It  is  a  remarkable  fact  that  recovery  in  these  cases 
usually  takes  place  very  promptly  after  free  drainage  has  been  secured,  with 
very  little  joint  disability  resulting. 

Chronic  Osteitis  and  Osteomyelitis. — This  affection  is  similar  in 
its  pathology  to  the  acute  variety  of  the  disease,  but  is  usually  circum- 
scribed, as  the  infective  process  is  limited 
to  a  smaller  area  of  bone-tissue  ;  it  may 
follow  years  after  an  attack  of  acute  osteo- 
myelitis, and  probably  results  from  the 
renewal  of  activity  of  micro-organisms 
which  have  remained  latent  at  the  site  of 
the  former  inflammatory  trouble  until 
started  into  activity  by  some  traumatism 
or  constitutional  infection.  It  may  de- 
velop in  the  region  of  the  epiphyses, 
constituting  a  circumscribed  epiphyseal 
abscess,  or  may  occur  in  the  region  of  a 
former  suppurative  osteomyelitis,  causing 
a  circumscribed  abscess  of  the  bone  at  that 
point.  The  bones  most  commonly  affected 
are  the  tibia,  femur,  and  humerus.  (Fig. 
462.) 

Chronic  osteomyelitis  gives  rise  to  a 
circumscribed  abscess  containing  from  a 
few  drops  of  pus  to  several  ounces.  The 
bone  around  the  cavity  is  usually  thick- 
ened, and  the  overlying  periosteum  may 
be  inflamed,  but  rarely  presents  the  con- 
ditions present  in  suppurative  periostitis. 
Necrosis  is  rare,  but  a  certain  amount  of 
caries  of  the  bone  may  be  associated  with 
this  affection.  In  the  region  of  the 
epiphyses  it  may  be  followed  by  suppu- 
rative arthritis  if  the  abscess  opens  into 
an  adjacent  joint.  In  chronic  osteomye- 
litis, thrombosis,  septicse-mia,  and  pytemia  are  rarely  seen.  Acute  osteomye- 
litis may,  however,  develop  at  the  site  of  a  chronic  osteomyelitis,  and  the 
affection,  unless  promptly  treated,  may  produce  a  fatal  result. 

Symptoms. — The  constitutional  symptoms  are  not  usually  marked ; 
fever  may  be  present  or  absent ;  there  may  be  swelling  to  a  slight  extent,  or 
it  may  be  wanting.     Usually,  however,  some  thickening  of  the  bone  at  the 


Chronic  osteomyelitis  ot  the  tibia. 


538 


CHRONIC  OSTEITIS  AND   OSTEOMYELITIS. 


seat  of  the  disease  can  be  demonstrated.  Fain  may  be  intermittent,  and  is 
of  a  boring  or  gnawing  character,  is  increased  by  exercise,  and  is  apt  to  be 
more  marked  at  night.  Tenderness  on  pressure  can  usually  be  elicited,  and 
is  probably  due  to  secondary  periostitis.  The  skin  jiresents  no  discoloration, 
but  cedema  may  be  present  if  the  periosteum  is  involved. 

Diagnosis. — Chronic  osteomyelitis,  especially  if  it  be  multiple,  may  be 
confounded  with  syphilitic  disease  of  the  periosteum  or  bone.  In  the  latter 
affection  sujDpuration  is  rare,  and  the  seat  of  the  bone-lesions  is  not  apt  to  be 
near  the  epiphysis,  as  is  the  case  in  chronic  osteomyelitis.  The  patient  also 
is  apt  to  present  other  evidences  of  syphilis,  and  the  lesions  usually  disap- 
pear rapidly  under  antisyphilitic  treatment. 

Chronic  osteomyelitis  may  bear  a  strong  resemblance  to  sarcoma  of  bone 
in  its  clinical  appearance  and  course,  the  true  nature  of  the  disease  being 
apparent  only  upon  exploratory  incision,  when  the  presence  of  typical 
sequestra  and  of  pyogenic  cocci  in  the  granulation-tissue  leads  to  the  correct 
diagnosis.  On  account  of  this  resemblance,  Kocher  and  Jordan  have  called 
attention  to  the  importance  of  exploratory  incision  before  amputation  for 
sarcoma  of  bone. 

Treatment. — Abscesses  resulting  from  chronic  osteomyelitis  should  be 
promiitly  opened  and  drained,  especially  if  they  arise  near  the  epiphyses, 
to  prevent  the  possibility  of  their  opening  into  adjacent  joints.     Subperi- 
osteal abscess  presents  marked  swelling  and  iiuctuation, 
Fig.  463.  ^^^^  should  be  treated  by  free  incision,  irrigation,  and 

I    "     '^''  drainage.    The  site  of  the  abscess  can  usually  be  located 

by  the  thickening  and  enlargement  of  the  bone  and 
tissues  at  that  point  and  by  the  oedema  of  the  overlying 
skin.  In  operating  upon  these  abscesses,  after  applying 
an  Esmarch  bandage  and  tube  to  render  the  parts  blood- 
less, the  bone  should  be  exposed  by  incision,  and  the 
periosteum  turned  aside  and  held  out  of  the  way  with 
retractors  ;  the  bone  is  then  trephined  or  opened  with  a 
gouge,  and  as  soon  as  pus  is  reached  the  walls  of  the 
cavity  should  be  cut  away  until  the  cavity  has  been  freely  ' 
exposed  (Fig.  463),  when  its  surface  should  be  thoroughly 
curetted  and  irrigated  with  a  solution  of  bichloride  of 
mercury.  After  the  cavity  has  been  thoroughly  cleansed, 
the  overhanging  edges  of  bone  should  be  removed  with 
a  gouge,  to  form  a  cavity  with  sloping  edges,  so  that  the 
soft  parts  can  fall  in.  The  cavity  should  then  be  loosely 
packed  with  gauze  and  an  antiseptic  or  sterilized  gauze 
di-essing  applied  ;  or,  after  thoroughly  cleaning  the  cavity, 
it  may  be  allowed  to  fill  with  blood-clot,  and  the  skin  may 
be  sutured  over  it.  It  is  essential  that  the  cavity  should  be 
aseptic  to  obtain  a  favorable  result  by  the  latter  method. 
Tuberculous  Osteitis  and  Osteomyelitis. — This  is  an  inflamma- 
tory affection  of  bone  resulting  from  infection  by  the  bacillus  tuberculosis, 
which  may  affect  the  long,  short,  and  flat  bones,  and  may  occur  as  a  primary 
or  a  secondary  aifection.     The  tubercular  infection,  as  in  cases  of  pyogenic 


Exposure  of  the  bone- 
cavity  in  chronic  osteo- 
myelitis. (After  Neuber.) 


TUBERCULOUS  OSTEITIS  AND   OSTEOMYELITIS.  539 

infection,  is  apt  to  involve  all  of  the  constituents  of  the  bone,  the  medulla, 
cortical  substance,  and  periosteum.  Primary  tuberculosis  of  bone,  which 
implies  that  the  tubercle  bacilli  have  localized  themselves  in  the  bone  and 
are  not  present  in  other  parts  of  the  body,  is  considered  by  careful  observers 
to  be  au  extremely  rare  affection.  Secondary  tuberculosis  of  bone  results 
from  tubercular  infection  of  bone  fi-ora  an  antecedent  tubercular  focus,  and 
constitutes  the  majority  of  the  cases  of  bone  tuberculosis. 

Tubercular  disease  of  bone  is  more  frequent  in  males  than  in  females 
after  ten  years  of  age,  and  is  much  more  common  in  young  adults  than  in 
those  in  middle  life  or  old  age.  The  epiphyseal  region  is  the  jjortion  of  the 
bone  in  which  the  localization  of  the  bacilli  is  most  common.  Traumatism 
is  considered  by  many  observers  to  play  an  important  part  in  the  devel- 
opment of  bone  tuberculosis,  but  clinical  experience  would  seem  to  contro- 
vert this  view,  for  it  is  extremely  rare  to  have  subjects  who  are  suffering 
from  tuberculosis  and  have  sustained  an  injury  of  the  bones  develop  tuber- 
cular affections  of  the  same  at  the  seat  of  injury  ;  it  is  probable,  however, 
that  a  slight  traumatism  may  act  as  an  exciting  cause  of  localization  of  the 
bacilli  at  the  seat  of  injury,  as  is  often  the  case  in  acute  infective  osteomye- 
litis. Heredity  is  generally  recognized  as  an  important  factor  in  the  devel- 
opment of  tuberculosis  of  bone ;  scarlet  fever,  measles,  diarrhoea,  typhoid 
fever,  and  pneumonia  are  also  recognized  as  diseases  which  affect  the 
patients'  general  nutrition  and  thus  render  them  more  susceptible  to  the 
development  of  bone  tuberculosis. 

Caries  of  bone  results  from  some  specific  irritant,  which  is  usually 
tuberculous  or  syphilitic  in  character.  In  tuberculous  caries  of  bone  the 
deposit  of  tubercle  causes  a  rarefying  osteitis  by  enlargement  of  the  HaA^er- 
siau  canals,  thickening  of  the  periosteum,  and  the  development  of  granula- 
tion-tissue, which  shows  the  structure  of  tuberculous  disease ;  caseation  or 
liquefaction  may  occur,  and  a  tubercular  abscess  may  result.  According 
to  the  changes  which  occur  in  the  inflamed  bone  we  have  resulting  caries 
funyosa,  which  is  characterized  by  an  excessive  production  of  granulation- 
tissue  ;  caries  sicca,  in  which  there  may  be  extensive  destruction  and  absorp- 
tion of  bone,  from  pressure  of  contiguous  parts,  without  the  production  of 
abscess  ;  or  caries  necrotica,  in  which  a  portion  of  bone  surrounded  by  rare- 
fying osteitis  and  tubercular  infiltration  may  have  its  vitality  so  completely 
destroyed  that  it  dies,  giving  rise  to  a  small  sequestrum.  The  treatment  of 
caries  of  bone  is  similar  to  that  of  tuberculosis  of  bone. 

Pathology. — Tuberculous  infection  usually  attacks  the  cancellous  struc- 
ture of  bone,  and  is  therefore  very  common  in  the  carpus,  the  tarsus,  the 
bodies  of  the  vertebrie,  and  the  articular  extremities  (5f  the  long  bones.  It 
rarely  is  developed  in  the  medullary  cavity  of  the  long  bones,  but  usually 
involves  the  bones  in  the  region  of  the  epiphyseal  lines.  The  first  change 
is  a  rarefying  osteitis  from  enlai-gement  of  the  Haversian  canals  ;  the  peri- 
osteum becomes  thickened,  and  infected  granulation-tissue  forms  more  Or 
less  rapidly.  These  deposits  are  surrounded  by  areas  of  inflammation, 
and  a  portion  of  the  bone,  being  cut  off  from  its  nutrition,  may  irndergo 
molecular  death,  or  a  mass  of  bone  may  lose  its  vitality,  giving  rise  to  a 
tuberculous  sequestrum.      Caseation  and  liquefaction  of  the  tuberculous 


540  TUBERCULOUS   OSTEITIS  AND   OSTEOMYELITIS. 

material  may  take  place,  producing  a  tuberculous  abscess,  composed  of 
degenerated  cells,  with  curdy,  cheesy  material,  and  bone  detritus ;  this 
fluid,  which  has  the  appearance  of  pus,  is  really  not  such,  unless  a  mixed 
infection  has  occurred  through  the  introduction  into  the  cavity  of  pyogenic 
organisms  from  the  circulation,  or  by  infection  of  the  cavity  from  without. 
The  process  may  extend  so  as  to  open  an  adjacent  joint,  or  may  open  upon 
the  skin ;  in  either  event  a  sinus  is  left  which  is  lined  with  tuberculous 
granulations.  When  tuberculous  abscesses  of  bone  have  opened  spontane- 
ously upon  the  surface,  their  infection  by  pyogenic  organisms  is  very  com- 
mon. Examination  of  the  bone  through  the  sinus  with  a  probe  will  usually 
reveal  softened  or  carious  bone,  and  in  some  cases  roughened  bone  may  be 
felt,  or  a  sequestrum.  On  the  other  hand,  circumscribed  areas  of  tubercu- 
lous deposits  may  be  shut  off  by  healthy  granulations  in  the  surrounding- 
bone,  absorption  or  calcification  of  the  broken-down  tissue  occur,  and  the 
bone  surrounding  the  diseased  structures  become  sclerosed. 

Symptoms. — Tuberculous  disease  of  bone  is  often  difficult  to  recog- 
nize earlj',  and  its  progress  is  generally  very  slow.  The  most  marked 
symptoms  are  pain,  which  may  be  spontaneous  or  be  elicited  only  by 
pressure  over  the  diseased  area,  and  enlargement  of  the  bone  or  of  the 
soft  parts  over  it,  causing  swelling,  which  can  best  be  observed  in  exf)Osed 
situations,  as  the  extremities  of  the  long  bones.  Loss  of  function  and  atro- 
phy of  the  muscles  are  common  symptoms,  largely  due  to  non-use  of  the 
part.  As  caseation  of  the  tuberculous  tissue  advances  and  the  material 
escapes  from  the  bone,  the  soft  parts  over  the  diseased  area  become  cedem- 
atous  and  sometimes  red,  and  fluctuation  can  be  detected  ;  redness  of  the 
skin  may  be  wanting,  however,  even  when  large  collections  of  fluid  can 
be  detected.  Fever  is  usually  absent  or  very  slightly  developed,  and  is  apt 
to  be  marked  only  if  infection  of  the  tuberculous  tissue  takes  place  from 
the  presence  of  pyogenic  organisms.  If  the  collection  of  tuberculous  fluid 
is  opened  or  ruptures  spontaneously,  thin,  watery  fluid  escapes,  containing 
curdy  and  cheesy  masses,  with,  at  times,  fine  particles  of  bone,  which  give 
it  a  sandy  or  gritty  feel.  The  sinus  remaining  after  the  escape  of  the  fluid 
is  lined  with  tuberculous  granulations,  which  are  cedematous  and  exuberant, 
and  if  not  infected  may  discharge  for  months  or  years  without  giving  the 
patient  much  j)ain  or  inconvenience. 

Diagnosis. — Chronic  inflammations  of  the  cancellous  structures  of 
bones  are,  as  a  rule,  tubercular,  and  it  is  only  in  cases  of  chronic  osteomye- 
litis that  an  error  of  diagnosis  is  likely  to  occur ;  the  latter  affection  is 
most  frequently  observed  in  young  adults,  and  is  apt  to  involve  the  articu- 
lar extremity  of  a  long  bone,  is  slow  in  its  progress,  is  more  localized,  and 
presents  a  circumscribed  area  of  swelling,  with  tenderness  on  pressure  over 
a  limited  extent  of  surface. 

Prognosis. — Althoiigh  spontaneous  healing  of  a  tubercular  focus  of 
bone  may  occur  if  the  patient  is  well  nourished  and  the  diseased  material  is 
shut  off  by  healthy  granulation-tissue  and  later  by  condensation  of  the  sur- 
rounding bone,  yet  this  is  not  a  usual  termination  after  caseation  and  lique- 
faction of  the  tuberculous  products  have  occurred.  If,  however,  such  a 
termination  has  occurred,  the  patient  later  is  liable  to  reinfection  from  the 


TUBERCULOUS  OSTEITIS  AND   OSTEOMYELITIS.  541 

tuberculous  focus,  and  may  develop  tuberculosis  of  the  bone  years  after  tbe 
primary  attack.  In  cases  in  which  there  is  no  tendency  to  healing,  sinuses 
form  and  continue  to  discharge,  and,  unless  the  condition  is  relieved  by 
operative  treatment,  the  patient  is  liable  to  die  from  amyloid  changes  in  the 
viscera,  from  exhaustion,  or  from  general  tuberculosis.  Pyogenic  infection 
of  a  tubercular  abscess  also  affects  the  prognosis  unfavorably.  The  prog- 
nosis in  children  and  young  adults  affected  with  osteotuberculosis  is  more 
favorable  than  in  those  in  middle  life  or  advanced  in  years. 

Treatment. — As  soon  as  the  diagnosis  of  tuberculous  disease  of  bone 
can  be  made,  both  constitutional  and  local  treatment  should  be  instituted. 
The  former  consists  in  imf)rovement  of  the  hygienic  surroundings  by  change 
of  climate,  exercise  in  the  fresh  air,  a  nutritious  diet,  and  the  employment 
of  remedies  which  are  recognized  as  arresting  the  progress  of  tubercular 
disease,  iodide  of  iron  and  cod-liver  oil  being  the  most  serviceable. 

The  local  treatment  of  bone  tuberculosis  consists  first  in  rest,  which  is 
especially  applicable  to  the  early  stage  of  the  disease  before  caseation  has 
occurred.  The  diseased  part  should  be  put  as  nearly  as  possible  at  absolute 
rest,  which  tends  to  arrest  the  progress  of  the  disease  and  favors  the  process 
of  repair.  The  parts  should  be  fixed  by  a  plaster-of- Paris  bandage,  which 
in  the  case  of  the  extremities  not  only  protects  and  fixes  them,  but  also 
prevents  subsequent  deformity  by  holding  them  in  their  normal  position. 
If  immobilization  is  secured,  the  patient  is  able  to  go  about  and  have  the 
advantage  of  exercise  in  the  open  air. 

Injections. — Parenchymatous  injections  which  destroy  or  inhibit  the 
growth  of  the  bacilli,  such  as  iodoform  emulsion,  ten  per  cent.,  balsam  of 
Peru  emulsion,  ten  per  cent. ,  or  full  strength,  and  chloride  of  zinc  solution, 
two  per  cent.,  have  been  employed  with  good  results.  Iodoform  emulsion 
is  the  remedy  which  is  most  used,  and  an  injection  of  a  drachm  or  two  of 
this  material  is  made  deei^ly  into  the  tubercular  tissues  or  softened  bone  at 
intervals  of  a  few  days  or  a  week.     (See  pages  65  and  66. ) 

Ignipuncture. — This  procedure  also  is  employed  in  the  treatment  of 
localized  tubercular  inflammations  of  bone,  and  consists  in  introducing-  the 
needle-point  of  a  Paquelin's  cautery  through  the  tissues  into  the  tubercular 
focus  in  the  bone  ;  one  or  more  punctures  may  be  made  into  the  cavity  at 
different  points.  After  making  the  punctures  an  antisei^tic  dressing  is 
applied,  and  at  the  end  of  several  weeks  the  eschar  separates,  and  healthy 
granulations  cover  the  wounds  made  by  the  cautery.  The  relief  from  pain 
following  ignipuncture  is  usually  marked.  Its  effect  is  to  destroy  directly 
a  portion  of  the  tubercular  products,  and  at  the  same  time  to  stimulate 
tissue  proliferation,  substituting  a  plastic  inflammation  for  a  tubercular  one. 

Operative  Treatment. — The  removal  of  tubercular  foci  of  disease  by 
operation  is,  ui^on  the  whole,  the  most  satisfactory  method  of  treatment,  if 
the  disease  is  so  situated  that  it  is  accessible.  This  procedure  may  be 
adopted  early  in  the  affection,  or  after  the  softening  of  the  tuberculous 
products  has  taken  xjlace.  Great  care  should  be  taken  to  sterilize  the  skin 
in  the  region  of  the  wound,  to  prevent  infection  of  the  tuberculous  area  of 
bone  by  pyogenic  organisms.  The  use  of  Esmarch's  apparatus  for  the  con- 
trol of  bleeding  during  the  oi^eration  will  be  found  most  satisfactory.     An' 


542  SYPHILITIC   OSTEITIS  AND   OSTEOMYELITIS. 

incision  should  be  made  fully  exposing  the  diseased  bone,  and  the  cavity 
thoroughly  cleansed  of  tuberculous  tissue  with  a  curette  or  gouge  ;  the  sur- 
rounding soft  parts  if  involved  should  be  thoroughly  curetted,  or  the 
tubercular  tissue  should  be  trimmed  away  with  scissors.  Synovial  pouches 
or  the  sheaths  of  tendons,  connective  tissue,  and  skin,  if  implicated  in  the 
disease,  should  be  carefully  cut  away.  In  operating  upon  cases  of  epi- 
physeal tuberculosis  care  must  be  taken  to  avoid  opening  the  joint. 

It  is  a  safe  rule  in  these  cases  to  remove  the  tissues  freely,  even  at  the 
expense  of  removing  some  non-infected  tissue.  After  a  sufficiently  free 
removal  of  tissue  has  been  effected,  the  cavity  should  be  irrigated  with 
bichloride  solution,  dried  with  gauze  pads,  and  dusted  with  iodoform,  and 
the  edges  of  the  wound  brought  together  by  sutures.  If  no  suppuration 
occurs,  the  parts  may  be  solidly  healed  in  a  few  weeks ;  if,  however,  sup- 
puratioA  occurs,  healing  does  not  take  place  promjjtly,  and  it  may  become 
necessary  to  reopen  the  wound  and  repeat  the  curetting.  If  sinuses  already 
exist,  and  the  wound  is  infected  and  discharging  pus,  the  cavity  should  be 
exposed  and  cleared  of  diseased  tissue,  and  should  then  be  irrigated  and 
loosely  packed  with  iodoform  gauze,  and  the  external  wound  shoidd  not  be 
closed.  After  a  few  days  the  gauze  should  be  removed  and  fresh  gauze 
packed  into  the  wound.  In  these  cases  healing  by  granulation  and  con- 
traction occurs,  and,  to  secure  this  object,  if  the  cavity  is  a  deep  one  the 
overhanging  edges  of  bone  should  be  removed  with  a  gouge,  to  allow  the 
soft  parts  to  be  drawn  in  to  fill  up  the  cavity.  In  all  operations  upon 
tuberculous  bone  the  more  thorough  the  operation  the  more  likely  is  com- 
plete healing  of  the  wound  to  occur. 

SYPHILITIC  DISEASES  OE  BONE. 

Syphilitic  affections  of  the  periosteum  and  bone  may  occur  compara- 
tively early  in  constitutional  syphilis,  but  are  much  more  frequently  seen  in 
the  later  stages  of  syphilis  or  in  hereditary  syphilis.  The  infection  of  syph- 
ilis is  rarely  confined  to  a  special  portion  of  the  bone,  but  involves  simul- 
taneously the  medulla,  cortical  substance,  and  periosteum.  The  early  bone 
lesions  of  secondary  syphilis,  however,  are  principallj^  confined  to  the  peri- 
osteum and  cortical  layers  of  the  bone.  At  the  present  time  the  bone  lesions 
of  syphilis  are  not  so  common  nor  so  extensive  as  they  were  some  years  ago  ; 
this  is  probably  to  be  accounted  for  by  the  comparatively  milder  course  that 
the  disease  now  runs  and  by  the  fact  that  the  treatment  of  the  early  stages 
of  the  disease  is  now  much  more  thorough  and  prolonged. 

Syphilitic  Osteitis  and  Osteomyelitis. — This  may  develop  early 
in  acquired  syphilis  or  in  the  later  stages  of  the  disease.  It  is  either  acquired 
or  hereditarjr,  and  consists  in  an  inflammation  of  the  periosteum  and  sub- 
jacent bone,  involving  the  Haversian  canals  and  the  medulla,  which  may 
contain  small  cells  and  extra vasated  red  blood- corpuscles.  The  bones  most 
frequently  affected  are  the  skull,  sternum,  ribs,  clavicle,  and  tibia.  The 
disease  in  the  early  stages  is  manifested  by  the  appearance  of  one  or  more 
tender  swellings,  which  occur  over  a  limited  jjortion  of  one  of  the  bones 
previously  mentioned,  and  constitute  the  periosteal  nodes,  in  which  the 
disease  is  limited  to  the  periosteum  and  the  superficial  layers  of  the  bone. 


SYPHILITIC  OSTEITIS  AND   OSTEOMYELITIS. 


543 


Examination  will  sliow  marked  thickening  of  the  periosteum  and  beneath  it 
an  eifusion  of  gelatinous  material.  If  not  modified  by  treatment  ossification 
in  time  occurs  and  a  permanent  mass  of  bone  remains.  The  disease  in  the 
later  stages  terminates  in  osteosclerosis,  which  may  involve  the  whole  shaft 
of  a  long  bone.  The  long  bones  may  present  curvatures  while  the  bone  is 
in  the  soft  stage,  jjresenting  deformities  resembling  rickets.  (Pigs.  464  and 
465.)    A  number  of  bones  are  usually  involved  in  a  symmetrical  manner. 


Fig.  464. 


Fig.  465. 


Skiagraph  of  syphilitic  osteomyelitis  of 
the  tibia. 


Syphilitic  osteomyelitis  of  the  tibia. 


Symptoms. — The  symptoms  of  this  alfection  are  pain  and  thickening 
of  the  affected  bones,  the  i^ain  being  severe  and  much  aggravated  at  night ; 
tenderness  uj)on  pressure  over  the  diseased  bone  is  marked ;  the  swelling 
may  be  apparent  to  the  sight  and  touch  in  sui^erficial  bones,  such  as  the 
tibia,  ulna,  clavicle,  or  sternum. 

Treatment. — This  consists  in  the  administration  of  iodide  of  potassium 
in  ten-  to  fifteen-grain  doses,  alone  or  combined  with  small  doses  of  mercury, 
which  xisually  gives  very  prompt  relief  from  the  pain  and  tenderness,  but 
relapses  are  very  apt  to  occur  in  time,  requiring  a  repetition  of  the  treat- 
ment. Cases  are  occasionally  met  with  in  which  in  spite  of  this  treatment 
the  pain  and  tenderness  do  not  disappear,  and  the  xjatient  becomes  worn  out 
by  the  loss  of  sleep.  In  such  cases  operative  treatment  should  be  under- 
taken, the  greatest  care  being  exercised  as  regards  asepsis,  for  if  microbic 
infection  occurs  in  the  wound,  caries  or  necrosis,  followed  by  a  persistent 
sinus,  may  result.  The  bone  over  the  seat  of  greatest  pain  should  be  exposed 
by  an  incision  several  inches  in  length,  in  the  long  axis  of  the  limb,  through 
the  soft  parts  and  the  periosteum  ;  a  Hey's  saw  may  then  be  used  to  make 
an  incision  which  opens  the  medullary  cavity  of  the  bone,  or  a  free  opening 


544 


GUMMATOUS  OSTEOPERIOSTITIS. 


Fig.  466. 


may  be  made  into  the  bone  with  a  gouge  ;  great  thickening  of  the  bone  is 
often  found  in  these  cases.  After  the  medulla  has  been  opened  for  several 
inches,  the  wound  is  irrigated  and  an  antiseptic  gauze  dressing  is  applied. 
Pain  is  usually  promjitly  relieved  by  this  operation,  and  the  wound  if  not 
infected  heals  promptly. 

Gummatous  Osteoperiostitis  or  Osteomyelitis,— This  affection, 
which  appears  in  the  later  stages  of  syphilis,  consists  in  a  circumscribed 
osteojjeriostitis  with  an  abundant  subperiosteal  deposit  of  embryonal  tissue, 
accompanied  at  the  same  time  with  more  or  less  diffused  osteosclerosis.  In 
these  cases  there  is  a  proliferation  of  the  cells  within  the  Haversian  canals, 
which  may  cause  absorption  of  the  o!5seous  tissue,  giving  rise  to  rarefying 
osteitis ;  some  portion  of  the  inflammatory  infiltration  may  soften  and  present 
the  characteristics  of  a  gumma,  while  other  portions  become  organized, 
obliterating  the  Haversian  canals  and  causing  a  condensing  osteitis,  which 
results  in  eburnation  or  sclerosis  of  the  bone.  Osteosclerosis  may  interfere 
with  the  nutrition  of  the  adjacent  bone  and  result  in  caries  or  necrosis.  If 
only  the  periosteum  and  superficial  layers  of  the  bone  are  involved,  recovery 
may  take  place  without  either  of  these  couditions 
resulting,  but  if  the  deeper  portions  of  bone  are 
involved,  caries  or  necrosis  is  likely  to  occur. 
(Fig.  466.)  In  syphilitic  necrosis,  owing  to  the 
diminished  vascularity  of  the  adjoining  bone,  the 
separation  of  the  dead  bone  is  a  slow  process, 
often  occupying  years. 

Symptoms. — Pain,  which  is  worse  at  night, 
is  a  most  marked  symptom.  In  bones  in  exposed 
situations  there  is  ob.served  a  localized  elastic 
swelling,  which  may  in  parts  present  the  symp- 
toms of  fluctuation ;  the  skin  over  the  swelling 
becomes  thin  and  red  and  may  eventually  give 
waj%  and  a  thin  watery  iiuid  be  discharged.  The 
long  bones  may  show  fracture  or  curvature.  If 
infection  occurs  by  pyogenic  organisms,  a  puru- 
lent discharge  issues  from  the  sinus.  Examination  of  the  sinus  with  the 
probe  usually  reveals  the  presence  of  roughened  or  carious  bone  at  its  bottom. 
Treatmient. — In  gummata,  if  spontaneous  0]3ening  has  not  occurred, 
even  though  the  skin  be  thin  and  red,  j)rompt  improvement  and  final 
disappearance  of  the  swellings  may  take  place  under  the  use  of  iodide  of 
potassium  in  doses  of  from  ten  to  thirty  grains  three  times  a  day.  If  the 
swelling  has  opened  spontaneously  the  effect  of  treatment  is  much  less  satis- 
factory, and  caries  or  necrosis  of  the  affected  bone  is  more  likely  to  occur. 
The  temptation  to  open  gummata  if  the  skin  is  thin  and  red  is  great,  but 
should  be  resisted,  for  such  swellings,  under  the  administration  of  iodide  of 
potassium,  will  often  disappear ;  whereas,  if  they  are  opened  and  become 
infected,  caries  or  necrosis  of  the  bone  is  very  ajjt  to  occur,  and  a  persistent 
sinus  results.  When  necrosed  or  carious  bone  is  present,  as  separation  of 
the  dead  bone  is  very  slow,  oi)erative  treatment  for  its  removal  should  be 
undertaken.     This  consists  in  exposing  the  diseased  boue  and  gouging  it 


'^M  hLl  t  1  tl  e    Lull 

( ^ter  Tre^  e^  ) 


SYPHILITIC  DACTYLITIS. 


545 


away,  removing  sequestra  if  present,  and  chiselling  away  some  of  tlie  dense 
bone  surrounding  the  diseased  area  ;  care  should  be  taken  to  leave  a  healthy 
bone  surface,  which  usually  heals  satisfactorily  if  the  wound  remains  aseptic. 

Bone  Lesions  in  Hereditary  Syphilis. — In  inherited  syphilis 
lesions  of  the  bones  are  frequent,  j)eriosteal  nodes,  osteoperiostitis,  with 
marked  hypertrophy  and  deformity  of  the  bones,  and  gummatous  osteoperi- 
ostitis, being  frequently  observed.  The  lesions  are  most  common  in  the 
long  bones,  and  are  apt  to  be  symmetrical,  and  ac- 
companied by  other  evidence  of  hereditary  syi^hilis, 
such  as  keratitis,  depression  of  the  nasal  bones,  and 
changes  in  the  teeth.  The  bone  lesions  are  apt  to 
be  manifested  between  the  sixth  and  the  eighteenth 
year,  and  the  tibia  and  ulna  seem  to  be  the  bones 
most  frequently  affected.  (Fig.  467.)  The  disease 
may  be  confounded  with  rhachitis  or  tuberculosis, 
but  the  nature  of  the  disease  can  usually  be  clearly 
demonstrated  by  the  presence  of  other  evidence  of 
hereditary  syphilis. 

Syphilitic  Dactylitis.— This  affection  is  com- 
mon in  hereditary  syphilis,  and  consists  in  an  osteo- 
periostitis of  the  phalanges  of  the  fingers,  which 
sometimes  originates  in  the  fibrous  tissues  over  the 
bones.     Swelling  is  first  observed  over  one  or  more 

phalanges,  which  gradually  increases  in  size,  and  ^^p'"'"'^  osteoperiostitis  of  the 
spontaneous  opening  is  apt  to  occur,  followed  by 

caries  or  necrosis  and  the  loss  of  one  or  more  phalanges.  The  disease  is 
often  symmetrical.     (Fig.  468.) 

Treatment. — In  cases  of  hereditary  syphilis  of  the  bones,  iodide  of  potas- 
sium in  doses  a]5propriate  for  the  age  of  the  patient  should  be  employed ; 

Fig  4b8 


Sj'philitic  dactylitis. 

young  children  do  not  bear  iodide  of  potassium  as  well  as  adults ;  it  often 
produces  irritation  and  inflammation  of  the  nasal  and  laryngeal  mucous 
membranes,  so  that  its  effect  should  be  carefully  watched.  Small  doses  of 
iodide  or  bichloride  of  mercury  are  often  more  efficient  than  iodide  of  potas- 
sium. Where  nodes  are  present  and  iu  cases  of  early  dactylitis  the  local 
use  of  equal  parts  of  mercurial  and  belladonna  ointments  will  often  be  found 
of  service.  Clinically  we  have  found  the  use  of  iodide  of  iron  and  cod-liver 
oil  of  great  value,  particularly  iu  those  cases  in  which  iodide  of  potassium 
cannot  be  taken.     The  progress  of  the  disease  maj^  often  be  arrested  by 

35 


546 


TUBERCULOSIS   OF  THE  SPINE. 


antisyphilitic  treatment,  but  more  or  less  thickening  and  deformity  of  the 
bones  remain  permanently. 

Actinomycosis  of  Bone. — Infection  of  bone  by  a  fungus  known  as 
actinomyces  is  most  common  in  the  lower  jaw,  the  fungus  reaching  the  bone 
through  a  carious  tooth,  but  may  also  affect  other  bones.     (See  page  59.) 

TUBERCULOSIS   OF   THE   SPINE. 

Pott's  Disease. — This  consists  in  a  tuberculous  inflammation  of  the 
bodies  of  the  vertebrje  and  of  the  intervertebral  cartilages,  and  is  most 
common  in  children  between  two  and  ten  years  of  age,  although  it  may  occur 
at  any  age.  In  some  cases  the  affection  appears  to  follow  a  slight  trauma- 
tism, and  unquestionably  an  injury  may  be  the  exciting  cause  in  a  subject 
who  possesses  a  tubercular  diathesis ;  in  other  cases  the  disease  develops 
without  apparent  exciting  cause.  It  is  observed  in  all  classes  of  life,  but  is 
most  common  among  the  poor,  in  whom  ill  feeding  and  defective  sanitary 
conditions  result  in  lessened  resistance  to  tuberculous  infection.  Certain 
portions  of  the  spine  are  especially  the  seat  of  the  disease  ;  thus,  about  five 
per  cent,  are  situated  in  the  cervical  region,  about  fifty  per  cent,  in  the 
dorsal  region,  and  about  thirty  per  cent,  in  the  lumbar  region.  Atlo-axoid 
disease  is  very  rare,  occurring  only  in  about  one  per  cent,  of  all  cases. 

Pathology. — The  disease  usually  begins  as  a  tuberculous  inflammation 
in  the  cancellated  structure  of  the  bodies  of  the  vertebrte,  and  may  involve 
the  anterior  or  the  posterior  surface  or  the  body  of  the  bone  at  its  juncture 
with  the  intervertebral  disk.  The  disease  sometimes  begins  in  a  tubercu- 
lous synovitis  of  the  intervertebral  articulations,  and  extends  to  the  bodies 
of  the  vertebrse  secondarily.  The  changes  which 
occur  in  the  spine  are  those  which  are  observed  in 
tuberculous  arthritis  or  osteitis  in  other  j)arts  of  the 
body.  The  destructive  process  causes  softening  and 
breaking  down  of  the  bodies  of  the  vertebrae  and 
intervertebral  cartilages.  The  bone  and  cartilages 
may  gradually  soften  and  break  down,  or  masses  of 
bone  may  be  separated  and  thrown  off  as  sequestra. 
The  caseation  and  licxuefaction  of  the  affected  tissues 
give  rise  to  spinal  abscess,  so  often  seen  in  these 
cases.  The  vertebrae  above  and  below  fall  together, 
and  a  backward  projection  of  one  or  more  spinous 
processes  produces  the  characteristic  angular  curva- 
ture. (Fig.  469.)  The  amount  of  deformity  depends 
upon  the  extent  of  the  disease  in  the  bodies  of  the 
vertebriB ;  a  limited  amount  of  destruction  of  the 
Destruction  of  the  bodies  lateral  Or  anterior  surfaces  of  the  vertebrte  may  be 
oUhevertebr<B  in  tuberculosis    accompanied  by  very  little  deformity.      Compres- 

of  the  spine.    ( Agnew. )  -l  .;  ./  .;  jr- 

sion  of  the  spinal  cord  maj^  result  from  the  pressure 
of  tubercular  i^roducts  between  the  dura  matter  and  the  bone,  or,  rarely, 
from  pressure  upon  it  of  the  displaced  bones.  The  spinal  nerves  having 
their  origin  from  the  cord  at  the  seat  of  disease  may  be  pressed  upon.  If 
the  disease  is  arrested  in  the  early  stage,  before  destruction  of  the  bodies 


TUBERCULOSIS  OF  THE  SPINE.  547 

of  the  vertebrfe  has  occurred,  the  parts  may  return  almost  to  their  normal 
condition,  no  marked  deformity  being  present,  but  there  is  apt  to  result 
more  or  less  ankylosis  at  the  seat  of  disease.  If  softening  and  breaking 
down  of  the  bodies  of  the  rertebrte  have  occurred,  with  caseation  and  lique- 
faction of  the  infected  tissues,  recovery  takes  place  with  ankylosis  and  great 
deformity  at  the  seat  of  disease. 

Symptoms. — These  vary  with  the  stage,  situation,  and  extent  of  the 
disease.  The  most  prominent  early  symptoms  are  rigidity,  weakness,  ten- 
derness, and  pain,  which  is  referred  not  to  the  seat  of  disease,  but  to  the 
distribution  of  corresponding  nerves  ;  later  there  are  developed  deformity 
and  abscess,  and  occasionally  there  is  implication  of  the  nerves  and  spinal 
cord,  causing  paralysis.  Eigidity  of  the  spiue  is  a  very  constant  early 
symptom  of  this  affection,  due  to  absence  of  movement  in  the  intervertebral 
joints,  which  at  first  is  caused  by  protective  muscular  action  and  later  by 
ankylosis.  Eigidity  can  be  noticed  if  the  patient  is  asked  to  look  at  some- 
thing behind  him,  when  he  will  turn  his  body  to  do  so,  or,  better,  by  getting 
him  to  pick  up  an  object  from  the  floor,  when  in  stooping  he  bends  the 
thighs  u]3on  the  trunk  and  the  knees  upon  the  thighs,  and  does  not  flex  the 
si^ine  in  the  usual  way.  In  walking  or  standing  there  is  noticed  the  same 
tendency  to  fix  the  spine.  The  patient  fixes  the  upper  part  of  the  spiue  by 
the  aid  of  the  trapezii  and  scapular  muscles,  which  raises  the  shoulders  and 
throws  oiit  the  arms,  and  in  walking  the  gait  is  a  shuffling  one,  to  avoid  the 
jar  communicated  to  the  diseased  vertebrfe  by  high  stepping.  Pain  in  the 
early  stage  of  the  disease  is  complained  of  in  the  regions  supplied  by  the 
nerves  which  come  off  from  the  cord  at  the  seat  of  disease.  In  disease  of 
the  lumbar  region  the  pain  is  abdominal,  and  may  be  associated  with  vesical 
irritability.  In  the  dorsal  region  pain  may  be  epigastric  or  intercostal,  and 
respiration  may  be  affected.  In  the  cervical  region  pain  or  numbness  may 
be  felt  in  the  arms,  an  irritating  cough  may  be  present,  and  deglutition  is 
sometimes  affected.  Pain  may  be  elicited  by  pressure  or  rough  handling, 
and  is  much  increased  upon  movement  or  in  jarring  of  the  spine  by  jump- 
ing. The  patieut  will  often  support  the  head  and  the  parts  above  the  seat 
of  disease  with  the  hands  placed  under  the  chiu  or  upon  the  pelvis,  to 
relieve  the  diseased  vertebrte  of  the  weight  of  the  superimposed  parts. 

Deformity  usually  occurs  later  in  the  disease,  depending  upon  the  amount 
of  breaking  down  in  the  bodies  and  the  falling  together  of  the  vertebrfe,  and 
may  be  gradual  or  rajiid  in  its  development.  It  is  most  commonly  antero- 
posterior, although  some  degree  of  hiteral  curvature  is  not  uncommonly 
associated  with  it.  In  the  dorsal  region  it  results  in  marked  change  in  the 
shape  of  the  thorax, — '^pigeon  hreasV^ 

Abscess  may  occur  comparatively  early  in  the  disease,  but  is  most  com- 
mon in  the  later  stages.  It  is  probably  present  in  almost  all  cases,  and  may 
be  extensive  and  reach  the  surface  of  the  body,  or  may  be  limited  in  extent 
and  undergo  gradual  absorption,  so  that  its  presence  is  not  obvious.  The 
direction  which  the  fluid  takes  depends  upon  the  seat  of  the  disease,  the 
anatomical  peculiarities  of  the  parts,  and  upon  gravitation. 

In  cervical  disease  the  pus  may  escape  either  into  the  oesophfigus, 
trachea,  or  pleura,  or  descend  into  the  posterior  mediastinum,  or  open  at 


648 


DIAGNOSIS   OF  TUBERCULOSIS   OF  THE  SPINE. 


I  soi^  abscess 


the  side  or  back  of  the  neck,  or  pass  forward  and  project  into  the  pharynx, 
forming  a  retropMryngeal  abscess,  which  is  especially  apt  to  occur  in  high 
cervical  disease.  In  dorsal  disease  the  abscess  may  present  upon  the  surface 
at  the  sides  of  the  diseased  vertebrte,  or  form  a  dorsal  abscess,  or  open  into 
the  pleura  or  lung,  or  pass  down  behind  the  diaphragm  and  point  in  the 

ilio- costal  space  and  form  a  lumbar  ab- 
^^  _  ■       '      _^  scess,  or  enter  the  sheath  of  the  psoas 

^^1  .f^lB     JH      muscle  and  j)ass  down  into  the   thigh 

upon  the  outer  side  of  the  femoral  ves- 
sels, giving  rise  to  a  2)soa3  abscess.  Con- 
traction of  the  hip  often  accompanies 
psoas  abscess  and  simulates  hip  disease. 
(Pig.  470.)  In  the  lumbar  region  the 
abscess  may  j)oint  in  the  loin,  or  in  the 
ischio-rectal  or  the  iliac  fossa. 

Paralysis. — This  is  usually  motor, 
sensation  being  rarely  affected,  and 
occurs  late  in  the  disease,  being  caused 
by  pachymeningitis,  or  by  pressure  of 
the  displaced  vertebrse  upon  the  cord  ; 
wasting  of  the  muscles  and  spastic  palsy 
may  be  present  if  the  disease  is  above 
the  lumbar  enlargement. 

Diagnosis. — An  early  diagnosis  in 
tuberculosis  of  the  spine  is  most  important.  Cases  presenting  symptoms 
pointing  to  this  affection  should  be  subjected  to  a  systematic  examination  ; 
the  patient  being  stripped,  the  spinal  column  should  be  inspected  for  rigidity 
and  deformity,  and  its  function  carefully  tested.  Spinal  rigidity  is  an  early 
and  very  constant  symptom,  and  may  be  demonstrated  by  making  the  patient 
stoop  to  pick  up  an  object  from  the  floor,  or  better  by  placing  him  on  a  table 
upon  his  face  and  abdomen,  when,  by  raising  the  body  by  the  legs,  the  flexi- 
bility of  the  spine  may  be  ascertained.  When  the  disease  is  well  advanced 
and  deformity  is  present,  the  diagnosis  can  be  made  with  little  difficulty. 
The  diagnostic  signs  vary  somewhat  with  the  region  of  the  spine  involved. 

Cervical  Tuberculosis. — The  position  of  the  head  is  changed,  the  occi- 
put being  drawn  downward  and  the  chin  elevated,  the  cervical  spine  is 
rigid,  and  there  are  reflex  spasm  of  the  neck  muscles,  pain  in  the  course  of 
the  occipital  nerves,  elevation  of  the  shoulders,  and  occasionally  a  projec- 
tion upon  the  posterior  wall  of  the  pharynx,  which  can  be  felt  with  the 
finger.     (Pig.  471.) 

Dorsal  Tuberculosis. — Hex-e  there  are  usually  present  epigastric  pain, 
pain  upon  concussion,  rigidity  of  the  spine,  and  grunting  respiration.  The 
presence  of  reflex  spasm  of  the  spinal  muscles  can  also  usually  be  elicited. 
(Pig.  472.) 

Lurnbar  Tuberculosis. — In  early  disease  of  this  region  of  the  spine 
the  attitude  is  visually  erect,  and  there  are  lordosis,  rigidity  of  the  spine, 
and  pain  in  the  course  of  the  sciatic  and  anterior  crural  nerves ;  reflex 
muscular  spasm  is  also  usually  present.     (Fig.  473.) 


DIAGNOSIS  OF  TUBEECULOSIS  OF  THE  SPINF. 


549 


The  conditions  with  which  spinal  tuberculosis  is  most  likely  to  be  con- 
founded are :  Bhachitic  curvature,  which  is  frequently  seen  in  children  suffer- 
ing from  rickets  ;  this  curvature  is  a  general  one,  involving  the  dorsal  and 
lumbar  regions,  and  disappears  if  the  child  is  lifted  by  placing  the  hands  in 

Fig.  472. 


Fig.  473 


^y  IJ 

Tuberculosis  of  the  cervical  vertebrae 


KyJt'\ 


Tuberculosis  of  the  dorsal 
vertebrae. 


Tuberculosis  of  the  lumbar 
vertebrae. 


the  axillae,  reappearing  as  soon  as  he  stands  or  assumes  a  sitting  posture, 
and  disappearing  again  when  he  is  laid  upon  his  belly.  The  absence  of 
rigidity  and  the  disappearance  of  the  curvature  upon  the  manipulations 
mentioned  serve  to  distinguish  it  from  tuberculosis  of  the  s]3ine. 

Erosion  of  the  Spinal  Column. — Aneurism  may  produce  erosion  and  rigidity, 
but  there  is  no  deformity  of  the  spine,  and  aneurism  is  not  met  with  at  the 
time,  of  life  at  which  spinal  tuberculosis  is  most  common.  The  characteristic 
signs  of  aneurism  can  usually  be  elicited  by  a  careful  examination. 

Maligna7it  disease  of  the  spine  may  produce  rigidity,  but  is  not  apt  to 
produce  angular  deformity.  There  is  pain  in  the  course  of  the  spinal 
nerves,  with  a  histoiy  of  malignant  di-sease  in  other  parts  of  the  body. 

Hysterical  Spine. — ^This  affection  may  be  confounded  with  tuberculosis  of 
the  spine,  but  may  be  distinguished  from  the  latter  affection  by  the  fact  that 
it  occiirs  usually  in  young  women  who  exhibit  no  spinal  rigidity  or  well- 
defined  local  tenderness,  and  who  present  cutaneous  hyxjertesthesia  and 
other  signs  of  hysteria.  The  IcypJiotio  rigidity  of  old  age  and  the  rigidity 
and  deformity  of  spondylitis  deformans  should  not  mislead  the  surgeon,  as  in 
these  cases  no  other  symptoms  of  tuberculosis  of  the  spine  are  present. 
Perinephric  abscess  may  be  confounded  with  tuberculosis  of  the  spine,  but  is 
distinguished  from  the  latter  affection  by  the  acuteuess  of  the  invasion, 
febrile  disturbance,  resistance  to  extension  of  the  hip,  and  a  tumor  in  the 


550 


TREATBIENT  OF  TUBERCULOSIS   OF  THE  SPINE. 


ilio-costal  space  wliicli  may  cause  later  deviation  of  tlie  spine  to  the  oppo- 
site side.  Appendicular  abscess  with  contraction  of  the  hip  may  be  con- 
founded with  tuberculosis  of  the  spine,  but  the  acuteness  of  the  invasion 
and  the  abdominal  symptoms  will  distinguish  it  from  the  latter  affection. 
All  abscesses  about  the  hip,  buttock,  or  back  should  be  carefully  examined 
for  a  possible  spinal  origin.     Torticollis  may  simulate  spinal  tuberculosis. 

Prognosis. — Tuberculosis  of  the  spine  should  always  be  looked  upon  as 
a  serious  affection.  The  disease  runs  a  slow  course,  usually  two  or  three 
years,  and  may  terminate  in  recovery  with  ankylosis  of  the  spine  at  the  seat 
of  disease,  or  in  death  from  pyaemia,  profuse  suppuration,  amyloid  disease 
of  the  liver  and  kidneys,  rupture  of  the  abscess  into  visceral  cavities,  tuber- 
cular meningitis,  or  visceral  tuberculosis.  In  children  the  prognosis  is  more 
favorable  than  in  adults.  Abscess,  which  occurs  in  the  majority  of  cases,  is 
less  likely  to  develop  or  to  assume  serious  proportions  where  treatment  is 
instituted  early  in  the  disease.  The  occurrence  of  abscess,  although  it  does 
not  necessarily  lead  to  a  fatal  termination,  always  adds  to  the  gravity  of  the 
condition.  Early  recognition  of  the  disease,  prompt  and  judicious  local 
treatment,  and  good  hygienic  surroundings  will  be  followed  by  ultimate 
recovery  in  the  majority  of  cases. 

Treatment. — The  treatment  of  tuberculosis  of  the  spine  consists  in  the 
use  of  constitutional  remedies  and  immobilization  of  the  spinal  column. 

Fig.  474. 


Extension  in  tuberculosis  of  the  cervical  vertebra. 


The  constitutional  treatment  consists  in  good  hygienic  surroundings,  good 
food,  regular  diet,  the  use  of  tonics,  iodide  of  iron,  and  cod-liver  oil,  fresh 
air,  and  change  of  climate,  sea  air  in  many  cases  being  most  beneficial. 
The  local  treatment  consists  in  fixing  the  spine  and  relieving  the  diseased 
and  softened  vertebrse  from  pressure,  thus  preventing  as  far  as  possible 
deformity  from  breaking  down  of  the  bodies  of  the  vertebrae,  and  placing 
the  diseased  parts  in  the  best  position  for  ankylosis.  Two  methods  of  treat- 
ment are  very  widely  employed, — prolonged  recumbency  with  fixation,  and 
the  use  of  spinal  fixation  apparatus,  such  as  plaster-of- Paris  or  leather  jackets, 
or  a  spinal  brace  constructed  of  steel  and  leather. 


TREATMENT  OF  TUBERCULOSIS   OF  THE   SPINE. 


551 


Fig.  47 


Prolonged  Recumbency  with  Fixation. — This  method  consists  iu 
keeping  the  patient  in  bed  upon  a  firm  mattress  with  a  low  pillow,  with 
sand-bags  placed  to  the  sides  of  the  body  and  the  head,  to  prevent  him  from 
tnrning  upon  the  side  ;  the  latter  is  especially  imjDortant  iu  cases  of  cervical 
disease.  In  moving  a  case  treated  by  recumbency  great  care  should  be  exer- 
cised not  to  bend  the  spine  at  the  seat  of  disease,  and  moderate  extension 
should  be  made  at  the  same  time.  In  cervical  or  high  dorsal  caries  treated 
by  recumbency  the  use  of  extension  by  a  weight  and  pulley  from  a  collar 
and  straps  fitted  to  the  chin  and  occiijut,  and  by  extension  apparatus 
applied  to  the  feet  and  legs,  will  often  be  found  to  relieve  the  patient's 
pain  and  diminish  the  deformity.  (Fig.  474.)  The  best  means  of  fixation 
of  the  spine  with  absolute  relief  of  pres-sure  is  by  the  use  of  the  Bradford 
frame,  which  is  a  rectangular  frame  made  of 
galvanized  gas-jjipe  or  steel  tubing  a  little 
longer  and  wider  than  the  patient  for  whom 
it  is  intended.  Across  the  frame  canvas  is 
stretched  in  two  or  three  sections  and  se- 
cured by  buckles.  The  patient  is  fastened 
to  the  frame  by  an  apron  covering  the  chest 
and  abdomen  and  by  axillary  straps.  Trac- 
tion may  be  effected  by  straps  attached  to 
the  ordinary  head  extension  apparatus  and 
fastened  to  the  head  of  the  frame,  or  a 
weight  and  pulley  may  be  used. 

The  treatment  will  often  have  to  be  kept 
up  for  a  period  of  months  or  even  years,  and, 
although  the  results  are  often  as  satisfactory 
as  those  obtained  by  other  methods,  the 
greatest  objection  urged  against  it  is  that 
the  child  cannot  be  taken  into  the  fresh  aii-, 
nor  have  a  change  of  climate,  if  that  be 
desirable.  These  objections  are  overcome 
by  the  use  of  the  Bradford  frame,  by  means 
of  which  the  patient  can  be  moved  into  the 
open  air  or  transported  with  safety.  We 
have  seen  many  cases  treated  by  recumbency 
in  which  good  results  followed,  for  children 
seem  to  bear  confinement  to  bed  remarkably 
well  if  properly  fed  and  if  due  care  is  exer- 
cised to  see  that  the  room  in  which  they  are 
confined  is  properly  ventilated.  Eecumbency  seems  to  be  especially  useful 
in  young  children,  who  do  not  bear  apparatus  as  well  as  older  ones.  In  the 
earlier  stages  of  the  affection  we  are  in  the  habit  of  keeping  these  patients 
recumbent  for  a  few  months,  and  later  applying  a  supijorting  brace. 

Fixation  Apparatus. — The  cheapest  and  most  generally  applicable 
fixation  apparatus,  and  the  one  which  accomplishes  the  best  results,  is  the 
plaster-of-Paris  jacket.  It  is  applied  by  suspending  the  child  from  a  tripod 
by  means  of  arm-slings  and  a  head-halter  (Pig.  475)  ;  only  moderate  exten- 


Patient  suspended  for  application  of  plaster- 
of-Paris  jacket. 


552 


TREATMENT  OF  TUBERCULOSIS   OF  THE  SPINE. 


sion  need  be  used,  the  child  resting  the  most  of  his  weight  upon  the  feet. 
A  neatly  iitting  woven  woollen  shirt  is  aj)plied  to  the  body  and  extends 
below  the  pelvis ;  a  pad  may  be  placed  upon  the  abdomen  just  below  the  ribs 
under  the  shirt  while  the  bandage  is  being  applied,  and  removed  after  it  has 
set,  to  allow  for  distention  of  the  stomach  and  bowels.  The  plaster- of-Paris 
bandage  is  moistened  in  water  and  squeezed  dry ;  the  first  turns  of  the 
bandage  should  be  passed  around  the  pelvis  just  above  the  trochanters,  and 
the  turns  should  then  be  carried  spirally  up  the  chest  to  the  axillary  folds. 
A  number  of  layers  of  bandage  should  be  applied  to  make  a  dressing  of 
sufiicient  firmness,  four  or  five  bandages  usually  being  required  for  a  child, 
a  larger  number  for  an  adult.  In  a  few  minutes  after  the  bandage  has  set 
the  patient  is  lifted  carefully  and  laid  upon  his  back  on  a  bed,  and  is  not 
allowed  to  move  until  the  bandage  has  become  quite  firm.  The  jjatient  is 
then  allowed  to  get  uj)  and  move  about.  This  dressing,  if  comfortable, 
need  not  be  removed  for  sis  weeks  or  two  months,  at  which  time  a  new 
bandage  should  be  applied  in  the  same  manner.  In  cases  of  cervical  or 
high  dorsal  disease  a  jury-mast  (Fig.  476)  is  attached  to  the  bandage,  to 

remove  the  weight  of  the  su- 
FiG.  477.  perincumbent  parts  from  the 

diseased  vertebrae  ;  two  metal 
strips  attached  to  a  plate  are 
incorporated  in  the  plaster 
bandage  to  seciu-e  the  jury- 
mast.  A  leather  jacket  made 
of  raw  hide  may  be  moulded 
over  a  plaster  cast  taken  from 
a  plaster  jacket ;  this  is  cut  in 
front  and  laced  so  that  it  can 
be  removed  at  times  for  the 
purpose  of  bathing  the  patient, 
or  can  be  removed  at  night. 
The  jury-mast  may  also  be 
attached  to  the  leather  jacket. 
(Fig.  477.) 

Spinal  Braces. — These  are 
often  used  in  the  treatment  of 
tuberculosis  of  the  spine,  and 
are  of  much  value  after  the 
acute  symptoms  have  sub- 
sided. The  usual  form  consists 
of  a  pelvic  band  of  steel  with  two  iiprights  of  the  same  material  fitting  to 
either  side  of  the  spine,  with  pads  opposite  the  site  of  deformity.  This  is 
fastened  to  the  body  by  shoulder-straps  and  a  canvas  ai^ron  encircling  the 
front  of  the  chest.  In  disease  of  the  cervical  and  upper  dorsal  region  a  head- 
piece which  supports  the  head  and  prevents  flexion  is  adjusted  to  it.  A 
metal  brace  may  be  used  to  furnish  fixation  in  cases  where  the  patient  is  under 
careful  supervision,  but  unless  carefully  applied  and  watched  it  is  useless 
to  apply  this  apparatus.     (Fig.  478.)    We  have  found  among  the  poorer 


Leather  splint  with  jury-mast. 


TREATMENT  OF  SPINAL  ABSCESS. 


553 


Spinal  brace. 


class  of  patients  that  the  parents  do  not  appreciate  the  importance  of  watch- 
ing the  case,  and  are  apt  to  remove  the  brace  and  allow  the  child  to  go  for 
days  without  it,  interfering  very  materially  with  a 
satisfactory  result. 

The  length  of  time  a  fixation  appaiatus  should 
be  worn  in  tuberculosis  of  the  spine  is  often  difficult 
to  decide.  It  is  wiser  to  continue  the  suj)port  for  a 
longer  time  than  seems  absolutely  necessary  than 
to  run  the  risk  of  removing  it  too  soon.  As  a  rule, 
supj)ort  in  cases  which  run  a  favorable  course  should 
be  employed  for  at  least  a  year  or  eighteen  months. 
Some  cases  require  this  treatment  for  a  longer  time. 
If  the  plaster- of-Paris  jacket  has  been  used  and  the 
case  is  doing  well,  after  a  year  or  eighteen  months  a 
leather  jacket  or  a  metal  brace  can  be  substituted 
for  the  plaster,  which  should  be  worn  for  a  time, 
and  can  finally  be  dispensed  with  when  there  is 
evidence  that  the  disease  has  been  arrested. 

Calot  practises  reduction  of  the  deformity  under 
anjesthesia  at  one  sitting  by  manual  extension  and 
counterextension  and  strong  manual  pressure  over 
the  seat  of  deformity,  the  head,  trunk,  and  neck 
afterwards  being  immobilized  by  a  plaster-of- Paris 
bandage.  This  method  of  treatment  has  not  been 
generally  adopted  at  the  present  time,  for  although  the  deformity  can  often 
be  entirely  obliterated,  even  when  marked  and  the  operation  is  attended 
with  little  danger,  there  is  a  strong  tendency  to  the  return  of  the  deformity, 
as  the  gaj)  between  the  bodies  of  the  vertebrae  is  not  filled  with  firm  bone. 

Goldthwaite  effects  correction  of  the  deformity  by  placing-  the  i)atient 
upon  a  special  frame  in  a  position  of  hyperextension  of  the  upper  i)art  of 
the  spine,  and  relies  often  upon  the  weight  of  the  body  to  overcome  the 
deformity.     The  plaster-of- Paris  dressing  is  then  apx^lied. 

Treatment  of  Spinal  Abscess.— Abscess  occurs  in  a  large  number 
of  cases  of  tuberculosis  of  the  spine,  and  its  occurrence  often  prevents  the 
wearing  of  suitable  apparatus.  Spinal  abscess  in  children  runs  a  much 
more  favorable  course  than  in  adults.  A  small  abscess  may  not  require 
operative  treatment,  and,  if  good  protection  is  afforded  by  the  apparatus, 
may  undergo  absorption.  If,  however,  the  abscess  increases  in  size,  the 
contents  may  be  removed  by  aspiration  or  incision.  Eepeated  aspiration, 
with  great  care  as  regards  asepsis,  is,  on  the  whole,  to  be  preferred  to  free 
incision.  In  aspirating  a  spinal  abscess  the  skin  overlying  the  abscess 
should  be  sterilized,  as  well  as  the  aspirating  needle  ;  the  needle  is  introduced 
into  the  cavity  of  the  abscess,  and  the  fluid  is  allowed  to  escape.  Difficulty 
in  completely  emptying  tuberculous  abscesses  is  often  experienced  through 
the  canula's  becoming  clogged  with  masses  of  broken-down  cellular  tissue. 
These  may  be  removed  by  introducing  the  plunger  into  the  canula  and 
freeing  its  canal.  After  the  fluid  has  beeu  removed  the  puncture  should  be 
closed  with  a  piece  of  gauze  painted  over  with  iodoform  collodion.     Aspira- 


554  TREATMENT  OF  SPINAL  ABSCESS. 

tion  may  have  to  be  repeated  a  number  of  times,  and  may  finally  be  followed 
by  disappearance  of  the  abscess.  If  the  cavity  fills  rapidly  and  the  skin 
becomes  red,  incision,  followed  by  curetting,  irrigation,  and  drainage,  with 
closure  of  the  wound,  should  be  practised.  Aspiration  of  spinal  abscess 
may  be  followed  by  the  injection  of  iodoform  emulsion  and  closure  of  the 
piincture.     We  have  seen  many  cases  do  well  imder  this  treatment. 

Free  incision,  with  curetting  of  the  walls  of  the  abscess  when  jjossible, 
is  accomxDanied  by  much  greater  risk  than  aspiration,  and  if  infection  of  the 
wound  occurs  the  danger  to  the  patient  is  much  increased  ;  hence  it  should 
be  employed  only  when  aspiration  is  not  satisfactory. 

Incision  and  removal  of  the  tuberculous  bone  have  been  j)ractised,  but 
the  oijeration  is  attended  with  a  definite  risk  to  life,  and  seems  to  be  indi- 
cated In  only  a  limited  number  of  cases.  It  is  often  extremely  difficult  or 
even  impossible  to  expose  the  diseased  area,  and  if  a  considerable  amount  of 
bone  is  removed  with  the  curette  the  spinal  colunin  may  be  seriously  weak- 
ened. In  disease  of  the  lower  dorsal  and  lumbar  spine,  in  which  an  abscess 
has  opened  upon  the  back  and  profuse  discharge  is  exhausting  the  patient, 
we  have  j)ractised  this  method  of  treatment  with  good  results.  The  diseased 
bone  should  be  exiDOsed  by  incision  and  thoroughlj^  curetted,  and  the  wound 
drained.  Where  a  sequestrum  is  present,  which  is  not  often  the  case  in 
tuberculosis  of  the  spine,  the  operation  is  followed  by  the  best  results. 
Contraction  of  the  thigh  upon  the  pelvis  from  irritation  of  the  psoas  muscle 
usually  requires  no  surgical  treatment  if  good  spinal  support  is  furnished  ; 
if,  however,  it  persists,  weight  extension  may  be  applied,  or  subcutaneous  or 
open  section  of  the  contracted  structures  may  be  practised. 

Paralysis  due  to  j)ressure  of  tuberculous  exudations  upon  the  cord,  or 
to  flexion  of  the  cord  by  reason  of  the  displaced  position  of  the  vertebrae, 
often  disappears  if  the  spine  is  properly  supported,  or  if  the  j)atient  is 
kept  for  a  time  upon  the  back,  with  extension  made  from  the  head  and  feet, 
or  is  suspended.  The  use  of  iodide  of  potassium  in  full  doses  may  be  of 
service.  Paraplegia  from  tuberculosis  of  the  spine,  although  a  serious  com- 
plication, generally  tends  to  a  spontaneous  cure,  the  duration  of  the  paraly- 
sis usually  being  about  a  year.  The  operation  of  laminectomy  for  paralysis 
following  disease  of  the  spine  is  of  service  only  if  the  symptoms  are  due  to 
tuberculous  exudations  or  displaced  bone  ;  if  there  is  evidence  of  secondary 
involvement  of  the  cord,  resulting  in  acute  or  chronic  myelitis,  operative 
treatment  should  not  be  practised.  When  the  conditions  for  oiieration  exist, 
the  seat  of  disease  should  be  exposed  by  incision,  and  one  or  more  of  the 
posterior  vertebral  arches  removed  ;  care  should  be  exercised  not  to  open  the 
spinal  membranes  ;  and  if  the  comj)ression  is  anterior  it  may  be  imijossible 
to  remove  the  cause.  The  operation  should  not  be  undertaken  until  more 
conservative  methods  of  treatment  have  been  tried. 

Rhachitis,  or  Rickets. — This  is  an  affection  which  arises  from  malnu- 
trition, being  princii>ally  observed  in  infants  and  children,  and  is  charac- 
terized by  constitutional  disturbances  and  marked  changes  in  the  bony 
skeleton.  It  is  met  with  principally  among  the  poorer  classes,  with  whom 
improper  food  and  imperfect  hygienic  surroimdings  are  common,  but  may 
occur  among  those  of  the  better  class  if  improper  diet  is  employed.     Chil- 


PATHOLOGY  OF  RICKETS.  555 

dren  who  are  feci  upon  the  breast  rarely  develop  rickets,  unless  the  lactation 
is  prolonged  or  the  milk  becomes  of  a  poor  quality  from  a  coincident  preg- 
nancy. Artificial  feeding  with  foods  which  contain  a  large  amount  of  starch 
or  with  skimmed  milk  deficient  in  fatty  matters,  and  diseases  of  the  gastro- 
intestinal canal  which  impair  the  digestion  and  the  assimilation  of  food,  are 
also  important  factors  in  the  production  of  this  disease.  In  America  the 
disease  is  less  frequent,  even  in  large  cities,  than  abroad;  and  is  most  com- 
monly observed  in  colored  and  Italian  children.  The  disease  has  rarely 
been  observed  as  a  congenital  affection,  but  usually  develops  from  the  sixth 
month  to  the  end  of  the  second  year,  and  may  occur  as  late  as  the  fifth  or 
sixth  year.  Late  rickets  has  been  observed  from  the  ninth  to  the  thirtieth, 
year,  but  at  this  time  of  life  the  affection  is  rare,  and  the  disease  in  such 
cases  is  probably  a  recurrence  of  rickets  which  had  previously  existed  and 
had  escaped  notice  or  had  been  imperfectly  cured. 

Pathology. — In  rickets  the  most  marked  changes  in  the  bone  are 
observed  at  the  epiphyseal  junctions  ;  there  is  increased  growth  of  the  epi- 
physeal cartilages  and  subperiosteal  layers  of  bone  in  this  region,  with  defi- 
cient deposit  of  lime  salts  and  increased  absorption  of  osseous  tissue.  The 
epiphyseal  ends  of  the  bones  become  rounded  and  swollen,  so  that  they  present 
marked  enlargements.  The  cartilage  on  section  is  semitransparent  and  in 
parts  abnormally  vascular.  The  periosteum  is  thickened  and  vascular,  and 
when  stripped  from  the  bone  contains  numerous  fragments  of  ill-formed 
osseous  tissue,  and  the  bone  beneath  is  red,  soft,  and  spongy,  so  that  it  can 
be  readily  cut  with  a  knife.  In  this  softened  condition  of  the  bones,  the 
weight  of  the  body  in  'talking  and  crawling,  and  muscular  action  exaggerate 
the  normal  curves,  so  that  marked  deformities  result.  The  limited  growth 
of  the  bones  in  length  makes  the  deformities  more  noticeable.  Ehachitic 
deformitj^  of  the  thorax,  consisting  in  an  anterior  projection  of  the  chest, 
with  thickening  or  beading  of  the  epiphyses,  involving  both  the  ribs  and 
the  cartilages,  and  constituting  the  rhachitic  rosary,  is  very  common.  Deform- 
ities of  the  spine  are  also  common,  and  consist  in  kyphosis  (Fig.  479),  lor- 
dosis, and  scoliosis.  The  skull  presents  the  following  changes  :  the  sutures 
are  imperfectly  united,  the  fontanelles  are  enlarged  or  remain  open ;  por- 
tions of  the  skull  are  ossified,  and  other  portions  become  very  thin,  so  that 
soft  yielding  spots  can  be  detected,  the  condition  known  as  craniotahes. 
The  frontal  portion  of  the  skull  is  unduly  prominent,  the  skull  is  broadened, 
and  the  face  appears  unnaturally  narrow  and  sharp.  The  pelvis  also  un- 
dergoes changes ;  the  iliac  bones  become  flattened,  the  i^romoutory  of  the 
sacrum  is  pushed  forward,  and  the  lateral  walls  of  the  pelvis  are  flattened. 
The  long  bones  present  very  characteristic  deformities ;  the  epiphyses  are 
enlarged,  most  markedly  at  the  wrist  and  elbow,  knee  and  ankle,  and  the 
bones  become  curved,  either  anteriorly  or  laterally,  so  that  the  deformities 
which  are  recognized  as  bow-leg,  knock-knee,  ajid  anterior  tibial  curvature 
result.  (Fig.  480.)  Dentition  is  much  delayed;  the  first  teeth  may  not 
ai:>pear  until  the  tenth  or  twelfth  month,  and  the  subsequent  eruption  of  the 
teeth  is  retarded  and  irregular. 

Symptoms. — In  infants  the  earliest  symptoms  of  rickets  are  restless- 
ness at  night,  profuse  perspiration  of  the  head,  constipation,  and  swelling 


656 


TREATMENT  OF  EICKETS. 


of  the  belly.  In  older  cliildren,  inability  to  sit  upright  and  delayed  denti- 
tion and  tardiness  in  walking  may  first  attract  attention  to  the  disease.  The 
epiphyses  are  enlarged,  and  examination  will  often  reveal  curvature  of  the 
spine,  changes  in  the  shape  of  the  head  and  breast,  and  marked  curvatures 
in  the  long  bones.  Chronic  bronchial  catarrh  and  laryngismus  stridulus  are 
sometimes  present.  The  most  important  diag- 
nostic sym]3toms  are  enlargement  of  the  epiph- 
yses, delayed  dentition,  and  open  fontanelles. 


Ehachitie  curvature  of  the  spine 


Deformities  in  rhachitis. 


Treatment. — When  the  disease  is  recognized  early  and  treatment  is 
begun  promptly,  the  prognosis  is  good,  the  patient's  general  condition 
improving  rapidly  and  the  deformity  disappearing  in  a  large  proportion  of 
the  cases.  The  most  important  part  of  the  treatment  of  rickets  is  change  or 
regulation  of  the  diet ;  fresh  milk  properly  diluted  should  be  substituted  for 
prepared  foods  ;  meat  juice  or  raw  meat  should  also  be  given.  Care  should 
be  taken  that  the  child  has  the  benefit  of  sunlight  and  fresh  air,  and  salt- 
water bathing  may  be  emj)]oyed  with  advantage.  The  condition  of  the 
digestive  tract  should  be  carefully  investigated,  and  pei)sin,  bismuth,  and 
tonics  are  often  required.  As  regards  medication,  the  use  of  cod-liver  oil  is 
most  satisfactory  ;  in  infants  it  is  not  well  borne  by  the  stomach,  and  may 
be  used  by  inunction,  being  rubbed  into  the  skin  of  the  belly  and  groins ; 
in  older  children  it  can  be  taken  by  the  mouth.  Syrux?  of  iodide  of  iron 
should  also  be  given  in  doses  proportioned  to  the  age  of  the  child.  Phos- 
phorus and  the  lactophosphates  of  lime  may  be  used  with  advantage.  Infants 
and  young  children  should  be  kept  recumbent  as  much  as  possible  during 
the  early  stages  of  the  disease,  with  a  view  of  diminishing  the  deformity 
which  results  from  the  weight  of  the  body.  In  the  earlj'  stage  of  rhachitis, 
deformities  of  the  bones  of  the  extremities  may  be  corrected  by  the  use  of 
orthopaedic  apparatus.  The  correction  of  deformities  resulting  from  rickets 
will  be  considered  in  the  article  uxdou  Orthopsedic  Surgery. 


CHAPTEE   XXV. 

SURGERY  OP  THE  JOINTS. 
By  Heney  E.  Whaeton,  M.D. 

INJURIES  OP  JOINTS. 

Contusions  of  Joints. — Contusions  of  joints  result  from  blows  or  falls, 
and  the  damage  done  to  tlie  joint  structures  varies  with  the  amount  of  force 
applied  and  the  character  of  the  articulation.  Severe  contusions  may  be 
followed  by  laceration  of  the  ligaments  and  synovial  membranes,  detach- 
ment of  the  cartilages,  and  injury  of  the  articular  ends  of  the  bone,  and  at 
the  same  time  the  joint  becomes  distended  with  blood,  while  in  slight  con- 
tusions the  only  injury  done  to  the  joint  may  consist  in  a  bruising  of  the 
periarticular  tissues,  with  slight  extravasation  of  blood.  Slight  contusions 
of  joints  in  healthy  subjects  are  usually  rapidly  recovered  from,  but  in 
weak  or  tuberculous  subjects  such  an  injury  may  be  the  exciting  cause  of 
a  destructive  tuberculous  affection  of  a  joint,  or  in  other  cases  of  abscess  or 
necrosis  of  the  ends  of  the  bones,  or  of  a  sarcoma.  In  neurotic  subjects 
contusion  of  a  joint  may  result  in  an  hysterical  joint.  In  patients  advanced 
in  years,  contusion  of  the  joints,  even  when  slight,  may  be  followed  by  a 
form  of  chronic  arthritis,  with  roughening  of  the  articular  surfaces  and  cal- 
careous deposits,  and  in  some  cases  absorption  of  the  articular  ends  of  the 
bones  may  result,  giving  rise  to  loss  of  function  and  shortening,  as  has  been 
observed  in  the  hip-joint. 

In  severe  contusions  with  laceration  of  the  ligaments,  synovial  mem- 
branes, and  articular  cartilages,  aiid  effusion  of  blood  and  serum  into  the 
joint,  the  effusion  may  be  gradually  absorbed,  but  masses  of  fibrous  material 
are  apt  to  be  left,  which  interfere  with  the  motion  of  the  joint,  producing 
more  or  less  ankylosis ;  if  the  articular  cartilages  have  been  detached  and 
have  undergone  absorption,  bony  ankylosis  may  result.  Severe  contusions 
may  also  be  followed  by  gangrene  of  the  damaged  and  distended  skin  and 
subcutaneous  tissues  over  the  joint,  or  suppuration  may  occur  in  the  joint, 
even  if  the  skin  is  not  injured ;  in  such  cases  the  pyogenic  microbes  gain 
access  to  the  joint  by  means  of  the  blood-vessels,  their  point  of  entrance  in 
many  cases  being  undiscernible,  suppuration  in  these  cases  being  determined 
by  the  diminished  resistance  of  the  tissues  at  the  point  of  injury. 

Treatment. — In  view  of  the  fact  that  slight  contusion  of  joints  are  often 
followed  by  serious  consequences,  all  contusions,  whether  slight  or  severe, 
should  receive  careful  attention.  The  first  indication  in  the  treatment  of 
such  injuries  is  to  put  the  joint  at  rest,  by  the  ajjplication  of  a  splint  or  by 
X^lacing  the  patient  in  bed  ;  elastic  pressure  by  means  of  a  rubber  or  flannel 
bandage,  or  cold  by  means  of  an  ice-bag,  or  cold  irrigation,  may  also  be 
employed  with  advantage ;  in  some  cases  warm  applications  are  more  com- 

557 


558  SPRAINS  OF  JOINTS. 

fortable  to  the  patient  aud  are  followed  by  equally  good  results.  After  the 
effusion  has  been  absorbed  aud  the  swelling  diminished,  massage  and  passive 
motion  should  be  employed,  but  this  should  not  be  practised  until  several 
weeks  have  elaj)sed  after  the  injury.  After  joint  contusions  more  or  less 
impairment  of  motion  and  pain  may  exist  for  months.  If  suppuration  occurs 
in  the  joint  after  contusion,  the  joint  shoidd  be  freely  opened,  with  full  anti- 
septic precautions,  and  irrigated,  gauze  drains  or  tubes  being  jjassed  through 
the  joint,  and  a  copious  gauze  dressing  and  splint  applied,  or  continuous 
irrigation  with  a  warm  solution  of  bichloride  or  sterilized  water  may  be  used 
for  a  few  days.  The  surgeon  should  bear  in  mind  the  possibility  of  anky- 
losis following,  and  keep  the  limb  in  the  most  favorable  position  for  use 
should  such  a  condition  result. 

Sprains  of  Joints. — These  injuries  consist  in  a  violent  wrenching  or 
twisting  of  a  joint,  accompanied  by  stretching  or  laceration  of  the  ligaments, 
with  effusion  of  blood  and  serum  into  the  joint  and  into  the  extra-articular 
tissues.  The  amount  of  damage  varies  according  to  the  severity  of  the 
injury.  In  some  cases  the  insertion  of  a  ligament  or  a  tendon  into  a  bone 
may  be  separated  with  a  thin  shell  of  bone,  resulting  in  an  injury  which  has 
been  described  as  a  sprain  fracture. 

Diagnosis. — As  swelling  is  usually  marked  after  severe  sprains,  it  is 
often  difficult  to  distinguish  this  class  of  injuries  from  fractures,  and  we 
consider  it  wise  in  such  cases  to  give  an  aufesthetic,  so  that  a  careful  exam- 
ination of  the  part  can  be  made  and  the  absence  of  fracture  demonstrated, 
or  to  have  an  X-ray  examination  made.  In  children  care  should  be  taken 
not  to  confuse  sprains  of  joints  with  epipluiseal  separations,  which  present 
very  similar  symj)toms.  Laceration  of  tendons,  effusion  of  blood  into  their 
sheaths,  and  avulsion  from  their  sheaths  are  conditions  which  often  compli- 
cate severe  sprains,  and  are  probably  the  causes  of  persistent  pain  and 
delayed  restoration  of  function  in  many  cases. 

Treatment. — The  early  treatment  of  a  sprain  consists  in  reducing  dis- 
placed tendons  if  present,  in  putting  the  part  at  rest  by  means  of  a  splint, 
and  in  the  use  of  hot  or  cold  applications,  or  of  elastic  pressure  by  means  of 
the  rubber  or  flannel  bandage.  Anodyne  applications,  such  as  lead  water 
and  laudanum,  may  also  be  employed,  and  later  fixation  may  be  obtained 
by  the  plaster- of- Paris  or  silicate  bandage,  after  wearing  which  for  a  time, 
massage  is  often  of  the  greatest  service.  In  slight  sprains  daily  massage, 
the  application  of  a  sui^porting  bandage,  and  the  use  of  the  joint  are  often 
all  that  is  necessary.  A  satisfactory  treatment  for  sprains,  which  is  appli- 
cable both  iu  the  early  and  in  the  later  stages,  is  strapping,  the  region  of  the 
■joint  being  covered  with  layers  of  rubber  adhesive  plaster  straps  firmly 
applied,  which  serve  to  fix  the  joint  and  at  the  same  time  to  make  pressure 
and  limit  the  effusion  if  applied  early,  or  to  hasten  its  absoriition  if  used 
later.  Since  we  have  employed  this  method,  recommended  by  Gibney  and 
Cotterell,  we  have  seen  the  function  of  the  part  re-established  much  earlier. 
In  applying  strapping  in  sprains  of  the  ankle  or  the  tarsus,  strips  of  rubber 
adhesive  plaster  one  and  a  half  inches  iu  width  and  eighteen  inches  in  length 
are  requii-ed.  The  limb  is  shaved,  and  the  first  strap  is  started  at  the  junc- 
tion of  the  middle  and  iipper  part  of  the  leg,  either  upon  the  inner  or  the 


WOUNDS  OF  JOINTS. 


559 


Fig.  481. 


\. 


Straj)ping  of  a  sprain  of  the  ankle-joint. 


outer  side,  and  applied  clo.sely  to  the  edge  of  tlie  teudo  Acbillis,  aud  carried 
across  the  sole  of  the  foot  to  the  base  of  the  great  or  little  toe ;  several  of 
these  straps  are  applied,  covering  in 
the  inner  or  outer  side  of  the  ankle. 
A  straj)  is  placed  -with  its  niiddle  at 
the  point  of  the  heel,  the  ends  being 
carried  to  a  point  on  the  foot  at  the 
junction  of  the  metacarpal  bones  and 
the  tarsus ;  a  number  of  these  ascend- 
ing straps  are  applied  in  an  imbri- 
cated manner,  until  the  ankle-joint  is 
covered  in.  The  straps  should  not  be 
apijlied  so  as  to  meet  in  front  of  the 
foot  or  ankle  and  make  circular  con- 
striction. (Fig.  481.)  After  the  aukle 
has  been  strapped,  the  foot,  ankle,  and 
leg  are  covered  with  a  gauze  bandage, 
and  the  patient  is  allowed  to  walk 
upon  the  injured  foot. 

In  the  chronic  stage  of  sprains, 
where  the  restoration  of  function  is 
slow,  forcible  movements  of  the  joint 

under  autesfchesia  to  break  up  adhesions  will  often  prom^jtly  restore  its  use- 
fulness. In  sprains  associated  with  wasting  of  the  muscles  the  use  of 
faradism  will  be  followed  by  good  results. 

Wounds  of  Joints. — These  are  among  the  most  serious  injuries  that 
come  under  the  care  of  the  surgeon,  the  gravity  of  the  injury  depending 
upon  the  anatomical  peculiarities  of  the  joint  involved,  the  size  of  the 
wound,  and  the  presence  or  absence  of  infection  of  the  wound.  Aseptic 
joint  wounds  made  by  the  surgeon  heal  promptly  without  constitutional 
disturbance,  but  a  wound  made  by  a  dirty  instrument,  or  one  which  becomes 
infected  subsequently,  may  cause  suppuration  of  the  joint,  which  may  result 
in  the  loss  of  the  limb  or  the  death  of  the  patient.  We  have  seen  a  puncture 
of  the  knee-joint  from  a  dirty  table-fork  followed  by  acute  septic  arthritis 
which  subsequently  required  amputation  of  the  thigh. 

Symptoms. — In  extensive  wounds  in  the  region  of  joints  the  fact  that 
the  joint  has  been  oi^ened  can  be  ascertained  by  inspection,  but  in  small 
gunshot  or  punctured  wounds  it  is  often  difficult  to  ascertain  definitely  that 
the  joint  has  been  opened.  The  most  reliable  symptoms  which  point  to  this 
injury  are  the  escape  of  synovial  fluid  and  the  rapid  swelling  of  the  joint 
from  an  effusion  of  blood.  Wounds  of  bursse  and  the  sheaths  of  tendons  in 
the  region  of  joints  will  be  followed  by  the  escape  of  synovial  fluid,  but,  as 
the  treatment  of  both  injuries  is  very  similar,  it  would  not  be  justifiable  to 
enlarge  the  wound  or  to  probe  freely  to  ascertain  the  exact  location  of  the 
wound,  but  the  case  should  be  treated  as  one  of  joint  wound. 

Treatment. — In  punctured  aud  small  wounds  of  joints,  the  skin  sur- 
rounding the  wound  should  be  sterilized,  the  wounds  being  irrigated  with 
sterilized  water  or  a  1  to  2000  bichloride  solution,  and  closed  by  sutures 


560  GUNSHOT  WOUNDS  OF  JOINTS. 

or  a  scab  of  gauze  and  iodoform  collodion,  and  a  gauze  dressing  applied 
over  this.  The  joint  should  then  be  immobilized  by  the  application  of  a 
plaster- of- Paris  bandage.  If  no  infection  of  the  wound  has  occurred,  repair 
takes  place  rapidly  and  the  function  of  the  joint  is  not  impaired.  If,  how- 
ever the  joint  in  a  few  days  becomes  swollen  and  painful  and  the  patient 
exhibits  constitutional  symptoms,  the  wound  should  be  exposed,  and,  if 
purulent  matter  escapes,  the  joint  freely  opened  by  incision  and  thoroughly 
irrigated  with  a  1  to  2000  bichloride  solution,  and  large  rubber  tubes  or 
gauze  drains  introduced,  or  continuous  irrigation  may  be  employed.  In 
complex  joints  like  the  knee-joint  it  is  often  difficult  to  secure  free  drainage 
from  all  the  pouches,  and,  if  not  properly  drained,  pus  may  buiTOw  up  the 
thigh  beneath  the  quadriceps  muscle,  so  that  care  should  be  taken  to  intro- 
duce a  number  of  tubes  to  secure  free  drainage.  Extensive  wounds  involv- 
ing the  joints  should  be  irrigated  and  foreign  bodies  removed,  and,  if  the 
edges  of  the  wounds  are  not  severely  contused,  a  few  sutures  should  be 
applied  at  intervals,  and  drainage-tubes  introduced  through  the  joint.  If, 
however,  there  is  much  laceration  of  the  soft  parts,  the  wound  should  be 
treated  as  an  open  one,  a  coj)ious  gauze  dressing  being  applied,  and  the 
joint  iised  uj)on  a  splint  or  by  a  plaster- of-Paris  bandage  fenestrated  over 
the  region  of  the  wound.  Even  in  cases  in  which  the  joints  have  been 
extensively  opened  by  wounds,  if  infection  can  be  prevented  and  proper 
treatment  instituted,  repair  may  take  place  with  a  useful  joint.  We  had 
recently  under  our  care  a  patient  who  had  received  an  extensive  wound  of 
the  knee-joint,  produced  by  a  butcher's  cleaver,  which  divided  the  patella 
transversely  and  opened  the  joint ;  in  this  case,  after  suture  of  the  patella 
and  free  drainage  of  the  joint,  it  was  closed,  and  the  patient  recovered,  with 
the  function  of  the  joint  little  impaired. 

In  wounds  of  joints  the  fact  should  not  be  lost  sight  of  that  ankylosis 
may  occur,  and  is  especially  likely  to  follow  if  suppuration  and  destruction 
of  the  articular  cartilages  have  occurred,  and  the  surgeon  should  therefore 
fix  the  limb  in  such  a  position  as  would  render  it  most  useful  if  this  result 
ensues.  Excision  or  amputation  may  be  subsequently  required  if  disorgani- 
zation of  the  joint  has  taken  place.  In  wounds  of  joints  of  the  upper 
extremity  excision  may  often  be  practised  with  good  results,  and  also  in  the 
ankle  and  tarsal  joints  ;  amputation  is  sometimes  demanded  in  joint  wounds 
of  the  lower  extremity. 

Gunshot  Wounds  of  Joints. — These  may  be  extra-  or  intra-articu- 
lar ;  the  former  may  be  considered  as  simiale  flesh  wounds,  and  are  not 
serious  injuries  unless  the  joint  be  opened  by  subsequent  sloughing  of  the 
tissues  over  it.  lutra-articular  wounds  result  from  direct  perforation  of  the 
joint  by  the  ball,  and  are  accompanied  by  injury  of  the  synovial  membrane, 
cartilage,  and  bone,  often  presenting  great  comminution  of  the  latter,  and 
are  always  most  serious  injuries.     (Pig.  482.) 

The  principal  danger  in  gunshot  wounds  of  joints  is  from  infection  of  the 
wound,  causing  septic  arthritis,  resulting  in  the  total  disorganization  of  the 
joint,  or  in  septicsemia  or  pytemia. 

Diagnosis. — The  diagnosis  of  this  injury  is  made  by  observing  the 
course  of  the  ball,  the  escape  of  synovial  fluid  from  the  wound,  the  disten- 


DISLOCATIONS. 


561 


tion  of  the  joint  with  blood  and  serum,  and  the  loss  of  function.  Gunshot 
wounds  of  the  burste  in  the  region  of  joints  may  be  accompanied  by  the 
escape  of  synovial  fluid.  Probing  in  gunshot  wounds  of  joints,  undertaken 
with  a  view  of  establishing  the  diagnosis  or  locating  the  position  of  the  ball, 
should  not  be  resorted  to,  for  much  damage  may 
result  from  this  procedure,  and  little  good  can  be 
accomplished. 

Treatment. — Where  there  is  great  laceration  of 
the  soft  parts  or  extensive  comminution  of  the  articu- 
lar ends  of  the  bones  with  injury  of  the  principal 
blood-vessels  and  nerves  of  the  region,  amj)utation 
should  be  employed,  while  in  cases  where  the  vessels 
have  escaped  injury  and  the  bone  injuries  are  less 
extensive,  excision  may  be  resorted  to.  At  the 
present  time,  however,  even  in  extensive  gunshot 
wounds,  the  expectant  method  of  treatment  may  be 
practised  with  safety,  consisting  in  the  employment 
of  rigid  asepsis  and  the  removal  of  loose  fragments 
of  bone,  or  of  the  ball,  if  it  can  be  located  without 
difficulty,  irrigation  of  the  wound,  introduction  of 
drainage,  the  aijplicatiou  of  an  antiseptic  gauze 
dressing,  and  fixation  of  the  joint  by  splints  or  the 

plaster-of- Paris   dressing.       If  suppuration    occurs   in         Gunshot  injury  of  the  knee- 

the  wound,  excision  or  amputation  may  be  subse-  joint-  (Army  Medical  mu- 
quently  required  ;  but  if  the  wound  runs  a  favorable  ^'^'™' 
course,  recovery  may  follow  with  more  or  less  imijairment  of  function  of 
the  joint  or  with  complete  ankylosis.  Bearing  in  mind  the  latter  possibility, 
the  surgeon  should  keep  the  joint  in  the  position  in  which  it  would  be  most 
useful  should  this  result  follow. 

In  simple  penetrating  or  perforating  wounds  of  joints  met  with  in  civil 
practice,  which  are  not  usually  accompanied  by  extensive  bone  injury,  the 
expectant  method  of  treatment  should  be  employed.  The  skin  surrounding 
the  wound  should  be  sterilized  and  the  wound  irrigated  with  a  1  to  2000 
bichloride  solution  and  dressed  with  a  copious  gauze  dressing,  the  joint 
being  fixed  upon  a  splint  or  by  the  application  of  a  plaster-of- Paris  di-essing. 
At  the  end  of  several  weeks,  if  the  wound  has  remained  aseptic,  it  will  be 
firmly  healed,  and  at  this  time  the  splint  may  be  removed  and  massage  and 
gentle  passive  movements  practised  to  re-establish  the  joint  function. 


DISLOCATIONS. 

A  dislocation  or  luxation  is  a  displacement  of  the  articular  surfaces  of 
the  bones  which  enter  into  the  formation  of  a  joint.  Diastasis  is  the 
separation  at  the  junction  of  one  bone  with  another,  and  is  principally  seen 
in  the  bones  of  the  pelvis,  at  the  symx>hysis  pubis  or  the  sacro-iliac  junction. 
Dislocations  may  be  complete,  when  the  bones  which  enter  into  the  forma- 
tion of  a  joint  are  entirely  separated  from  one  another  ;  or  incomplete  or 
partial,  when  portions  of  the  articulating  surfaces  of  the  bones  remain  in 
contact  with  one  another ;  this  form  of  dislocation  is  often  described  as  a 

36 


562  DISLOCATIONS. 

subluxation.  Dislocations  are  also  classified  as  traumatic,  when  the  dis- 
placement of  the  bones  results  from  the  application  of  external  force ; 
pathological,  when  the  displacement  of  the  bones  results  from  alteration 
in  a  diseased  joint,  or  from  jaaralysis  of  the  muscles  holding  the  bones  in 
contact;  and  congenital,  when  due  to  malformation  of  the  articular  sur- 
faces. Dislocations  may  also  be  classified  as  simple,  when  the  disj^laced 
articular  surfaces  of  the  bones  are  not  exposed  to  the  air  by  a  wound  in  the 
soft  parts ;  compound,  when  the  displaced  ends  of  the  bones  are  exposed 
to  the  air  by  a  wound  of  the  overlying  soft  parts,  produced  either  by  the 
force  which  caused  the  displacement  or  by  rupture  of  the  surrounding  soft 
parts  by  the  displaced  bones ;  and  complicated,  when  in  addition  to  the 
displacement  of  the  bones  there  is  a  fracture  involving  one  or  both  of  the 
displaced  bones,  or  laceration  of  au  important  artery,  vein,  or  nerve.  A 
primitive  dislocation  is  one  in  which  the  bones  remain  in  the  position  in 
which  they  were  first  thrown  by  the  luxating  force,  while  in  a  secondary 
or  consecutive  dislocation  the  original  position  of  the  displaced  bone  is 
changed,  by  a  continuance  of  the  displacing  force,  by  muscular  contraction, 
or  by  manipulations  in  attemi^ts  at  reduction.  A  recent  dislocation  is  one 
in  which  no  marked  inflammatory  changes  have  occurred  in  the  articulating 
surface  of  the  bones  or  in  the  surrounding  tissues.  An  old  dislocation  is  one 
in  which  changes  have  occurred  in  the  articular  surfaces  of  the  bones  and 
the  surrounding  tissues.  The  terms  recent  and  old  are  not  used  to  indicate  the 
time  which  has  elapsed  since  the  receipt  of  the  injury,  but  rather  the  rapid- 
ity with  which  changes  hindering  the  reduction  of  the  dislocation  have 
occurred  ;  for  instance,  a  luxation  of  ^  the  elbow-joint  is  an  old  dislocation  at 
a  much  earlier  period  than  one  of  the  shoulder-joint.  Irreducible  dislo- 
cation is  one  which  resists  the  usiial  methods  of  reduction.  Habitual  dis- 
location is  one  which  recurs  frequently  owing  to  relaxed  or  torn  ligaments 
or  altered  joint  surfaces  ;  it  may  be  produced  voluntarily. 

Causes. — The  exciting  causes  of  dislocation  are  violence,  either  directly 
or  indirectly  applied;  and  muscular  contraction ;  the  latter  is  i^robably  a 
much  less  active  factor  in  the  jiroductiou  of  dislocations  than  in  that  of 
fracture.  Force  may  act  directly  upon  the  articulation,  jDroducing  a  disloca- 
tion, or  may  be  indirectly  applied,  as  in  the  case  of  dislocation  of  the  head 
of  the  humerus  or  the  head  of  the  femur  from  falls  upon  the  hand  or  the 
foot.  The  frecxuency  of  dislocation  is  estimated  by  Gurlt  to  be  one  disloca- 
tion to  ten  fractures.  Kronlein  in  four  hundred  cases  of  dislocation  found 
the  relative  freciuency  in  the  special  joints  to  be  as  follows :  Shoulder, 
fifty  per  cent.;  elbow,  twenty-five  per  cent.;  hip,  knee,  jaw,  clavicle,  two 
per  cent.,  and  ankle,  one-half  per  cent. 

T\iQ predisposing  causes  of  dislocation  are:  Form  of  the  Articulation. — 
Ball-and-socket  joints,  from  the  range  of  movement  which  they  permit, 
are  more  liable  to  dislocation  than  ginglymoid  or  hinge  joints ;  the  com- 
parative frequency  of  dislocation  of  the  shoulder-joint  as  compared  with 
that  of  the  elbow-joint  is  explained  by  this  cause.  Age. — Dislocations  are 
very  uncommon  in  childhood,  because  of  the  absence  of  great  muscular 
power,  the  presence  of  epiphyseal  cartilages,  and  the  flexibility  of  the  soft 
parts  about  tlie  joints.     They  are  most  common  in  adult  life,  but  are  not 


CHANGES  PRODUCED  BY  DISLOCATION.  563 

common  in  advanced  age.  Sex. — Dislocations  are  much  moie  common  in 
males  tlian  in  females,  for  the  reason  that  males  are  much  more  exposed  to 
the  exciting  causes.  Defective  Articular  Development. — The  imiierfect 
development  of  the  articular  cavity  or  the  articular  ends  of  the  bones  is  also 
a  predisposing  cause  of  dislocation.  Muscular imrcdysis  producing  relaxation 
of  the  ligaments  of  a  joint,  and  articular  disease  resulting  in  distention  of  the 
capsule  of  the  joint  and  elongation  of  the  ligaments,  are  predisposing  causes 
of  dislocation.    The  unequal  groivth  of  parallel  bones  may  result  in  dislocation. 

Symptoms. — The  prominent  symptoms  of  dislocation  are  :  Change 
in  the  Shape  of  the  Articulation. — This  is  caused  by  the  change  in  the 
position  of  the  articulating  surfaces  of  the  bones,  and  tension  or  relaxation 
of  the  muscles  in  direct  relation  to  the  joint ;  thus,  iiattening  of  the  shoul- 
der is  a  marked  symjptom  in  dislocation  of  the  shoulder,  and  in  many  cases 
of  dislocation  prominence  of  the  disi^laced  bone  may  materially  alter  the 
shape  of  the  joint.  Change  in  the  Length  of  the  Limbs. — This  may 
consist  either  in  shortening  or  in  elongation.  Loss  of  Function. — This  is 
usually  present,  the  dislocated  part  being  no .  longer  capable  of  executing 
th^  ordinary  movements,  being  generally  rigid,  muscular  contraction  assist- 
ing in  the  fixation  of  the  j)art.  Change  in  the  Direction  of  the  Limb. 
— This  is  usually  very  marked  in  dislocation,  and  is  produced  by  tension  of 
the  ligaments  and  mtxscles,  as  well  as  by  contact  of  the  displaced  bone  with 
an  abnormal  bony  surface.  This  change  is  well  demonstrated  in  dislocation 
of  the  head  of  the  humerus  and  of  the  femur.  Crepitus. — True  crepitus 
cannot  be  elicited  in  cases  of  dislocation,  but  moist  creijitus  can  often  be 
obtained  which  results  from  the  friction  of  a  cartilaginous  surface  over 
bone  and  resembles  that  obtained  in  the  case  of  inflamed  burste  or  tendons. 
SivelUng,  pain,  and  discoloration  may  also  be  present  after  dislocation,  but 
these  conditions  do  not  differ  materially  from  those  observed  after  fracture. 
Injury  to  vessels  in  dislocation  is  shown  by  the  appearance  of  a  hsematoma  ; 
if  an  artery  be  involved,  there  will  be  failure  of  distal  x^ulsation,  with  local 
or  distal  thrill  or  bruit ;  aneurism  or  gangrene  may  follow.  Injury  to  nerves  is 
indicated  by  numbness,  pain,  or  paralysis  in  the  parts  supplied  by  the  nerves. 

Changes  prodiiced  by  Dislocation.— The  immediate  effects  pro- 
duced by  dislocation  are  rupture  of  the  capsule,  tearing  of  the  ligaments, 
bruising  or  tearing  of  tendons  or  muscles  adjacent  to  the  joint,  and  injury 
of  blood-vessels  and  nerves.  The  soft  parts  may  be  interposed  between  the 
head  of  the  bone  and  the  socket,  or  the  head  of  the  bone  may  buttonhole  the 
ligaments.  In  dislocations  following  muscular  relaxation,  with  elongation 
of  the  ligaments,  displacement  of  the  bone  may  occur  without  laceration  of 
the  ligaments.  If  a  dislocation  is' promptly  reduced,  the  rent  in  the  capsule 
heals,  and  the  parts  are  soon  restored  to  their  normal  condition.  If,  how- 
ever, the  dislocation  is  not  reduced,  the  articular  surfaces  of  the  bone 
undergo  changes.  In  a  ball-and-socket  joint  the  ligaments  become  wasted, 
the  head  of  the  bone  atrophies,  the  cartilages  disapi^ear,  the  articular  cavity 
becoming  filled  up  and  its  margins  absorbed  and  flattened,  and  the  head  of 
the  bone,  if  it  rests  upon  a  bony  surface,  forms  for  itself  a  new  socket ;  the 
bone  atrophying  under  pressure  of  the  head  and  new  bone  being  thrown  out 
around  this  point.     If  the  head  of  the  bone  rests  uj)on  muscle,  tendon,  or 


564 


REDUCTION  OF  DISLOCATIONS. 


fascia,  the  soft  tissues  undergo  condensation,  a  cup-sliaped  cavity  of  fibrous 
tissue  is  formed,  whicli  is  attached  to  the  margins  of  the  displaced  bone, 
forming  a  new  capsular  ligament,  and  a  synovia-like  fluid  is  often  secreted. 

(Kg.  483.)  In  the  case  of  unreduced 
ginglymoid  or  hinge  joints,  the  bony 
prominences  are  rounded  off  in 
time,  the  bones  accommodate  them- 
selves to  their  changed  relations, 
and  more  or  less  motion  may  be 
regained,  although  the  restoration 
of  function  is  not  usually  so  marked 
as  in  the  case  of  ball-and-socket 
joints. 

Prognosis. — Spontaneous  re- 
duction of  dislocations  is  not  un- 
common, especially  in  the  shoulder. 
The  restoration  of  function  after  the 
reduction  of  i-ecent  dislocations  is 
usually  more  or  less  complete,  al- 
though it  is  not  uncommon  for  stiff- 
ness or  weakness  of  the  joint  to  per- 
sist for  some  time.  The  occurrence 
of  a  dislocation  predisposes  to  sub- 
sequent dislocation  in  the  same  joint 
upon  exposure  to  violence,  being 
due  to  weakness  of  the  ligaments  following  the  previous  injury.  Ari  unre- 
duced dislocation  causes  a  certain  amount  of  permanent  disability,  although 
in  some  joints  a  fair  amount  of  restoration  of  function  takes  place  after  a 
time  if  the  patient  persists  in  using  the  part. 

Treatment. — The  indications  in  the  treatment  of  dislocation  are  to 
restore  the  displaced  parts  to  their  normal  position  as  soon  as  possible,  and 
later  to  encom-age  the  restoration  of  function  in  the  joint. 

Reduction  of  Dislocations. — The  principal  obstacles  to  the  reduction 
of  dislocations  are  the  anatomical  relations  of  the  joint  and  muscular  resist- 
ance ;  the  latter  may  be  manifested  by  reflex  tonic  contraction  due  to  trau- 
matic irritation,  to  voluntary  contraction  when  the  patient  resists  the  efforts 
of  the  surgeon,  and  to  passive  muscular  force  from  the  stretching  of  the 
muscles  across  the  bony  prominences.  The  interposition  of  ligaments, 
nerves,  blood-vessels,  and  fascia  may  sometimes  act  as  a  mechanical  obstacle 
to  the  reduction  of  dislocations.  Anaesthesia. — This  is  a  most  powerful 
aid  in  the  reduction  of  dislocations ;  the  active  element  of  muscular  spasm 
is  entirely  obliterated,  and  the  general  relaxation  favors  the  manipula- 
tions necessary  for  the  restoration  of  the  displaced  bone.  An  anaesthetic 
should,  as  a  rule,  be  given  before  attempting  the  reduction  of  a  disloca- 
tion, unless  there  is  some  contraindication  to  its  use,  such  as  cardiac  or 
renal  disease.  Manipulation. — At  present  the  most  widely  employed 
method  of  reducing  dislocations  is  manipulation,  which  consists  iu  the 
employment  of  those  movements  which  relax  the  muscles,  preventing  the 


New  socket  formed  upon  the  dorsum  of  the  ilium  in  un 
reduced  dislocation  of  the  femur.   (After  Agnew.) 


COMPOUND  DISLOCATIONS.  565 

return  of  the  displaced  bone,  and  favor  tlie  contraction  of  muscles  which 
may  aid  the  reduction  of  the  dislocation,  at  the  same  time  the  bone  being 
moved  in  such  a  direction  as  to  favor  its  replacement.  The  great  majority 
of  dislocations  can  be  reduced  by  manij)ulation.  In  cases  in  which  the 
reduction  cannot  be  accomj)lished  by  manipulation,  it  may  occasionally  be 
necessary  to  resort  to  the  application  of  force  by  extension  and  couuter- 
estension,  or  to  open  incision.  Extension  and  Counterextension. — 
This  method  of  reduction  is  liable  to  do  great  violence  to  the  soft  parts  in 
the  neighborhood  of  the  joint,  causing  laceration  and  rupture  of  muscles, 
veins,  and  blood-vessels,  and  even  avulsion  of  limbs,  and  is  now  resorted 
to  only  in  exceptional  cases.  It  may  be  employed  by  the  hands  of  the  sur- 
geon or  his  assistants,  or  by  the  use  of  various  mechanical  devices,  such  as 
compound  pulleys,  the  Spanish  windlass,  Jarvis's  adjn.ster,  or  the  Indian 
puzzle.  The  extending  bands  usually  employed  are  made  by  folding  sheets 
or  towels  into  cravats  and  applying  them  to  the  limb  by  a  noose  knot  or 
clove  hitch  at  some  distance  from  the  displaced  end  of  the  bone. 

Complicated  Dislocations. — A  serious  complication  of  dislocation  is 
the  occui-rence  of  a  fracture  in  the  same  bone.  In  such  cases  an  antesthetic 
should  be  administered,  and,  if  the  shaft  of  the  bone  has  been  fractured,  the 
fragments  at  the  seat  of  fracture  should  be  fixed  with  splints  or  a  plaster-of- 
Paris  dressing,  while  manipulations  are  made  to  reduce  the  dislocation. 
When  this  has  been  accomplished,  an  appropriate  dressing  should  be  applied 
for  the  fracture.  Should  the  fracture  have  occurred  so  near  the  exti'emity  of 
the  bone  that  the  fixation  of  the  fragments  is  impossible,  attemj^ts  to  reduce 
the  displaced  bone  should  be  made  by  manipulation,  and  when  this  has 
been  accomplished  the  dressing  for  the  fi-acture  should  be  applied.  Wounds 
of  blood-vessels  and  nerves  may  also  complicate  dislocations,  and  should 
be  treated  upon  general  principles. 

Compound  Dislocations.— In  this  variety  of  dislocation  the  end  or 
ends  of  the  displaced  bones  are  exposed  to  the  air  through  a  wound  in  the 
soft  parts,  and  the  existence  of  such  a  wound  increases  very  materially  the 
gravity  of  the  injury.  Compound  dislocations  may  result  from  force  applied 
from  without  lacerating  the  tissues  and  exposing  the  displaced  bones  in  the 
wound,  or  more  frecjueutly  from  the  luxated  bone  being  driven  through  the 
soft  parts  and  skin  from  within,  and  are  much  rarer  than  compound  fractures. 
Hamilton,  in  a  collection  of  one  hundred  and  sixty-six  dislocations  records 
eight  only  as  compound.  These  are  most  common  at  the  elbow-  and  knee- 
joints,  but  are  rare  at  the  shoulder-  and  very  uncommon  at  the  hip-joint. 
They  are  often  complicated  with  a  fracture  of  the  ends  of  the  displaced 
bones,  or  mixture  of  important  blood-vessels  and  nerves. 

Treatment. — Formerly  compound  dislocations  of  the  larger  joints  were 
followed  by  so  great  a  mortality  under  conservative  methods  of  treatment 
that  they  were  considered  cases  in  which  primary  amputation  was  urgently 
indicated.  Amputation  is  now  rarely  employed,  excei^t  in  cases  comjjlicated 
by  extensive  laceration  of  the  soft  parts  and  of  important  blood-vessels,  as 
it  is  often  possible  to  save  the  limb  and  preserve  the  function  of  the  joint. 

The  treatment  depends  largelj^  upon  the  amount  of  laceration  of  the  soft 
parts,  the  condition  of  the  large  blood-vessels  at  or  near  the  seat  of  injury. 


566  SPECIAL  DISLOCATIONS. 

and  the  existence  of  a  fracture  at  the  ends  of  the  displaced  boues.  In  a 
compound  dislocation  in  which  the  injury  to  the  blood-vessels  and  soft  jjarts 
or  bone  is  not  extensive,  the  protruding  bone  or  bones,  as  well  as  the  wound, 
should  be  carefully  sterilized,  the  reduction  accomplished,  the  wound  drained 
and  dressed  with  a  copious  antiseptic  dressing,  and  the  part  put  at  rest  upon 
a  splint  or  fixed  by  a  plaster-of- Paris  dressing.  In  the  smaller  articulations, 
such  as  those  of  the  fingers  and  toes,  the  results  of  this  method  of  treatment 
are  usually  satisfactory.  In  the  case  of  compound  dislocations  of  the  larger 
joints,  some  diversity  of  opinion  exists  among  surgeons  as  to  whether  it  is 
wiser  to  reduce  the  dislocation  and  close  the  wound,  or  to  excise,  either 
partially  or  completely,  the  ends  of  the  displaced  bones.  We  think  the 
judgment  of  most  surgeons  now  is  in  favor  of  sterilization  of  the  ends  of  the 
bones  and  the  wound,  of  reducing  the  dislocation  and  introducing  drainage, 
and,  after  applying  an  antiseptic  dressing,  fixing  the  parts  by  splints  or 
the  plaster-of- Paris  dressing.  Tenotomy  of  resisting  tendons  facilitates  the 
reduction  of  compound  dislocations,  and  subsectuently  favors  immobiliza- 
tion of  the  parts.  In  compound  dislocations  where  there  is  a  fi'acture  of 
the  ends  of  one  or  both  bones,  excision,  either  partial  or  complete,  should 
be  practised.  After  excision  the  wound  should  be  drained,  and  the  part 
dressed  and  fixed  upon  a  splint,  and  at  the  end  of  ten  days  or  two  weeks, 
when  the  wound  has  healed,  ]3assive  motion  should  be  carefully  employed, 
to  prevent  bony  ankylosis,  except  in  the  case  of  the  knee.  We  have  seen 
most  satisfactory  results  follow  excision  of  the  shoulder-,  elbow-,  and  ankle- 
joints  in  such  cases. 

Habitual  Dislocation. — If  this  form  of  dislocation  causes  marked 
disability,  its  treatment  consists  first  in  the  use  of  massage  of  the  part  com- 
bined with  fixation.  If  under  this  treatment  imjirovement  is  not  marked, 
operative  treatment  should  be  employed.  In  the  shoulder,  in  which  this 
variety  of  dislocation  is  most  common,  this  consists  in  exi^osure  of  the  ante- 
rior portion  of  the  capsule  of  the  joint  and  its  j)artial  resection  and  closure 
by  sutures  to  shorten  the  capsule. 

Irreducible  Dislocation. — This  form  of  dislocation  is  often  accom- 
panied by  great  deformity,  disability,  and  pain,  and  is  sometimes  compli- 
cated by  a  fracture  of  one  or  both  of  the  dislocated  surfaces  of  the  joint. 
Treatment. — This,  after  all  bloodless  methods  of  reducing  the  dislocation 
have  failed,  consists  in  exposing  the  joint  by  incision  and  displacing  or 
dividing  the  soft  tissues  which  interfere  with  its  reduction,  or  in  excising 
a  portion  of  the  displaced  bone.  The  results  following  these  procedures 
are  often  most  satisfactory. 

SPECIAL   DISLOCATIONS. 

Dislocations  of  the  Lower  Jaw, — These  are  comparatively  rare 
accidents,  constituting  about  four  per  cent,  of  all  dislocations.  They  are 
more  common  in  females  than  in  males,  and  are  extremely  rare  in  childhood. 
These  dislocations  may  be  bilateral,  unilateral,  or  incomplete. 

A  i^redisposing  cause  of  these  dislocations  may  be  a  shallow  glenoid 
cavity,  the  articular  eminences  being  unusually  low.  Eelaxation  of  the  liga- 
ments or  weakness  of  the  muscles  of  mastication,  as  is  sometimes  observed  in 


DISLOCATIONS   OF  THE  LOAVER  JAW. 


567 


feeble  sulijects,  may  also  predispose  to  these  injuries.  The  causes  which 
produce  them  are  violence  from  falls  received  upon  the  chin,  unusually  wide 
opening  of  the  mouth,  biting  upon  hard  substances,  and  dental  operations. 
These  displacements  are  produced  when  the  lower  jaw  is  strongly  depressed, 
the  condyles  moving  forward  and  carrying  with  them  the  interarticular  carti- 
lages upon  the  articular  eminences.  When  the  condyles  of  the  jaw  are  iu 
this  ijosition,  if  the  jaw  is  still  further  depressed,  the  condyles  break  through 
the  front  of  the  capsular  ligament,  and  are  jjulled  from  their  articular  emi- 
nences by  the  action  of  the  external  pterygoid,  masseter,  and  temporal 
muscles.  (Fig.  484.)  The  rent  iu  the  capsule  may  take  place  below  the 
articular  cartilage,  leaving  it  in  its  normal  position  ;  it  has  been  known  to 
constitute  an  obstacle  to  reduction  by  being  pushed  backward  behind  the 
condyle. 

Bilateral  Dislocation. — When  both  condyles  of  the  inferior  maxilla 
are  removed  from  their  articulating  cavities  the  front  teeth  will  be  found 
separated  for  an  inch  or  more  ;  the  mouth 
remains  oj)en,  and  the  line  of  the  teeth  iu  Tic  4S5 

the  lower  jaw  is  in  advance  of  that  of  the 

Fig.  484.. 


Position  of  the  lower  jaw  in  bilateral  dislocation.    (Agnew.)  Bilateral  dislocation  of  the  lower  jaw. 


upper.  The  chin  is  unduly  prominent  (Fig.  485),  the  jaw  is  fixed,  and  pain 
is  usually  a  prominent  symptom .  A  slight  prominence  can  usually  be  felt 
immediately  behind  the  malar  bone,  which  is  caused  by  the  coronoid  process 
and  the  tendon  of  the  temporal  muscle. 

Unilateral  Dislocation. — In  this  dislocation  one  condyle  only  is  dis- 
placed, in  conseqirence  of  which  the  lower  jaw  is  carried  towards  the  oppo- 
site or  uninjured  side,  giving  the  chin  a  twisted  appearance;  the  jaws  are 
somewhat  separated,  the  mouth  is  held  partially  open  and  the  jaw  is  fixed, 
and  a  dejaression  is  felt  in  front  of  the  ear  on  the  side  of  the  displacement 
and  a  prominence  on  the  sound  side.  The  incisor  teeth  of  the  lower  jaw  on 
the  sound  side  are  external  to  those  of  the  upper  jaw. 

Subluxation. — This  aifection  is  often  habitual,  and  the  symptoms  are 
sudden  immobility  of  the  jaw,  coming  on  while  chewing  or  biting  ujson  hard 
substances,  slight  separation  of  the  incisor  teeth,  and  inability  to  apj^roxi- 
mate  the  teeth.  It  is  caused  by  the  interarticular  cartilages  slipping  behind 
the  condyles  and  fixing  them  upon  the  articular  eminences. 


568  DISLOCATIONS   OF  THE  LOWER  JAW. 

Diagnosis. — Dislocation  of  the  jaw  may  be  confounded  with  a  fracture 
of  the  neck  of  the  condyle.  In  fractui-e  there  is  mobility,  with  a  prominence 
of  the  fragment  below  the  zygomatic  line,  and  the  chin  falls  towards  the 
injured  side,  while  in  dislocation  of  one  condyle  there  is  immobility  and  the 
chin  inclines  to  the  opposite  side. 

Treatment. — The  patient  should  be  seated  in  a  chair  or  jplaced  upon  a 
bed,  and  an  assistant  should  suj)port  the  head,  while  the  surgeon  standing 
in  front  of  the  patient,  having  ]3rotected  his  thumbs  by  wrapping  them  with 
a  piece  of  muslin,  passes  them  into  the  mouth  and  backward  until  they  rest 
upon  the  molar  teeth  of  each  side.  The  jaw  should  first  be  pressed  down- 
ward, then,  by  elevating  the  anterior  portion  of  the  bone,  the  condyles  will 
be  drawn  into  position  by  the  action  of  the  temi^oral  and  masseter  muscles. 
(Fig.  486.)  The  condyles  usually  slip  into  place 
Fig.  486.  with  an  audible  sound,  and  as  soon  as  the  surgeon 

feels  that  the  jaw  has  changed  its  position  he 
should  remove  his  thumbs  to  prevent  them  from 
being  bitten.  In  cases  of  dislocations  of  some 
standing,  enough  force  may  not  be  obtained  by 
the  use  of  the  thumbs,  and  wooden  levers  may 
be  employed  to  depress  the  jaw  at  the  same  time 
that  the  pressure  is  made  beneath  the  chin.  Dis- 
locations of  the  jaw  of  several  weeks'  standing 
have  been  reduced  by  simjjle  manipulation.  If 
it  is  found  impossible  or  difficult  to  reduce  a 
dislocation  of  the  jaw  by  reason  of  the  muscular 
rigidity  and  contraction,  it  is  well  to  anaesthetize 
the  patient,  when  it  can  usnally  be  reduced  with- 
,  ^. ,      .       ,  ,  ont  much  difficulty.     Subluxation  of  the  iaw,  if 

Eeduction  of  dislocation  of  the  ''  ''        ' 

lower  jaw.  not  reduced  by  the  patient  by  muscular  action, 

can  usualljf  be  rednced  by  introducing  a  narrow 
wooden  wedge  between  the  teeth  and  prying  the  jaws  apart,  or  the  coronoid 
processes  may  be  pressed  downward  and  backward  with  the  fingers.  This 
dislocation  when  habitual  may  also  be  treated  by  exposing  the  articulation 
and  suturing  the  articular  cartilage  to  the  periosteum. 

After  the  reduction  of  dislocation  of  the  lower  jaw,  a  Barton's  bandage 
should  be  applied  to  secure  the  lower  jaw  in  contact  with  the  ujjper  for  a 
week  or  ten  days.  The  patient  should  be  careful  in  making  movements  of 
the  jaw  until  the  rent  in  the  caj)sular  ligament  is  healed,  for  fear  of  repro- 
ducing the  displacement. 

The  treatment  of  irreducible  dislocations  of  the  jaw  consists  in  exposing 
the  articulation  by  incision  and  excising  the  tissues  which  prevent  reduction, 
or  in  using  the  steel  hook  of  McGraw  introduced  through  a  small  wound 
made  beneath  the  zygoma,  the  hook  being  passed  around  the  jaw  at  the 
sigmoid  fossa.  While  traction  is  made  downward  and  backward,  an 
assistant  pulls  the  chin  forward  and  upward. 

Noisy  Movements  of  the  Temporo-Maxillary  Articulation. — These 
consist  in  snaiiping  sounds  heai'd  during  the  movements  of  the  jaw  in  chew- 
ing, and  are  produced  by  the  condyles  of  the  jaw  slipping  forward  upon 


DISLOCATIONS  OF  THE  STERNUM.  569 

their  articular  eniinences  when  the  jaw  i.s  depressed,  and  then  suddenly 
slipping  backward  during  its  elevation.  The  condition  is  probably  due  to 
relaxation  of  the  ligaments  of  the  articulation,  and  seems  to  predispose  to 
dislocation.  The  treatment  of  this  condition  consists  in  the  injection  of  a 
few  drops  of  absolute  alcohol  into  the  ligaments. 

Congenital  dislocations  of  the  lower  jaw  are  extremely  rare.  A  case 
has  been  reported  by  Mr.  E.  "VV.  Smith  in  which  there  was  very  imperfect 
development  of  the  glenoid  cavity,  interarticular  cartilages,  ligaments,  and 
muscles  upon  the  affected  side. 

Dislocations  of  the  Sternum.— Dislocation  or  diastasis  of  the  bones 
of  the  sternum  from  each  other  is  a  rare  injury,  and  may  consist  in  the  sepa- 
ration of  the  body  of  the  bone  from  the  manubrium,  or  the  ensiform  process 
from  the  body. 

Dislocation  of  the  Body  of  the  Sternum  from  the  Manubrium. — 
This  dislocation  may  be  produced  bj'  direct  force  or  by  forcible  extension 
of  the  body.  The  displacement  may  be  forward  or  backward.  When 
resulting  from  direct  force  applied  to  the  body  of  the  sternum,  this  is 
usually  displaced  backward  and  the  manubrium  projects  forward,  or  the 
manubrium  may  be  driven  backward  as  the  result  of  direct  force  and  occupy 
a  i^osition  behind  the  body  of  the  bone.  The  costal  cartilages  usually  retain 
their  attachments  to  the  manubrium.  Displacements  of  the  manubrium  from 
the  body  of  the  bone  may  be  associated  with  fractures  of  the  ribs  or  of  the 
costal  cartilages.  Symptoms. — These  are  interference  with  resjjiration 
and  a  projection  upon  the  anterior  surface  of  the  sternum,  due  to  either  the 
lower  end  of  the  manubrium  or  the  upper  end  of  the  body  of  the  bone, 
according  as  the  bones  are  displaced  backward  or  forward.  The  gravity  of 
this  accident  depends  largely  upon  its  association  with  injury  of  the  intra- 
thoracic viscera.  Treatment. — Attempts  should  be  made  to  reduce  the 
displacement  in  cases  of  dislocation  of  the  manubrium  or  the  body  of  the 
bone,  but  are  not  always  followed  by  success.  An  ansesthetic  should  be 
administered  if  the  patient's  condition  will  permit  of  it,  and  flexion  or 
extension  of  the  trunk  should  be  made,  with  direct  pressure  over  the  pro- 
jecting bone.  If  it  is  found  impossible  to  reduce  the  deformity  no  violent 
attempts  should  be  made,  as  j)atients  have  recovered  with  marked  deformity, 
and  have  subsequently  suffered  little  inconvenience  from  it ;  but  if  the  dis- 
placement causes  great  discomfort  the  displaced  bone  should  be  exjiosed  by 
incision  and  elevated. 

Dislocation  of  the  Ensiform  Process. — This  is  occasionally  produced 
by  blows  or  kicks  upon  the  epigastrium.  The  injury  may  be  followed  by 
severe  pain  in  the  region  of  the  stomach,  and  difficulty  in  respiration  and 
occasionally  vomiting,  which  may  persist  for  some  time.  Treatment. — 
Eeduction  may  be  accomplished  by  manipulation,  which  consists  in  passing 
the  fingers  below  the  process  and  attempting  to  push  it  forward,  or  by 
making  a  puncture  in  the  skin,  introducing  a  tenaculum  into  the  cartilage, 
and  drawing  it  forward.  If  the  deformity  recurs  and  is  accompanied  by 
troublesome  symjjtoms,  excision  should  be  resorted  to. 

Dislocations  of  the  Ribs  and  Costal  Cartilages.— The  heads  of 
the  ribs  may  be  dislocated  at  their  junction  with  the  vertebrae,  or  the  ribs 


570 


DISLOCATIONS  OF  THE  CLAVICLE. 


may  be  dislocated  from  the  costal  cartilages,  or  the  cartilages  from  the 
sterniiuj,  or  one  cartilage  from  another. 

Dislocation  of  the  Heads  of  the  Ribs. — This  Is  a  very  rare  disloca- 
tion, which  results  from  the  application  of  great  force  and  has  resulted 
fatally  in  all  of  the  recorded  cases  from  associated  injuries,  with  one 
exception. 

Dislocations  of  the  Ribs  from  the  Costal  Cartilages. — These 
dislocations  are  also  rare,  and  result  from  crushing  force  applied  to  the 
chest,  as  in  "buffer"  accidents,  and  are  often  fatal  from  injuries  of  the 
thoracic  viscera. 

Dislocations  of  Cartilage  from  the  Sternum. — These  dislocations 
are  more  common,  and  also  result  from  severe  crushing  force  applied  to  the 
chest. 

Dislocations  of  One  Cartilage  from  Another. — Dislocations  of  the 
sixth  to  the  tenth  costal  cartilages  from  one  another  usually  result  from  falls 
upon  the  back,  or  from  violent  contraction  of  the  pectoral  or  abdominal 
muscles ;  the  upper  margin  of  the  lower  cartilage  slips  beneath  the  upper 
cartilage. 

Symptoms. — The  marked  symptoms  in  these  injuries  are  pain  and 
restriction  in  respiratory  movements  and  deformity  at  the  seat  of  injury. 
As  before  stated,  many  of  these  cases  have  resulted  fatally  from  associated 
injuries  of  the  thoracic  viscera. 

Treatment. — This  consists  in  reducing  the  displacement  by  pressure, 
and  placing  a  compress  over  the  seat  of  injury,  and  the  application  of  broad 
strips  of  adhesive  plaster  to  iix  the  motion  of  the  chest  on  the  side  of  the 
injury,  as  in  the  case  of  fracture  of  the  ribs. 

Dislocations  of  the  Clavicle. — Dislocations  of  the  clavicle  may 
occur  at  the  sternal  or  at  the  acromial  end  of  the  bone. 

Dislocation  of  the  Sternal  End  of  the  Clavicle. — The  sterno- 
clavicular articulation  possesses  an  interaiticular  fibrocartilage  attached 

below  to  the  first  costal  cartilage  and  above 
to  the  clavicle.  The  articulation  is  sur- 
rounded by  a  capsular  ligament,  strength- 
ened anteriorly  and  j)osteriorly  by  the 
sterno- clavicular  and  costo-clavicular  liga- 
ments. (Fig.  487.)  Sterno-clavicular  dis- 
locations of  the  clavicle  may  be  forward, 
backward,  or  upward. 

Forward  Dislocation. — This  is  a  fre- 
quent dislocation  of  the  clavicle,  in  which 
the  bone  takes  a  position  in  front  of  and  in 
contact  with  the  upper  extremity  of  the  sternum,  and  is  caused  by  force 
applied  to  the  shoulder,  forcing  it  violently  downward  and  backward,  and 
may  also  result  from  blows  upon  the  shoulder,  forcing  it  forward  and 
inward.  Symptoms. — These  are  the  presence  of  a  swelling  in  front  of  the 
upper  part  of  the  sternum,  a  tense  ridge  corresponding  to  the  clavicular 
origin  of  the  sterno-cleido-mastoid  muscle,  a  diminished  sjiace  between  the 
acromion  xjrocess  of  the  scapula  and  the  sternum,  and  a  sinking  downward 


Fig.  487. 


Sterno-clavieular,   costo-clavicular,   and 
.  interclavicular  ligaments.    (Agnew.) 


DISLOCATIONS   OF  THE  CLAVICLE. 


571 


Fig  4SS 


auci  inward  of  the  shoulder.  (Fig.  488.)  Pain  is  usually  present  upon 
motion  of  the  arm,  and  the  movements  of  the  arm  are  much  restricted. 
Incomplete  dislocation  of  the  sternal  end  of  the  clavicle  may  occur,  and  is 
accompanied  by  the  same  symptoms  in  a  lesser  degree.  This  dislocation 
may  also  be  associated  with  a  fracture  of  the  edge  of  the  articular  surface 
of  the  sternum  or  clavicle.  Treatment. — 
Eeduction  is  effected  by  drawing  the  shoulders 
backward  and  at  the  same  time  making  press-. 
ure  upon  the  end  of  the  clavicle.  It  is  often 
easy  by  this  manipulation  to  reduce  the  de- 
formity, but  it  is  difficult  to  maintain  the 
reduction .  The  dressing  consists  in  a  compress 
applied  over  the  replaced  head  of  the  bone, 
with  the  shoulders  held  backward  by  a  figure- 
of-eight  bandage,  or  the  patient  may  be  placed 
in  bed  in  the  recumbent  i^osture  and  a  com- 
press held  over  the  rei^laced  end  of  the  bone 
by  means  of  a  bandage  or  strips  of  adhesive 
plaster.  When  the  patient  is  allowed  to  get 
about,  to  prevent  a  reproduction  of  the  deform- 
ity the  arm  should  be  fixed  to  the  side  of  the 
body  by  means  of  a  Velpeau's  bandage,  fixa- 
tion dressings  being  maintained  in  this  dislo-  Deformity  m  antenoi  dibiocation  of 
cation  for  six  or  eight  weeks,  until  adhesions  tiiestemai  end  of  the  clavicle.  (After 
have  occurred  at  the  seat  of  injviry.    In  one 

case  Geisuny  transplanted  the  attachment  of  the  sterno-cleido-mastoid  muscle 
from  the  clavicle  to  the  first  rib  and  thus  held  the  clavicle  in  place.  In 
spite  of  the  most  careful  treatment,  more  or  less  permanent  deformity  is 
unavoidable.  ^Notwithstanding  this,  however,  the  functional  results  obtained 
are  usually  satisfactory. 

Backward  Dislocation. — This  is  a  rare  dislocation,  and  may  be  pro- 
duced by  force  applied  directly  to  the  anterior  portion  of  the  clavicle,  near 
the  sternal  extremity,  or  indirectly  by  force  received  ujion  the  posterior 
and  outer  aspects  of  the  shoulder ;  the  displaced  end  of  the  clavicle  may 
occupy  a  position  below  and  behind  the  top  of  the  sternum  or  slightly  above 
it.  Symptoms. — A  prominence  may  be  felt  just  behind  or  above  the  top 
of  the  sternum ;  the  shoulder  drops  forward  and  inward,  and  there  is  a 
depression  where  the  head  of  the  clavicle  should  be,  and  the  displaced  bone 
may  press  upon  the  trachea  or  oesophagus  and  cause  dyspnoea  or  dysphagia  ; 
in  sixteen  cases  Polaillon  found  dyspnoea  in  six  cases  and  dysphagia  in 
three.  Treatment. — Reduction  is  effected  by  standing  behind  the  patient 
and  drawing  the  shoulders  upward  and  backward,  and  ijressing  with  the 
fingers  upon  the  head  of  the  bone,  when  the  bone  will  slip  forward  into  its 
normal  position.  After  the  deformity  has  been  reduced,  the  patient  should 
be  placed  in  bed  upon  a  firm  mattress ;  if,  however,  the  patient  cannot  stay 
in  bed,  it  is  well  to  apply  a  compress  and  a  posterior  figure-of-eight  bandage 
to  the  shoulders,  to  draw  them  backward  so  as  to  prevent  recurrence  of  the 
displacement.     The  dressings  should  be  retained  fi-om  six  to  eight  weeks. 


572 


DISLOCATIONS   OF  THE  CLAVICLE. 


Upward  dislocation  of  the  sternal  end  of  the  clavicle. 
(Agnew.) 


Dislocation  Upward. — This  dislocation  is  a  very  rare  one,  and  usually 
results  from  indirect  force  applied  to  the  shoulder  or  the  acromial  end  of  the 
clavicle.  Symptoms. — These  are  a  prominence  above  the  top  of  the 
sternum  (Fig.  489),  depression  of  the  shoulder,  pain,  and  tenseness  of  the 
sternal  origin  of  the  sterno-cleido-mastoid  muscle,  which  is  stretched  over 

the  end  of  the  displaced  bone. 
Treatment. — In  reducing  this 
displacement  the  arm  should  be 
drawn  upward  and  outward, 
while  the  head  of  the  clavicle  is 
pressed  downward  into  its  artic- 
ular cavity.  A  compress  should 
be  applied  over  the  seat  of  injury 
and  fastened  in  position  by  a 
roller  bandage  or  by  adhesive 
straps,  and  the  arm  immobilized. 
If  it  is  found  impossible  to  main- 
tain the  reduction,  the  displaced 
bone  should  be  exposed  by  inci- 
sion aud  secured  in  its  normal 
position  by  silver  wire  sutures. 
Dislocations  of  the  Acromial  End  of  the  Clavicle. — These  are 
sometimes  described  as  dislocations  of  the  scapula.  They  are  of  three  varie- 
ties,— one  in  which  the  end  of  the  clavicle  is  displaced  upward  from  the 
acromion  process  ;  another  in  which  the  end  of  the  clavicle  is  below  the 
acromion  process  ;  and  one  in  which  the  clavicle  takes  a  position  below  the 
acromion  and  coracoid  processes.  The  first  variety  is  that  most  fi-eciuently 
seen,  constituting  from  three  to  six  per  cent,  of  all  dislocations.  Dislocations 
of  the  acromial  end  usually  result  from  force  applied  to  the  clavicle  or  to 
the  acromion  process. 

Dislocation  Upward. — This  is  marked  by  a  projection  above  the 
acromion  process,  dro^jping  of  the  shoulder,  and  more  or  less  disability  of 
the  arm.  Examination  with  the  fingers  will  reveal  the  displaced  acromial 
end  above  the  acromion  process.  (Fig.  490.)  Treatment. — The  reduction 
of  this  displacement  is  usually  not  a  matter  of  difficulty,  and  is  accom- 
plished by  pushing  the  head  of  the  humerus  upward,  at  the  same  time 
making  downward  or  slightly  lateral  pressure  upon  the  displaced  acromial 
end  of  the  clavicle.  Although  the  reduction  can  be  accomplished  with  ease, 
the  greatest  difficulty  is  often  experienced  in  maintaining  it.  A  very  satis- 
factory method  of  retaining  the  end  of  the  bone  in  place  has  been  recommended 
by  Stimson,  consisting  in  applying  a  long  strif)  of  adhesive  plaster  three  inches 
wide,  the  centre  being  placed  over  the  flexed  elbow  and  its  ends  carried  up  in 
front  of  and  behind  the  arm,  crossing  over  the  end  of  the  clavicle  and  being 
secured  on  the  front  and  back  of  the  chest  respectively,  while  the  bone  is 
held  in  place  by  pressure  upon  the  clavicle  and  the  elbow.  For  additional 
security  the  forearm  may  be  su^jported  in  a  sling  and  the  arm  bound  to  the 
side  of  the  chest.  (Fig.  491.)  In  this  dislocation,  wiring  the  displaced 
end  of  the  bone  in  place  has  been  practised.     We  therefore  think  it  is  well 


DISLOCATIONS  OF  THE  CLAVICLE. 


573 


in  persistent  cases  of  this  dislocation  to  cut  down  upon  and  expose  the  dis- 
placed bone  and  secure  it  in  its  normal  position  by  heavy  wire  sutures. 
Fig.  490.  Fig.  491. 


Deformitj  m  upward  dislocation  of  the  acromial  end  of 
the  clavicle.    (After  Agnew.) 


Stimson  b  dre'^bing  for  upward  dislocation  of 
the  acromial  end  of  the  clavicle. 


Dislocation  Downward. — This  is  a  comparatively  rare  accident,  the 
acromial  end  of  the  clavicle  passing  below  the  acromion  and  coracoid  pro- 
cesses. The  acromion  process  is  abnormally  prominent,  and  a  groove  or 
gutter  can  be  felt  along  its  inner  border  ;  more  or  less  disability  of  the  arm 
is  present,  and  the  displaced  end  of  the  clavicle  may  be  felt  under  the  acro- 
mion process.  Treatment. — This  displacement  is  reduced  by  manipula- 
tion, the  bone  being  fixed  in  place  after  reduction  by  the  application  of  a 
compress  and  adhesive  straps  or  by  wire  sutures,  and  by  securing  the  arm 
to  the  side  by  a  Velpeau's  bandage. 

Subcoracoid  Dislocation  of  the  Clavicle. — This  displacement  is 
extremely  rare,  but  a  few  cases  have  been  reported.  It  is  said  to  result 
from  the  shoulder  being  forced  uj)ward,  outward,  and  backward,  while  at 
the  same  time  the  acromial  end  of  the  clavicle  is  driven  downward.  Treat- 
ment.— This  consists  in  reducing  the  displacement  by  manipulation  and 
applying  a  similar  dressing  to  that  used  in  downward  dislocation  of  the 
acromial  end  of  the  clavicle. 

Sirnultaneous  Dislocation  of  Both  Ends  of  the  Clavicle. — This 
very  unusual  dislocation  has  occasionally  been  observed,  and  is  the  result 
of  extreme  violence,  in  which  the  shoulder  is  pressed  inward,  the  sternal 
end  being  usually  dislocated  forward  and  the  acromial  end  upward.  Treat- 
ment.— This  is  similar  to  that  employed  in  single  dislocation  of  the  clavicle. 
The  dressings  should  be  retained  for  sis  or  eight  weeks.  The  results  follow- 
ing the  reduction  of  simultaneous  dislocation  of  both  ends  of  the  clavicle 
have  been  quite  satisfactory. 

Dislocation  of  the  Inferior  Angle  of  the  Scapula. — This  dislo- 
cation occurs  when  the  latissimus  dorsi  muscle,  which  passes  over  the  lower 
angle  of  the  scapula,  slips  beneath  the  lower  extremity  of  the  bone.  The 
accident  occasionally  occurs  in  children  from  lifting  them  by  one  arm,  or 


574 


DISLOCATIONS   OF  THE  SHOULDER-JOINT. 


may  result  from  paralysis  of  the  serratns  magnus  muscle.  There  is  a  marked 
projection  of  the  lower  angle  of  the  scaj)ula,  which  increases  when  the  arm 
is  drawn  forward ;  i)aiu  and  disability  of  the  arm  may  also  be  present.. 
Treatment. — To  reduce  this  displacement  the  muscle  should  be  relaxed  by 
carrying  the  arm  well  backward,  and  when  in  this  position  manipulation 
with  the  fingers  should  be  made  to  replace  the  muscle.  It  may  be  found 
impossible  to  reduce  the  deformity  in  some  cases. 

Dislocations  of  the  Shoulder-Joint. — Dislocation  of  this  joint 
occurs  more  frequently  than  of  any  other  joint  in  the  body,  forming  a  little 
over  fifty  per  cent,  of  all  dislocations.  This  fact  is  due  to  the  great  extent 
of  movement  permitted  by  the  scapulo-humeral  articulation,  the  shape  of 
the  glenoid  cavity,  and  the  great  leverage  due  to  the  length  of  the  upper 
extremity.  It  may  result  from  indirect  violence,  such  as  falls  upon  the  elbow 
or  hand,  or  from  direct  violence,  as  a  severe  blow  upon  the  anterior  or 
posterior  part  of  the  shoulder,  or  from  muscular  action. 

Varieties. — The  most  frequent  dislocations  of  the  shoulder-joint  are 
(1)  dislocation  of  the  head  of  the  bone  downward  and  slightly  inward,  sub- 
glenoid;  (2)  forward,  suhcoracoid ;  (3)  suhclavicidar ;  (4)  backward  on  the 
dorsum  of  the  scapula,  subsjyinous.  Anomalous  dislocations  occasionally 
occur,  either  from  force  acting  in  a  particular  way  or  aj)plied  after  one  of 
the  ordinary  dislocations  has  occurred.  Among  the  anomalous  dislocations 
may  be  mentioned  the  vertical  dislocation  of  the  arm  above  the  head,  luxatio 
erecta  and  the  siipracoracoid. 

Subglenoid  Dislocation. — In 
this  dislocation,  which  is  comiiara- 
tively  rare,  the  capsular  ligament 
is  torn  on  its  lower  and  inner  por- 
tion, and  the  head  of  the  humerus 
slips  through  it  and  takes  a  position 


Fig.  492. 


Fig.  49?,. 


^ 


Subglenoid  di=;loeation  of  the  humeius  _  (  Vfter 
AgneA\.) 


ity  ill  a  recent  subglenoid  dislocation  of  the 
humerus. 


on  the  anterior  border  of  the  scapula  immediately  below  the  glenoid  cavity. 
(Fig.  492. )  The  head  of  the  bone  rests  between  the  tendon  of  the  triceps 
and  subscapularis,  which  may  be  more  or  less  lacerated.  The  axillary  blood- 
vessels and  nerves  may  suffer  more  or  less  from  pressure,  and  the  muscles 


DISLOCATIONS  OF  THE  SHOITLDER-JOINT. 


575 


surrounding  the  articnlatiou  also  may  be  injured.  It  is  not  unusual  in  this 
dislocation  for  the  deltoid  muscle  to  be  paralyzed  from  damage  done  to  the 
circumflex  nerve.  The  deformity  is  well  shown  in  Fig.  493.  It  may  follow 
a  fall  or  a  blow  upon  the  anterior  surface  of  the  shoulder,  or  force  which  drags 
the  arm  over  the  head,  or  result  from  violent  muscular  contraction . 

Subcoracoid  Dislocation. — In  this  dislocation,  which  is  the  most 
common  of  tlie  shoulder  dislocations,  the  capsular  ligament  is  lacerated  at 
its  inner  and  lower  portion  and  the  head  of  the  bone  takes  a  position  upon 
the  lower  border  of  the  subscapularis,  which  is  usually  somewhat  torn,  and 
upon  the  inner  surface  of  the 

neck  of  the  scapula  below  the  Fig.  495. 

coracoid  process.  The  fre- 
ciuency  of  this  dislocation  is 
probably  due  to  the  fact  that 
many   subglenoid    dislocations 


Subcoracoid  dislocation  of  the  humerus. 
(After  Agnew.) 


Deformity  in  a  recent  subcoracoid  dislocation  of  the 
humerus. 


are  converted  into  this  variety  by  muscular  contraction.  (Fig.  494.)  The 
deformity  in  this  dislocation  is  shown  in  Fig.  495. 

Subclavicular  Dislocation. — Here  the  head  of  the  bone  rests  upon 
the  side  of  the  chest  below  the  clavicle  (^Fig.  496),  and  is  covered  by  the 
pectoralis  major  aud  minor  muscles  ;  the  capsule  is  usually  extensively  toru, 
as  well  as  the  subscapularis,  and  thei'e  is  sometimes  avulsion  of  the  greater 
tuberosity  of  the  humerus.  The  supraspinatus  and  infraspinatus  muscles 
aud  the  portion  of  the  deltoid  which  arises  from  the  acromion  j)rocess  of  the 
spine  of  the  scapula,  with  the  inner  fibres  of  the  coraco-brachialis  muscle 
and  the  short  and  long  head  of  the  biceps,  are  put  uj)on  the  stretch.  The 
axillary  vessels  and  nerves  are  often  se^'erely  pressed  uj)on. 

Subglenoid,  subcoracoid,  and  subclavicular  dislocations  may  arise  from 
any  force  which  carries  the  arm  violently  backward  and  u^award,  pressing  the 
head  of  the  humerus  against  the  acromion,  rupturing  the  inner  part  of  the 
capsular  ligament.  In  some  cases  the  capsule  is  not  torn,  in  others  the  edge 
of  the  glenoid  cavity  may  be  broken  off.  The  humerus  will  strike  the  acro- 
mion when  the  arm  is  at  ninety  degrees  or  less  with  the  body.  These  dislo- 
cations also  result  from  blows  or  falls  upon  the  outer  surface  of  the  shoulder. 


576 


DISLOCATIONS  OF  THE  SHOULDER-JOINT. 


Fig.  496. 


Subclavicular  dislocation  of  the 
humerus.    (After  Agnew.) 


Symptoms. — The  signs  of  dislocation  of  the  head  of  the  humerus  which 
are  common  to  these  varieties  are  an  alteration  in  the  shape  of  the  shoulder  ; 
the  rotundity  of  the  shoulder  disappears,  and 
it  becomes  flattened ;  the  acromion  process  be- 
comes abnormally  prominent,  and  beneath  this 
is  a  marked  depression  in  which  the  fingers  cau 
readily  be  sunk.  The  axillary  fold  is  lower  and 
more  marked  than  on  the  sound  side.  The  elbow 
stands  off  from  the  body,  and  it  will  be  found 
impossible  to  place  the  hand  of  the  injured  limb 
upon  the  shoulder  of  the  sound  side  and  bring 
the  arm  against  the  chest.  This  is  the  test  jjointed 
out  by  Dugas,  and  we  consider  it  a  most  valuable 
one.  There  is  also  marked  restriction  of  the 
movements  of  the  shoulder-joint,  and  the  dis- 
placed head  of  the  bone  can  be  located  by  the 
fingers.  Pain  is  more  marked  in  some  varieties 
of  shoulder  dislocation  than  in  others,  and  is  often 
accompanied  by  numbness  of  the  fingers  in  con- 
sequence of  pressure  upon  the  axillary  nerves. 
Diagnosis. — The  diagnosis  of  dislocation  of  the  head  of  the  humerus  is 
not  difficult  if  the  patient  is  seen  soon  after  the  injury  ;  if,  however,  much 
swelling  has  occurred,  it  is  in  many  cases  made  with  difficalty.  Therefore 
in  obscui'e  cases  it  is  wise  to  administer  an  anaesthetic  and  make  a  care- 
ful and  methodical  examination  of  the  joint  to  determine  the  presence  of 
dislocation  or  of  fracture  of  the  neck  of  the  humerus,  or  to  demonstrate 
the  association  of  these  two  injuries.  In  a  case  of  injury  of  the  shoulder- 
joint,  in  which  the  arm  rests  against  the  side  of  the  body  and  can  be  moved 
freely,  if  Dugas' s  test  can  also  be  made,  and  if  the  fingers  cannot  be  thrust 
into  the  space  beneath  the  acromion  process,  the  possibility  of  dislocation  can 
be  dismissed.  Dislocation  of  the  head  of  the  humerus  may  be  confounded 
with  fracture  of  the  neck  of  the  humerus,  of  the  neck  of  the  scapula,  or 
of  the  acromion.  In  all  these  cases  there  will  be  preternatural  mobility, 
crepitus,  and  ease  of  reduction,  with  a  tendency  to  a  recurrence  of  the 
deformity  as  soon  as  the  limb  is  released  from  the  reducing  force.  In  dislo- 
cation the  acromion  stands  out  prominently,  the  shoulder  is  flattened,  the 
arm  stands  out  from  the  side  of  the  body,  the  fingers  can  be  thrust  in  a  space 
under  the  acromion,  the  head  of  the  bone  can  usually  be  felt  in  an  abnormal 
position,  and  there  is  pronounced  rigidity  of  the  arm.  Fractures  of  the 
surgical  neck  of  the  humerus  or  sej^aration  of  the  uiJi^er  epiphysis  may  pre- 
sent a  prominence  in  front  of  the  shoulder,  but  the  change  in  the  shape  of 
the  shoulder,  the  position  of  the  arm,  and  the  mobility  are  entirely  differ- 
ent from  that  observed  in  cases  of  dislocation. 

Treatment. — The  principal  methods  practised  in  the  reduction  of  dislo- 
cations of  the  head  of  the  humerus  are  manipulation,  and  extension  and 
counterextension. 

Reduction  by  Manipulation. — This  consists  in  placing  the  arm  in  such 
a  position  that  the  muscles  inserted  into  the  upper  extremity  of  the  humerus 


DISLOCATIONS   OF  THE  SHOULDER. 


577 


which  are  rendered  tense  by  the  displacement  will  be  relaxed,  and  the  head 
of  the  bone  will  be  moved  into  its  normal  position.  Eeduction  of  many 
dislocations  of  the  head  of  the  humerus  may  be  accomplished  without  the 
use  of  an  anaesthetic,  but  the  manipulations  are  painful,  and  the  muscular 
resistance  is  often  so  marked  that  it  is  wise  to  administer  an  auEesthetic. 
In  reducing  a  dislocation  of  the  humerus  by  manipulation,  the  patient 
should  be  placed  in  the  recum- 
bent position  and  auiDesthetized,  F'°-  "^^T. 
and  the  forearm  flexed  upon  the 
arm,  to  relax  the  long  head  of  the 
biceps  muscle ;  the  arm  is  next 
grasped  at  the  elbow  and  ab- 
ducted, lifting  fi-om  the  glenoid 
cavity  the  untorn  superior  and 
posterior  portions  of  the  capsule 
which  are  drawn  over  it.  Exter- 
nal rotation  is  made  at  the  same 
time,  which  tends  to  open  a  longi- 
tudinal rent  in  the  capsule.  The 
surgeon  should  next  place  the 
fingers  of  the  other  hand  upon  the 
head  of  the  humerus,  which  can  be  felt  under  the  skin  in  the  axilla,  and  as 
the  arm  is  drawn  outward  and  brought  to  the  side  of  the  chest  the  head 
of  the  bone  slips  into  its  socket. 

Kocher's  Method. — In  reducing  a  dislocation  of  the  head  of  the  hume- 
rus by  this  method  the  elbow  is  flexed  at  a  right  augie  and  pressed  closely 
against  the  side  ;  the  forearm  is  then  ^ 

turned  as  far  as  possible  away  froiu  the 
Fig  49'i 


Kocher's  method  of  reducing  dislocation  of  the  shoulder : 
first  manipulation. 


Second  manipulation  in  Kocher's  method. 


Third  manipulation  in  Kocher's  method. 


trunk,  causing  external  rotation  of  the  arm.  (Pig.  497.)  If  the  head  of 
the  humerus  does  not  roll  outward  in  front  of  and  below  the  acromion  during 
this  manipulation,  the  attempt  will  fail.  While  the  external  rotation  is 
maintained  the  elbow  should  be  carried  well  forward  and  upward  (Fig.  -198)  ; 
the  arm  should  next  be  rotated  inward,  and  the  elbow  lowered.     (Fig.  499.) 

37 


578 


TREATMENT  OE  DISLOCATIONS   OF  THE  SHOULDER. 


Motlie's  method  of  reduction  of  dislocation  of  tlie  humerus. 


Sometimes  it  may  be  of  use  to  have  an  assistant  press  the  head  outward  with 
the  fingers  or  by  a  band  in  the  axilla  during  the  latter  manipulation.  This 
method  may  fail  when  the  capsule  is  badly  torn,  but  in  such  cases  reduction 
can  usually  be  accomijlished  by  some  of  the  other  methods. 

Reduction  by  Extension  and  Counterextension.— The  reduction 
by  extension  and  counterextension  consists  in  making  counterexteusiou  by 

placing  the  heel  in  the  axilla, 
^ici-  500.  or,  better,  upon  the  side  of 

the  chest  near  the  axilla,  and 
while  traction  is  made  upon 
the  arm  downward  from  the 
arm  or  the  forearm  by  the 
hands  at  an  angle  of  forty-five 
degrees,  it  is  gradually  SAvung 
to  the  side.  This  method  is 
not  without  danger  from  in- 
jury of  the  axillary  vessels 
and  nerves. 

Mothe's  Method.— This 
method  of  extension  and  coun- 
terextension is  also  used  in 
the  I'eduction  of  dislocations  of  the  head  of  the  humerus.  The  patient  being 
in  the  recumbent  position,  the  surgeon  takes  liold  of  the  arm  on  the  injured 
side  above  the  elbow  with  one  hand,  and  places  the  other  hand  upon  the 
top  of  the  shoulder  in  order  to  fix  the  scapula,  making  strong  traction  upon 
the  arm.  (Fig.  500.)  With  this  manipulation  the  head  of  the  bone  may 
be  slipped  into  its  socket. 

Traction  Method. — Stimson  has  recently  emjiloyed  with  success  a 
method  of  reduction  of  dislocations  of  the  shoulder  which  consists  in  jilacing 
the  patient  upon  his  side  upon  an  elevated  can- 
vas cot  which  contains  a  perforation  about  six 
inches  in  diameter,  through  which  the  injured 
arm  is  allowed  to  pass  and  hang  vertically.  A 
weight  of  ten  pounds  is  attached  to  the  wrist  or 
elbow,  and  in  a  few  minutes — not  over  six,  ac- 
cording to  Stimson — the  reduction  takes  place 
quietly  and  without  pain. 

Subspinous  Dislocation. — In  this  rare  dis- 
location the  head  of  the  humerus  rests  on  the 
dorsum  of  the  scapula  behind  the  glenoid  cavity 
and  immediately  below  the  spine  of  the  scajjula. 
(Pig.  501. )  The  head  of  the  bone  rarely  passes 
backward ;  posterior  displacement  was  found 
only  in  five  cases  in  two  hundred  dislocations  of 
the  shoulder. 

This  dislocation  is  produced  by  force  applied  to  the  anterior  surface  of  the 
shoulder,  or  by  internal  rotation  of  the  arm.  The  head  of  the  bone  may  pass 
between  the  infraspinatus  and  teres  minor,  or  directly  through  the  latter. 


Subspinous  dislocation  of  the 
humerus.    (Agnew.) 


DISLOCATIONS   OF  THE  SHOULDER. 


579 


Symptoms. — The  shoulder  is  broadened  and  fuller  posteriorly,  the  arm 
is  nearer  to  the  side  than  in  anterior  dislocation  and  is  rotated  inward,  the 
coracoid  process  is  more  prominent,  and  the  anterior  jjortion  of  the  shoulder 
is  flattened. 

Treatment. —Eeduction  is  accomplished  by  traction,  gentle  rotatory 
movements,  and  pressure  upon  the  head  of  the  bone. 

Luxatio  Erecta. — Among  the  rare  dislocations  of  the  head  of  the 
humerus  is  that  known  as  luxatio  erecta.     (Pig.  502. )    In  this  dislocation 


Fig.  50.3 


Luxatio  erecta. 


Supracoracoid  dislocation,     (namilton.) 


the  arm  is  held  vertically,  the  forearm  resting  on  the  top  of  the  head  and 
being  held  there  by  the  patient  to  escape  the  jjain  caused  by  lowering  it. 
The  head  of  the  bone  is  generally  at  the  same  point  as  in  the  subglenoid  or 
subcoracoid  dislocations,  but  the  shaft  points  upward  instead  of  downward  ; 
it  can  often  be  easily  converted  into  the  other  varieties  by  simj)ly  lowering 
the  elbow.  There  is  also  a  variety  in  wliich  the  arm  is  fixed  in  abduction  at 
ninety  degrees  from  the  body. 

Treatment. — The  reduction  of  this  dislocation  can  usually  be  accom- 
plished by  traction  uijward  without  changing  the  position  of  the  limb  until 
the  head  of  the  bone  has  been  drawn  into  the  glenoid  cavity. 

Supracoracoid  Dislocation. — A  few  cases  of  dislocation  of  the  head 
of  the  humerus  have  occurred  in  which  the  bone  occupied  a  position  above 
the  coracoid  process.  The  head  of  the  humerus  lies  in  the  interval  between 
the  acromion  and  coracoid  processes,  in  front  of  the  clavicle  and  usually 
above  its  level.  (Fig.  503.)  The  arm  occupies  a  position  by  the  side  of 
the  body,  and  is  directed  rather  backward.  Eeduction  is  effected  by  traction 
ujjon  the  arm  and  bj^  elevation  of  the  elbow. 

Subluxation  of  the  Head  of  the  Humerus.— A  condition  described 
as  subluxation  of  the  head  of  the  humerus  is  one  which  is  distinguished  by 
a  depression  beneath  the  acromion  upon  the  posterior  aspect  of  the  joint, 
and  a  well-rounded  prominence  formed  by  the  head  of  the  humerus  lying  in 
contact  with  the  coracoid  process.     This  injury  should  rather  be  described 


580  COMPLICATIONS  OF  DISLOCATIONS  OF  THE  HUMERUS. 

as  a  rupture  of  the  long  tendon  of  the  biceps  muscle,  in  consequence  of  which 
the  supraspinatus  muscle  draws  the  bone  out  of  its  normal  position. 

After-Treatment. — After  reduction  of  dislocations  of  the  shoulder,  the 
arm  should  be  fixed  against  the  side  of  the  body  and  the  forearm  carried  in 
a  sling  for  a  week  or  ten  days,  or  a  Velpeau's  bandage  maybe  applied.  At 
the  expiration  of  ten  days  the  dressings  should  be  removed  and  the  patient 
should  carry  the  arm  in  a  sling,  and  be  encouraged  to  use  it,  being  careful 
not  to  make  any  violent  motions  of  the  shoulder-joint. 

Complications  of  Dislocations  of  the  Humerus.— Old  Dis- 
locations of  the  Humerus. — Old  dislocations  of  the  humerus  have  been 
reduced  after  mouths  or  even  years,  but,  as  a  rule,  the  older  the  disloca- 
tion the  greater  the  difficulty  in  its  reduction,  and  the  manipulations  may 
be  accompanied  by  risk  of  injurj^  to  the  axillary  vessels ;  this  is  particu- 
larly the  case  if  marked  inflammatory  action  followed  the  original  displace- 
ment of  the  bone,  and  if  adhesions  are  present  between  the  head  of  the 
bone  and  the  vessels  in  the  axilla.  If  a  patient  has  had  the  head  of  the 
humerus  out  for  several  years,  does  not  suffer  from  pain,  and  has  regained 
a  certain  amount  of  motion  of  the  arm  from  the  formation  of  a  new  articu- 
lation, it  would  be  unwise  to  make  attempts  to  replace  it.  If  pain  and 
disability  are  marked,  excisiou  of  the  head  of  the  bone  may  be  practised 
with  good  results. 

In  unreduced  dislocations  of  recent  occurrence  attempts  should  always 
be  made  to  replace  the  bone.  To  accomplish  reduction  the  patient  should 
be  thoroughly  ansesthetized,  and  the  surgeon  should  seize  the  arm  at  the 
elbow  and  first  rotate  the  head  of  the  bone  freely  to  break  up  any  adhesions 
which  may  exist.  After  the  surgeon  is  assured  that  the  adhesions  have  been 
thoroughly  separated,  he  should  endeavor  to  reduce  the  dislocation  by 
manipulation  or  by  Kocher's  method.  If  these  fail,  he  should  next  try 
some  of  the  various  methods  by  extension  and  counterextension.  The 
principal  risks  in  the  reduction  of  old  dislocations  of  the  humerus  are 
rupture  of  the  axillary  artery  or  vein,  injury  of  the  brachial  plexus  of 
nerves,  and  fracture  of  the  neck  or  shaft  of  the  humerus. 

Rupture  of  the  Axillary  Artery. — This  accident  has  occurred  during 
the  reduction  of  old  dislocations  of  the  humerus.  The  signs  which  indicate 
this  accident  are  a  rapidly  developed  swelling  in  the  axilla  and  under  the 
j)ectoral  muscles,  absence  of  the  pulse  at  the  wrist,  pallor  of  the  face,  and 
in  some  instances  syncope.  In  such  a  case  pressure  should  be  applied  to 
the  subclavian  vessel,  and  the  axillary  artery  should  be  cut  dowii  upon  and 
secured  by  ligatures  apj)lied  on  each  side  of  the  ruptm-e.  Rupture  of  the 
Axillary  Vein. — This  accident  has  also  occurred  during  attempts  to  reduce 
old  dislocations  of  the  humerus.  It  is  to  be  distinguished  from  rupture  of 
the  axillary  artery  by  the  facts  that  the  patient  does  not  exibit  the  consti- 
tutional sj' mptoms  of  loss  of  blood  in  so  marked  a  degree  as  in  cases  of 
rupture  of  the  artery,  and  that  the  radial  pulse  is  present.  If  this  accident 
occurs  during  manipulation,  a  compress  should  be  placed  in  the  axilla  and 
the  ai-m  bound  firmly  to  the  side  ;  it  is  not  unusual,  although  a  large  amount 
of  blood  may  have  escaped,  to  have  the  hemorrhage  thus  controlled,  and 
for  the  patient  to  go  on  to  recovery.     If  this  fails,  the  vein  should  be  ligated. 


COMPOUND  DISLOCATION   OF  THE  HUMERUS.  581 

Injury  of  Nerves. — The  brachial  plexus  of  nerves  may  be  damaged  iu 
forcible  attempts  to  reduce  old  dislocations  of  the  humerus,  the  injury 
being  followed  by  paralysis  of  the  arm.  Fracture. — Fracture  of  the  neck 
or  shaft  of  the  humerus  has  occurred  iu  the  manipulations  practised  to 
reduce  old  dislocations  of  the  humerus.  If  fracture  occurs  high  np  in  the 
bone,  no  further  attempts  can  be  made  to  restore  the  dislocation,  and  the 
patient  should  be  encouraged  to  use  the  arm,  to  favor  the  formation  of  a 
false  joint  at  the  seat  of  fracture. 

Dislocation  of  the  Humerus  with  Fracture  of  the  Neck  of  the 
Humerus. — These  two  accidents  may  result  from  the  application  of  the 
same  force.  The  diagnosis  of  this  injury  can  usually  be  made  by  discov- 
ering that  the  head  of  the  bone  occupies  an  abnormal  position  and  is  not 
affected  by  movements  of  the  arm  ;  crepitus  may  also  be  elicited.  The 
deformity  of  the  shoulder  is  that  of  dislocation,  but  the  arm  is  movable  and 
the  elbow  can  be  brought  into  contact  with  the  chest. 

Treatment. — The  patient  should  be  antesthetized,  and  the  head  of  the 
bone  pressed  back  into  the  glenoid  cavity  with  the  fingers,  if  possible,  after 
which  the  fracture  should  be  dressed  in  the  manner  described  for  the  treat; 
ment  of  fractures  of  the  surgical  neck  of  the  humerus.  If  it  is  found 
imx)ossible  to  reduce  the  displaced  head  of  the  bone,  it  should  be  exposed  by 
incision,  the  capsule  freely  incised,  and  after  reduction  of  the  head  of  the 
bone  the  fragments  wired.  If  this  is  not  possible,  excision  of  the  head  of 
the  bone  should  be  practised. 

Compound  Dislocation  of  the  Humerus. — In  this  variety  of 
dislocation,  if  the  vessels  remain  uninjured,  the  skin  and  the  exposed  head 
of  the  bone  should  be  thoroughly  sterilized,  the  bone  reduced,  and  the 
wound  closed.  If  the  head  of  the  bone,  however,  has  been  fractured,  it  is 
safer  to  excise  it  before  attem^jting  reduction.  In  cases  of  compound  dislo- 
cation of  the  head  of  the  humerus  complicated  with  laceration  of  the 
axillary  artery,  amputation  at  the  shoulder-joint  would  probably  be  required, 
although  even  here  conservative  treatment  might  be  attempted,  the  vessel 
being  tied  and  the  dislocated  bone  replaced. 

Simultaneous  Dislocation  of  the  Heads  of  both  Humeri. — This 
injury  is  occasionally  seen,  and  has  resulted  from  falling  ujjon  the  hands 
when  the  arms  were  outstretched.  The  reduction  is  accomj)lished  in  the 
same  manner  as  in  single  dislocations. 

Congenital  Dislocations  of  the  Humerus. — These  have  occasionally 
been  met  with  in  association  with  malformations  of  other  joints.  The 
variety  of  dislocation  is  either  subcoracoid  or  subspinous.  Iu  congenital 
dislocations  of  the  humerus  the  upper  arm  is  usually  very  markedly  atro- 
phied, while  the  forearm  retains  its  natural  size.  These  dislocations  have 
not  furnished  very  satisfactory  results  as  regards  treatment.  One  case  has 
been  reported  in  which  the  humerus  was  permanently  restored  to  its  articu- 
lating cavity  after  repeated  manipulations.  Erb's  i^aralysis  has  sometimes 
been  mistaken  for  this  dislocation. 

Dislocations  of  the  Bones  of  the  Forearm.— Dislocations  of 
the  bones  of  the  forearm  are  most  common  during  early  life,  probably 
because  of  the  tendency  to  hyperextension  of  the  elbow  iu  children,  and 


582  DISLOCATIONS   OF  THE  BONES   OF  THE   FOEEAEM. 

present  a  number  of  different  displacements :  (1)  tbe  head  of  the  radius 
may  be  dislocated  from  the  humerus  ;  (2)  the  ulna  may  be  dislocated  from 
the  humerus  ;  (3)  both  radius  and  ulna  may  be  dislocated  from  the  humerus ; 
(4)  the  inferior  extremity  of  the  ulna  may  be  dislocated  from  the  radius. 

Radio-Humeral  Dislocations. — The  head  of  the  radius  may  be 
detached  from  the  sigmoid  cavity  of  the  ulna,  and  be  displaced  forward, 
backward,  or  outward.  In  these  dislocations  the  lateral  and  annular  liga- 
ments are  torn,  and  the  head  of  the  bone  rests  in  front  of,  behind,  or  external 
to  the  external  condyle  of  the  humerus.  Displacement  of  the  head  of  the 
radius  is  a  frequent  accident,  and  is  often  overlooked. 

Forward  Dislocation  of  the  Head  of  the  Radius. — This  is  the 
most  common  dislocation  of  the  head  of  the  radius,  and  is  usually  j^roduced 

by  a  fall  upon   the  hand 
^^'^-  ^'^'^-  while  the  latter  is  in  a  state 

of  j)ronation,    or   by  force 
,  applied  to  the  side  of  the 

elbow.  Forced  pronation 
will  throw  the  radius 
against  the  ulna  as  a  ful- 
crum and  force  the  head  of 
the  bone  out  anteriorly, 
tearing  the  anterior  portion 

Forward  dislocation  of  the  head  of  the  radius.  (After  Agnew.)  *-'-'■  ^"^^  CapSUle.  Symp- 
toms.— The  radial  side  of 
the  forearm  is  shortened  and  inclined  outward,  and  a  depression  exists 
immediately  below  the  external  condyle  of  the  humerus.  The  head  of  the 
radius  can  be  felt  in  front  of  the  elbow,  and  may  be  recognized  by  placing 
the  thumb  upon  it  and  pronating  and  suijinating  the  forearm.  (Fig.  504. ) 
The  biceps  muscle  is  relaxed,  the  forearm  cannot  be  thoroughly  extended, 
and  flexion  beyond  ninety  degrees  is  interfered  with  by  the  displaced  head 
of  the  bone  being  arrested  against  the  lower  portion  of  the  humerus. 

Treatment. — To  reduce  this  dislocation  the  forearm  should  be  flexed 
upon  the  arm,  to  relax  the  biceps  muscle,  extension  being  made  from  the 
hand  and  counterextension  from  the  arm ;  the  surgeon  then  presses  the 
head  of  the  bone  downward,  backward,  and  outward  towards  the  lesser 
sigmoid  cavity  of  the  ulna,  and  at  the  same  time  pronates  the  hand,  and 
follows  this  by  supination.  The  displacement  can  usually  be  reduced  with- 
out much  difficulty,  but  in  some  cases  the  ca^jsule  hinders  reduction  and  the 
displacement  is  often  reproduced  upon  making  flexion  or  extension  of  the 
arm.  After  reduction  the  arm  should  be  secured  in  the  flexed  position  by 
the  apijlication  of  a  M'ell-padded  anterior  angular  splint,  with  the  addition 
of  a  compress  over  the  anterior  surface  of  the  head  of  the  radius.  This  splint 
should  be  changed  at  intervals  of  two  or  three  days  and  worn  for  two  or  three 
weeks  ;  passive  motion  and  massage  should  be  begun  after  ten  days.  After 
removing  the  splint  the  patient  should  be  cautioned  against  making  violent 
flexion,  pronation,  or  supination  of  the  forearm,  as  it  is  often  a  matter  of 
some  weeks  before  the  repair  of  the  capsular  ligament  is  sufSciently  firm  to 
prevent  the  recurrence  of  the  displacement.     In  unreduced  forward  disloca- 


DISLOCATIONS   OF  THE   HEAD   OF  THE  EADIUS.  583 

tions  of  the  head  of  the  radius  patients  often  regain  very  fair  use  of  the 
arm,  but  have  some  limitation  in  flexion  of  the  forearm  upon  the  arm.  If 
the  displacement  causes  pain  or  interferes  very  decidedly  with  the  use  of 
the  arm,  attempts  should  be  made  to  reduce  it ;  if  this  cannot  be  done,  the 
procedure  which  offers  the  best  result  as  regards  increased  usefulness  of  the 
arm  is  excision  of  the  head  of  the  radius  by  an  anterior  incision  made  over 
the  head  of  the  bone ;  a  section  of  the  bone  being  made  just  above  the 
insertion  of  the  tendon  of  the  biceps  muscle.  We  have  seen  very  satisfac- 
tory results  follow  this  procedure  in  these  cases. 

Backward  Dislocation  of  the  Head  of  the  Radius. — This  is  a  rare 
form  of  dislocation,  in  which  the  head  of  the  radius  escapes  through  the 
posterior  portion  of  the  capsular  ligament  and  rests  behind  the  external 
condyle  of  the  humerus.  (Fig.  505.)  It  may  result  fi-om  force  applied  to 
the  front  of  the  head  of  the  radius,  or 

more  frequently  may  be   caused  by  a  ^''^^  °^^- 

fall  upon  the  hand  when  the  bones  of 
the  forearm  are  in  extreme  pronation 
or  supination.  Symptoms. — The  fore- 
arm is  slightly  flexed,  the  hand  is 
pronated,  supination  is  impossible,  a 
depression  can  be  felt  below  the  external 
condyle  of  the  humerus,  and  the  head 
of  the  radius  can  be  located  behind 
the  condyle  ;  flexion  and  extension  of 

.-,        ~  ^  1      T      •     ■   1      T        Backward  dislocation  rf  tlR  I    id  of  the  radius. 

the  forearm  are  also  much  diminished.  {Aitei  A„in.n.) 

Treatment. — The  forearm  should  be 

flexed,  and  an  assistant  makes  counterextension  from  the  arm  while  the  sur- 
geon makes  extension  from  the  hand,  and  by  supinating  the  forearm  and 
pressing  the  head  of  the  bone  forward  towards  the  articular  cavity  the 
reduction  can  usually  be  accomplished.  After  reduction  the  forearm  and 
arm  should  be  placed  on  an  obtuse-angled  splint,  which  should  be  worn  for 
several  weeks. 

Outward  Dislocation  of  the  Head  of  the  Radius. — This  is  an 
extremely  rare  dislocation  ;  the  head  of  the  bone  rests  upon  the  epicondy- 
loid  ridge.  The  symptoms  are  a  prominence  above  and  in  front  of  the 
external  condyle  of  the  humerus,  flexion  of  the  forearm  in  a  position  between 
jjronation  and  supination,  and  impairment  in  the  movements  of  flexion  and 
extension  of  the  forearm.  Treatment. — This  can  be  accomplished  by 
making  extension  and  counterextension  when  the  arm  is  moderately  flexed, 
at  the  same  time  pressing  the  head  of  the  bone  downward  and  forward.  If 
reduction  cannot  be  accomjjlished  by  manipulation,  excision  of  the  head  of 
the  radius  should  be  practised.  The  limb  should  be  fixed  upon  an  angular 
splint  after  reduction. 

Dislocation  of  the  Ulna  from  the  Humerus. — This  consists  in  a  pos- 
terior displacement  of  the  ulna  upon  the  humerus,  the  radius  maintaining 
its  normal  position,  the  coronoid  process  sliding  backward  to  the  olecranon 
fossa,  or  resting  uj)on  the  posterior  face  of  the  internal  condyle  of  the 
humerus.     The  forearm  swings  inward  around  the  Ions;  axis  of  the  humerus 


584 


DISLOCATIONS  OF  THE  EADIIJS  AA^D  ULNA. 


on  the  head  of  the  radius  agaiust  the  external  condyle  as  a  centre.  The 
treatment  of  this  dislocation  is  similar  to  that  for  dislocation  of  both  bones 
of  the  forearm. 

Dislocation  of  the  Radius  and  Ulna. — This  dislocation  may  take 
place  backward,  for-ward,  outward,  and  inward. 

Backward  Dislocation  of  the  Radius  and  Ulna  at  the  Elbow. — 
This  is  one  of  the  most  common  dislocations  at  the  elbow-joint,  and  results 
from  force  directly  or  indirectly  applied  to  the  hand  and  forearm  ;  it  may 
also  be  produced  by  hyperextension.  The  anterior  and  lateral  ligaments  are 
usually  torn,  the  corouoid  process  of  the  ulna  drops  into  the  olecranon  fossa 
of  the  humerus,  and  the  radius  occupies  the  posterior  siuface  of  the  external 
condyle  ;  the  tendons  of  the  biceps  and  the 
brachialis  anticus  muscles  are  stretched  over  ^^'^-  ^O"- 

the  articiilar  surface  of  the  humerus.    (Fig. 
506.) 

Symptoms. — These  are  shortening  of 
the  forearm,  with  a  marked  prominence  in 
front  of  the  elbow,  caused  by  the  lower  ex- 
tremity of  the  humerus,  and  a  j)rominence 
behind  the  elbow  (Fig.  507),  caused  by  the 


Backward  dislocation  of  tlie  bones  of  the  forearm. 
(Agnew.) 


DeformitT  m  back«  ard  dislocation  of  the 
hones  of  the  forearm. 


olecranon  process  of  the  ulna  ;  the  elbow  is  rigid,  and  flexion  and  extension 
are  difficult. 

Diagnosis. — Posterior  dislocations  at  the  elbow  are  very  frequently  con- 
founded with  fractures  of  the  condyles  of  the  humerus  or  supracondyloid 
fractures  of  the  humerus.  In  dislocation  there  is  rigidity  of  the  elbow, 
with  a  prominence  in  front  of  and  another  behind  the  elbow.  The  relative 
position  of  the  olecranon  process  and  the  two  condyles  of  the  humerus  is 
disturbed  in  dislocation,  but  is  not  in  fracture.  In  fracture  the  olecranon 
process  and  the  external  and  internal  condyles  are  on  the  same  line ;  in 
dislocation  the  olecranon  process  occupies  a  position  posterior  to  the  con- 
dyles. The  posterior  j)rojection  in  dislocation  is  increased  by  flexion  and 
diminished  by  extension,  whereas  in  fracture  the  posterior  projection  is 
diminished  by  flexion  and  increased  by  extension.  In  dislocation  crepitus 
is  absent ;  in  fracture  it  can  be  obtained.  In  fracture  the  deformity  disap- 
pears upon  extension  and  counterextension,  but  reappears  as  soon  as  the 
force  is  removed.  In  dislocation,  when  the  deformity  is  once  reduced  by 
extension  and  counterextension  there  is  no  tendency  to  its  reproduction. 


DISLOCATIONS   OF  THE  EADIUS  AND  ULNA. 


585 


Treatment. — Eeduction  in  recent  cases  is  usnally  very  easy,  especially 
if  muscular  resistance  is  removed  by  the  administration  of  an  ansesthetic. 
It  may  be  accomplished  by  fixing  the  arm  and  bringing  the  forearm  into 
hyperextensiou,  wheu  by  making  traction  and  sudden  flexion  the  bones 
will  slip  into  place.  After  reduction  the  arm  should  be  placed  upon  a  well- 
X^added  anterior  angular  splint,  which  is  retained  for  two  or  three  weeks, 
after  the  first  week  passive  movements  and  massage  being  practised  to 
prevent  stillness  of  the  joint. 

Forward  Dislocation  of  the  Radius  and  Ulna. — This  is  a  rare 
form  of  dislocation,  in  which  the  radius  and  ulna  occupy  a  position  in  front 
of  the  condyles  of  the  humerus.  It  may  exist  in  two  forms  :  the  top  of  the 
olecranon  may  rest  in  front  of  the  trochlea,  or  the  posterior  surface  of  the 
olecranon  may  occupy  this  j)osition.  In  complete  dislocation  of  the  radius 
and  ulna  forward  the  broad  siirface  of  the  humerus  can  be  felt  posteriorly, 
with  the  olecranon  process  and  the  head  of  the  radius  anteriorly. 

Treatment. — This  dislocation  may  be  reduced  by  making  forced  flexion 
of  the  forearm,  and  at  the  same  time  i:)ushing  the  bones  of  the  forearm 
towards  the  elbow. 

Lateral  Dislocations  of  Both  Bones  of  the  Forearm. — These  are 
rare  injuries ;  they  are  with  few  exceptions  incomplete,  and  are  produced 
by  violence  acting  ui^on  the  lower  and  the  upper  arm  in  opposite  directions. 
In  incomplete  outward  dislocation  the 


Fig.  508. 


Fig.  509. 


ulna  is  not  entirely  removed  from  the 
articular  surface  of  the  humerus  ;  the 
radius  may  either  remain  in  contact 
with  the  outer  margin  of  the  radial 
surface  of  the  humerus  or  rest  between 
the  latter  and  the  epicondyloid  emi- 
nence. (Fig.  508.)  When  the  dis- 
location is  more  comjjlete  the  head  of 
the  radius  may  be  entirely  external 
to  the  external  condyle,  while  the 
outer  articular  surface  of  the  humerus 
occupies  the  sigmoid  cavity  of  the 
ulna.  In  inward  dislocation  the  ulna 
rests  upon  the  internal  condyle,  and 
the  head  of  the  radius  may  be  in  the 
great  sigmoid  cavity  or  upon  its  an- 
terior or  posterior  surface.  (Fig.  509.) 
The  ulna  may  also  be  displaced  behind 
the  internal  condyle  of  the  humerus, 
and  the  radius  occuj)y  the  olecranon 
cavity,  forming  a  postero-lateral  dis- 
location. 

Symptoms. — The  arm  is  flexed  and  inclined  inward  or  outward,  the 
internal  or  external  condyle  is  covered  by  the  projection  of  the  olecranon 
process  of  the  ulna  or  the  radius,  the  external  condyle  is  more  j)rominent 
from  the  absence  of  the  head  of  the  radius,  and  the  hand  is  pronated. 


Outward  dislocation  of 
the  bones  of  the  forearm. 
(After  Agnew.) 


Inw  ard  dislocation  of 
the  bones  of  the  fore- 
arm.   (After  Agnew. ) 


586  OLD  DISLOCATIONS   OF  THE  ELBOW. 

Treatment. — Eeduction  of  these  dislocations  is  effected  by  grasping 
the  forearm  with  one  hand  and  the  arm  with  the  other  and  making  exten- 
sion and  counterextension  while  forcing  the  humerus  and  the  bones  of  the 
forearm  in  opposite  directions.  Sometimes  the  sigmoid  caTity  of  the  iilna 
lying  against  the  condyle  can  be  slipped  laterally  over  the  condyle  of  the 
humerus  without  much  flexion  or  extension.  If  there  is  much  difficulty, 
reduction  may  be  accomplished  by  swinging  the  forearm  into  line  with 
the  arm  and  bringing  it  into  a  position  of  hyijerextension. 

Postero-Jateral  dislocations  should  Ije  treated  as  posterior  dislocations,  by 
bending  the  front  of  the  elbow  around  the  knee,  or  by  flexion  and  extension 
conjoined  with  lateral  pressure.  The  after-treatment  of  these  dislocations 
is  similar  to  that  employed  in  posterior  dislocations  of  the  elbow. 

Divergent  Dislocation  of  the  Radius  and  Ulna. — In  this  form  of 
dislocation  the  bones  do  not  accompany  each  other,  but  are  displaced  in 
divergent  directions.  It  is  observed  in  two  forms,  the  antero-posterior,  in 
which  the  ulna  passes  behind  the  humerus  and  the  radius  in  front,  and  the 
transverse,  in  whicli  the  ulna  passes  to  the  inner  side  behind  the  epitrochlea 
and  the  radius  to  the  outer  side.  Treatment. — Traction  in  the  axis  of  the 
forearm,  combined  with  outward  lateral  flexion,  will  usually  reduce  the 
ulna,  and  the  radius  at  the  same  time  can  be  reduced  bj^  pressure  with  the 
thumbs  combined  with  pronation  and  adduction  of  the  forearm. 

Subluxation  of  the  Head  of  the  Radius. — This  is  a  form  of  dis- 
placement which  is  observed  in  children  and  usually  results  from  extension 
by  pulling  upon  the  forearm.  The  lesion,  according  to  Streubel,  consists 
in  a  forward  displacement  of  the  head  of  the  radius  with  a  slipping  of  a 
portion  of  the  capsule  between  the  humerus  and  the  head  of  the  radius, 
or  a  slipping  of  the  head  of  the  radius  out  of  the  grasp  of  the  orbicular 
ligament.  It  is  not  an  uncommon  accident.  We  have  seen  a  number  of 
cases,  princij)ally  in  dispensary  i)ractice.  The  arm  rests  against  the  side 
of  the  body,  is  partly  flexed  at  the  elbow,  and  is  pronated.  There  is  tender- 
ness upon  pressure  over  the  head  of  the  radius,  and  the  patient  refuses 
to  use  the  arm.  Treatment. — The  surgeon  seizes  the  arm  with  one  hand 
and  the  forearm  with  the  other,  and  upon  making  supination  or  pronation 
a  sharp  click  is  heard  or  felt,  and  the  motions  of  pronation  and  supination 
are  restored.     K"o  special  after-treatment  is  required. 

Old  Dislocations  of  the  Elbow. — If  the  attempts  at  reduction  are 
postponed  for  a  week  or  longer  it  may  be  difficult  or  impossible  to  return 
the  bones  to  their  normal  position.  The  patient  should  be  autesthetized, 
and,  the  adhesions  being  broken  up  so  that  the  motions  of  flexion  and 
extension  can  be  freely  made,  attempts  should  be  made  to  reduce  the  dislo- 
cation by  manipulation.  If  these  fail,  the  dislocation  may  be  allowed  to 
remain  unreduced,  and  the  function  is  sometimes  remarkably  good.  If  the 
displacement  of  the  bones  is  accompanied  with  pain,  or  the  patient's  arm 
is  useless  by  reason  of  the  limited  motion,  excision  of  the  elbow  may  be 
resorted  to,  with  a  view  to  giving  the  patient  increased  motion,  although 
a  certain  amoiint  of  weakness  in  the  arm  may  result. 

Compound  Dislocations  of  the  Elbow.— These  are  serious  injuries, 
but  if  the  blood-vessels  have  not  been  torn  the  possibility  of  saving  the  limb 


DISLOCATIONS   OF  THE   WRIST.  587 

is  good.  In  the  treatment  of  compound  dislocations  of  the  elbow  the  skin 
and  the  wound  should  be  thoroughly  sterilized,  and  the  surgeon  may  either 
reduce  the  displaced  bone  or  make  a  partial  excision  of  the  joint,  that  is, 
remove  the  lower  i^ortion  of  the  humerus  and  allow  the  articular  surface  of 
the  ulna  to  come  in  contact  with  the  sawed  surface  of  the  humerus.  In 
compound  dislocation  associated  with  fracture  no  definite  rule  can  be  given 
for  excising  portions  of  certain  bones,  the  rule  in  such  cases  being  to  remove 
fragments  involved  in  the  fracture.  After  removing  the  necessary  amount 
of  bone,  the  wound  should  be  drained  and  closed  and  a  copious  antiseptic 
dressing  applied,  and  the  arm  secured  upon  an  internal  or  an  anterior  angu- 
lar splint.  If  infection  of  the  wound  does  not  occur,  repair  in  these  cases  is 
often  very  promjpt,  and  the  functional  results  following  partial  excision  are 
often  superior  to  those  following  the  simple  reduction  of  the  displaced  bones. 

Dislocation  of  the  Inferior  Radio-Ulnar  Articulation. — This  con- 
sists in  a  seiDaration  of  the  lower  extremity  of  the  ulna  from  the  semilunar 
cavity  of  the  radius,  and  the  ulna  may  be  displaced  either  backwai'd  or 
forward.  The  injury  is  often  associated  with  fracture  of  the  lower  end  of 
the  radius. 

Backward  Dislocation. — This  usually  results  from  extreme  and  vio- 
lent pronation  of  the  hand,  and  may  be  associated  with  a  fracture  of  the 
carpal  extremity  of  the  radius.  The  posterior  radio-ulnar  and  sacciform 
ligaments  are  often  ruptured,  and  the  triangular  interarticular  cartilage  is 
disconnected  at  its  apex  from  the  root  of  the  styloid  process  of  the  ulna. 
Symptoms. — The  symptoms  of  this  injurj^  are  a  movable  prominence  at  the 
back  of  the  wrist  at  the  inner  side,  the  styloid  process  of  the  ulna  being  no 
longer  in  line  with  the  fifth  metacarpal  bone.  The  hand  is  in  a  state  of 
pronation,  and  the  fingers  are  flexed.  Treatment. — To  reduce  this  dis- 
placement the  hand  should  be  strongly  supinated  and  the  displaced  bone  at 
the  same  time  pressed  directly  forward. 

Forward  Dislocation. — This  displacement  is  caused  by  violent  supina- 
tion of  the  hand,  and  is  usiially  accompanied  by  rupture  of  the  anterior 
ligaments  of  the  joint.  Symptoms. — A  prominence  may  be  felt  under  the 
palmar  surface  of  the  Avrist,  somewhat  to  the  radial  side,  and  it  will  be 
noticed  that  the  prominence  of  the  lower  end  of  the  ulna  at  the  back  of  the 
wrist  is  absent ;  the  hand  is  pronated  or  partly  supinated.  Treatment. — 
Reduction  may  be  accomplished  by  forced  pronation  of  the  hand  and  by 
pressing  the  head  of  the  ulna  backward.  There  is  often  a  strong  tendency 
to  the  reproduction  of  the  displacement,  which  can  be  counteracted  by  the 
use  of  a  firm  comj)ress  placed  over  the  posterior  surface  of  the  bone,  and  the 
application  of  two  straight  padded  s^jlints ;  these  should  not  be  removed 
permanently  for  three  or  four  weeks.  After  the  removal  of  the  splints  it  is 
wise  to  give  some  fixation  to  the  part  by  strapping  the  wrist  with  rubber 
plaster  or  by  the  use  of  a  comjoress  and  bandage  for  a  considerable  time. 

Dislocations  of  the  Wrist. — These  are  comparatively  rare  disloca- 
tions, and  may  be  either  backward  or  forward. 

Posterior  Dislocation  at  the  Wrist. — This  displacement  follows  the 
application  of  force  to  the  back  of  the  hand,  producing  extreme  flexion, 
which  causes  rupture  of  the  posterior  radio-carpal  and  lateral  ligaments, 


588 


COMPOUND   DISLOCATIONS   OF  THE  WEIST. 


and  allows  the  carpus  to  rest  upon  the  posterior  surface  of  the  radius  and 
ulna.  Symptoms. — These  consist  in  thickening  in  the  antero-posterior 
diameter  of  the  wrist,  and  fixation  of  the  wrist  with  the  hand  slightly 
extended  and  the  fingers  flexed.  (Pig.  510.)  Treatment.— This  displace- 
ment may  be  reduced  by  grasping  the  hand  of  the  patient  and  making 
extension  with  slight  flexion,  abduction,  and  adduction.  When  the  deform- 
ity has  been  reduced  it  has  no  tendency  to  reappear. 

Fig.  511. 


Fig.  510. 


Deformity  in  posterior  dislocation  of  the 
wrist.    (Agnew.) 


Deformity  in  anterior  dislocation  of  tlie  wrist. 
Agnew.) 


Anterior  Dislocation  at  the  Wrist. — This  displacement  may  result 
from  forcible  extension  of  the  wrist ;  the  anterior  carpal  and  lateral  ligaments 
are  ruj)tured,  and  the  bones  of  the  carpus  rest  upon  the  anterior  siu'face 
of  the  radius.  Symptoms. — The  symptoms  of  this  displacement  are  fixa- 
tion of  the  hand  in  the  extended  position  and  a  prominence  upon  the 
posterior  surface  of  the  wrist  of  the  lower  end  of  the  radius  and  ulna 
(Fig.  511.)  Dislocation  at  the  wrist  is  most  apt  to  be  confounded  with  frac- 
ture of  the  lower  end  of  the  radius.  (See  page  473.)  Treatment. — Eeduc- 
tion  is  accomplished  by  making  extension  from  the  hand  with  counter- 
extension  from  the  arm,  at  the  same  time  the  carpus  being  extended  upon 
the  forearm  and  the  ends  of  the  ulna  and  radius  pressed  forward. 

After  the  reduction  of  dislocations  of  the  wrist  the  hand  and  forearm 
should  be  placed  upon  a  well-padded  straight  splint,  or  upon  a  Bond's 
splint,  and  secured  by  the  application  of  a  roller  bandage  ;  the  splints  should 
be  retained  for  several  weeks. 

Compound  Dislocations  of  the  Wrist. — These  are  serious  injuries, 
and  are  often  associated  with  extensive  laceration  of  the  skin,  ligaments, 
and  tendons  in  connection  with  the  wrist-joint.  If  the  principal  blood- 
vessels and  nerves  remain  uninjured,  although  there  may  be  extensive  lacera- 
tion of  the  soft  j)arts,  with  comminution  of  the  bones,  it  is  often  possible  to 
save  the  part  and  to  secure  a  useful  hand.  In  cases  where  there  is  extensive 
comminution  of  the  bones,  the  loose  fragments  should  be  removed  and  the 
wound  and  the  surrounding  skin  should  be  sterilized.  After  reducing  the 
displacement  the  part  should  be  placed  upon  a  well-padded  palmar  splint 
and  a  copious  antiseptic  dressing  applied.  In  cases  of  ruptured  nerves  or 
tendons  associated  with  this  injury,  these  should  be  brought  together  with 
sutures,  and  important  vessels,  if  injured,  secured  by  ligatures. 

Congenital  dislocations  of  the  wrist  are  occasionally  seen,  in  which 
the  carpus  may  be  displaced  backward,  forward,  or  laterally.  The  treatment 
of  these  cases  has  not,  as  a  rule,  been  satisfactory,  but  in  every  case  an 
attempt  should  be  made  to  secure  fixation  of  the  wrist  in  its  normal  posi- 


DISLOCATION   OF  THE   CARPAL  BOXES. 


589 


tion  by  splints  or  luecbanical  appliances  which  allow  of  motion  in  certain 
directions  and  yet  prevent  the  displacement  of  the  bones. 

Dislocation  of  the  Carpal  Bones. — Displacement  of  the  first  row  of 
the  carj)al  bones  on  the  second  row  and  of  single  bones  of  the  carpus  are 
rare,  from  the  fact  that  the  bones  are  bound  together  by  strong  ligaments. 
Medio-Carpal  Dislocations. — Complete  or  incomplete  displacements  of 
the  first  on  the  second  row  of  the  carpal  bones  either  forward  or  backward 
have  occasionally  been  observed.  The  deformity  is  marked,  and  reduction 
is  accomplished  by  extension  and  manif)ulation.  The  carpal  bones  most 
liable  to  be  displaced  are  the  os  magnum,  the  semilunar,  and  the  pisiform. 
The  diagnosis  of  displacement  of  individual  bones  of  the  carj)us  is  difficult ; 
an  X-ray  examination  may  be  useful. 

Dislocation  of  the  Os  Magnum. — This  is  recognized  by  a  prominence 
immediately  behind  the  carjaal  extremitjr  of  the  third  metacarx^al  bone. 
Dislocation  of  the  Semilunar  Bone. — This  injury  is  characterized  by  the 
presence  of  a  hard  body  on  a  line  with  the  metacarpal  bone  of  the  index 
finger  and  below  the  posterior  margin  of  the  carpal  extremity  of  the  radius. 
Dislocation  of  the  Pisiform  Bone. — When  this  occurs  the  bone  is 
detached  from  the  cuneiform  bone  and  drawn  upward,  and  often  can  be 
recognized  as  a  hard  mass  above  the  wrist.  Treatment. — Eeduction  should 
be  attempted  by  pressing  the  displaced  bone  back  into  jilace,  but  reduction 
is  often  impossible,  and  if  deformity  and  loss  of  function  is  marked  excision 
of  the  displaced  bone  should  be  practised.  After  reduction  or  excision  of 
the  bone  the  hand  and  forearm  should  be  placed  u]30u  a  well-padded  i^almar 
sijlint. 

Dislocation  of  the  Metacarpus. — Dislocation  of  the  metacarpus  as 
a  whole  is  extremely  rare.     The  accident  will  be  recognized  by  a  promi- 
nence on  the  back  and  front  of  the  hand,  with  shorteu- 
FiG.  512.  ing  of  the  hand.    (Fig.  512.)    Treatment.— Eeduction 

is  accomplished  by  extension  and  counterextension, 
with  manipulation,  and  after  the  deformity  has  been 
reduced  the  hand  and  forearm  should  be  placed  upon 
a  palmar  splint  and  a  compress  applied  over  the  carpo- 
metacarpal joints. 

Dislocation  of  the  Metacarpal  Bones.— These 
are  generally  compound.  The  soft  parts  are  apt  to  be 
extensivelj"  lacerated,  and  excision  of  one  or  more 
bones  or  amputation  may  be  demanded.  If,  however, 
the  soft  parts  have  not  been  extensively  iujui-ed,  the 
displaced  bones  should  be  reduced  by  extension  and 
direct  pressure,  and,  after  sterilizing  and  dressing  the 
wound  with  a  gauze  dressing,  the  hand  and  forearm 
should  be  immobilized  by  the  application  of  a  palmar 
splint. 

Dislocation  of  the  Metacarpal  Bone  of  the 
Thumb.— This  may  take  place  either  backward  or  for- 
ward, and  usually  results  from  extreme  flexion  or  extreme  extension  of  the 
thumb.     The  symptoms  are  shortening  of  the  thumb  and  a  prominence 


Forward  dislocation  of  the 
metacarpus.    (Agnew.) 


590 


DISLOCATIONS   OF  THE  FINGERS. 


Fig.  51.3. 


below  the  styloid  process  of  tlie  radius.  Treatment. — Eeduction  is  effected 
by  grasping  the  j)roximal  phalanx  of  the  thumb  and  pressing  the  carpal 
extremity  of  the  metacarpal  bone  downward.  The  tendency  to  reproduction 
of  the  deformity  is  usually  marked,  and  to  prevent  this  a  moulded  binder's 
board  splint  should  be  fitted  to  the  thumb  and  wrist  and  secured  by  a  bandage. 
Dislocations  of  the  Thumb. — The  most  common  dislocation  of  the 
thumb  is  a  displacement,  either  forward  or  backward,  of  its  proximal 
phalanx. 

Backward  Dislocation. — This  dislocation  usually  results  from  force 
applied  to  the  phalanx  while  it  is  in  a  state  of  flexion,  causing  a  displace- 
ment of  the  jjroximal  end  of  the  phalanx  behind  the 
head  of  the  metacarpal  bone.  This  displacement  is  one 
which  jiresents  marked  deformity  (Fig.  513),  and  its 
reduction  is  often  attended  with  great  difficulty.  This 
difficulty  in  reduction  seems  to  arise  from  the  fact  that 
the  neck  of  the  metacarpal  bone  is  grasped  between 
the  heads  of  the  short  flexor  of  the  thumb,  or  the  head 
of  the  metacarpal  bone  may  be  buttonholed  through 
the  rent  in  the  capsule,  or  the  sesamoid  bones  may  be 
interposed.  Treatment. — Eeduction  may  be  accom- 
plished by  fixing  the  metacarpal  bone  of  the  thumb 
and  extending  the  thumb,  and  then  drawing  it  down- 
ward and  suddenly  flexing  it,  bj'  which  manipulation 
the  displaced  bone  may  slip  into  place  ;  or  the  surgeon 
may  make  direct  pressure  with  his  thumbs  upon  both 
projecting  heads  of  the  bones  while  making  extension. 
In  other  cases,  in  spite  of  all  manipulations,  it  may  be 
found  impossible  to  reduce  the  deformity  ;  one  head  of 
the  short  flexor  should  then  be  divided  subcutaneously, 
and  by  making  the  foregoing  manipulations  the  dis- 
placement may  be  reduced.  Or  the  displaced  bone  may  be  exposed  by  an 
incision,  and  any  structures  which  interfere  with  its  reduction  divided  and 
the  displacement  reduced. 

Dislocations  of  the  Phalanges  of  the  Fingers.— These  may  be 
metacarpo-phalangeal  or  interphalangeal  (Fig.  514),  and  are  usually  not 
difficult  of  reduction  ;  in  such 

cases  reduction  can  be  accom-  Fig.  514. 

plished  by  over-extension  of 
the  distal  phalanx,  followed  by 
manipulation  and  flexion. 
(Fig.  515.)  The  after-treat- 
ment consists  in  flxing  the  dis- 
placed bone  by  the  application 
of  a  moulded  binder's  board 

splint  for  a  few  weeks  and  in  practising  passive  motion  to  restore  the 
function  of  the  joint. 

Compound  Dislocation  of  the  Phalanges. — In  compound  dislo- 
cations of  the  phalanges  the  wound  should  be  thoroughly  sterilized  and  the 


Deformity  in  backward 
dislocation  of  the  proximal 
phalanx  of  the  thumb. 


Anterior  dislocation  of  phalanx  of  the  finger.     (Agnew.) 


DISLOCATIONS   OF  THE   HIP.  591 

dislocation  should  be  reduced,  tlie  wound  closed,  and  the  j)arts  fixed  by  a 
moulded  binder's  board  splint.     Where  there  is  extensive  comminution  of 

Fig.  515. 


Reduction  of  metacarpo-phalangeal  dislocation  of  the  index  finger.    (Agnew.) 

the  bones  in  conjunction  with  the  dislocation  of  the  i)halanges,  excision  of 
the  comminuted  portions  should  be  practised. 

Dislocation  or  Diastasis  of  the  Bones  of  the  Pelvis.— Diastasis 
of  the  bones  of  the  pelvis  results  from  heavy  bodies  passing  over  the  pelvis, 
or  from  crushing  forces  such  as  occur  iu  railway  accidents,  and  is  often 
associated  with  fracture  of  the  pelvic  bones.  Diastasis  iu  the  pelvic  bones 
is  most  commonly  seen  at  the  sacro-iliac  symphysis  or  at  the  pubic  sym- 
physis ;  the  former  rarely  occurs  alone,  both  sides  being  involved,  or  the 
pubic  juncture  may  also  be  involved.  Diastasis  of  the  jjubic  symphysis 
may  occur  during  labor.  Symptoms. — These  are  similar  to  those  of  frac- 
ture of  the  pelvic  bones.  (See  page  480.  j  A  patient  who  has  sustained 
a  pubic  or  a  sacroiliac  diastasis  is  unable  to  stand,  and  complains  of  a 
sense  of  falling  apart  in  the  region  of  the  pelvis,  and  upon  examination 
by  grasping  the  bony  i^rominences  of  the  pelvis  and  making  motion, 
mobility  can  usually  be  felt  at  the  seat  of  separation.  Prognosis. — 
This  is  usually  grave,  by  reason  of  associated  injuries  of  the  pelvic  organs  ; 
if  such  do  not  exist,  reijair  with  good  function  may  be  expected.  Treat- 
ment.— This  consists  in  placing  the  patient  in  bed  uxjon  his  back  on  a  firm 
mattress,  and,  after  reducing  the  displacement  by  manipulation,  applying 
a  stout  nuislin  binder  around  the  pelvis,  or  the  latter  may  be  strapped  with 
broad  stri^js  of  adhesive  plaster.  This  support  should  be  retained  for  a 
period  of  a  month  or  six  weeks  ;  at  the  end  of  this  time  union  is  sufficiently 
firm  to  allow  the  patient  to  get  up  and  walk  about. 

Dislocation  of  the  Coccyx. — This  injury,  which  is  comparatively 
rare,  may  result  from  force  received  directly  upon  the  region  of  the  coccyx, 
and  consists  in  a  forward,  backward,  or  lateral  displacement  of  this  bone. 
The  amount  of  pain  and  disability  following  the  anterior  displacement  of 
the  coccyx,  which  is  the  most  common,  is  out  of  proiaortion  to  the  extent  of 
the  injury.  This  injury  may  be  diagnosed  by  introducing  the  finger  into 
the  rectum  and  feeling  the  coccyx  displaced  forward.  Its  reduction  is 
accomj)lished  withoiit  diificulty  by  manipulation  with  the  finger  in  the 
rectum.  After  reduction  the  displacement  is  apt  to  recur,  and  if  it  is 
accompanied  with  much  disability  and  pain,  the  most  satisfactory  treatment 
consists  in  cutting  down  upon  the  coccyx  and  excising  it. 

Dislocations  of  the  Hip. — Dislocations  of  the  hip  have  been 
observed  at  all  ages,  but  are  most  frequent  in  adult  life,  and  are  more 
common  in  males  than  in  females.     The  head  of  the  femur  may  be  primarily 


592 


DISLOCATIONS   OF  THE   HIP. 


&isp\aceA,—w2ncard,  backward,  downioard,  aud  forward, — and  may  also 
undergo  a  number  of  secondary  displacements.  The  mechanism  of  dislo- 
cations of  the  hip  has  been  very  carefully  described  by  Bigelow,  who  con- 
siders that  the  typical  displacements  of  the  hip  result  when  the  iliofemoral 
or  Y  ligament  remains  untorn  in  whole  or  in 
Fic-  516-  part.      The  Y  ligament  consists  of  a  mass  of 

fibrous  tissue  composed  of  two  branches,  which 
have  a  common  origin  from  the  anterior  inferior 
spinous  j)rocess  of  the  ilium,  the  external  por- 
tion being  inserted  into  the  outer  part  of  the 
anterior  intertrochanteric  line,  and  the  inner 
15art  into  the  internal  portion  of  the  same  ridge. 
This  ligament  serves  to  reinforce  anteriorly  the 
capsule  of  the  hip-joint,  and  limits  extension 
aud  abduction  ;  the  pubo-femoral  ligament  also 
limits  the  latter.  (Pig.  516.)  Bigelow  held  the 
opinion  that  tyjjical  dislocations  of  the  hip  re- 
sulted when  both  branches  of  the  Y  ligament 
remained  untorn,  and  that  in  irregular  disloca- 
tions both  branches  of  the  Y  ligament  were  rup- 
tured, the  head  of  the  boue  then  occupying  almost 
any  position  intermediate  to  the  regular  ones. 
AUis  holds  that  the  head  of  the  bone  in  all  dis- 
locations of  the  hip  escapes  from  the  lower  seg- 
ment, and  when  outward  is  first  dorsal,  and  then 
may  be  displaced  upward  or  downward  ;  when  inward  is  first  thyroid,  and 
then  majr  be  displaced  upward  or  downward. 

Mechanism. — The  mechanism  of  this  displacement  is  as  follows:  1. 
Slight  motion  brings  the  neck  of  the  femur  against  the  acetabulum,  prjdng 
the  head  of  the  bone  out  of  the  socket.  2.  The  acetabulum  is  shallowest  at 
its  lowest  part,  and  here  the  capsule  is  weakest.  3.  The  capsule  is  at  the 
short  arm  of  a  long  lever.  4.  The  flexed  knee  allows  powerful  rotation. 
5.  External  rotation  and  abduction  are  limited  by  the  Y  aud  pubo-femoral 
ligaments,  while  internal  rotation  brings  the  head  of  the  bone  against  the 
weakest  part  of  the  capsule  and  causes  dislocation. 

Classification. — Dorsal  or  backward  dislocations  of  the  hip  comprise 
seventy-six  per  cent,  of  the  cases  and  include  («.)  iliac,  seventy-two  per 
cent.,  and  (h)  ischiatic,  twenty- eight  per  cent.  Anterior  dislocations  com- 
prise twenty-four  per  cent,  of  the  cases,  and  include  obturator  and  perineal 
dislocations  and  pubic  dislocations,  which  include  ileo-pectineal  and  intra- 
pelvic  dislocations.  Supracotyloid  and  subcotyloid  dislocations  are  occa- 
sionally observed. 

Dislocation  of  the  Hip  Upward  and  Backward  (Iliac). — In  this 
dislocation  the  head  of  the  femur  after  escaping  from  the  acetabulum  rests 
upon  the  dorsum  of  the  ilium.  (Fig.  517.)  This  dislocation  may  result 
from  falls  upon  the  knee  or  the  foot  when  the  limb  is  adducted,  or  from  force 
applied  to  the  back  when  the  pelvis  is  flexed  upon  the  thighs,  or  from  the 
foot  and  thigh  being  fixed  while  the  pelvis  is  forcibly  twisted. 


Illo-temoral  or  Y  ligament. 


DISLOCATIONS   OF  THE   HIP. 


593 


Fig.  517. 


Fig.  518. 


Symptoms. — These  are  flexion  and  adduction  of  tlie  thigh,  marked 
prominence  of  the  great  trochanter,  inversion  of  the  foot,  and  fixation  or 
rigidity  of  the  hipjoint.  There  is  also  marked  shortening  of  the  limb, 
varying  from  one  to  three  inches,  and  the  head  of  the  bone  in  certain  cases 
may  be  felt  in  its  abnormal  position. 

Diagnosis. — Iliac  dislocation  of  the  hip  is  often 
confounded  with  fracture  of  the  neck  of  the  thigh-bone, 
but  little  difliculty  should  be  experienced  if  the  surgeon 
bears  in  mind  the  facts  that  in  dislocation  of  the  hip 
the  trochanter  is  very  prominent,  the  knee  is  adducted, 
the  limb  flexed,  and  the  foot  inverted,  that  there  is 
no  crepitus,  and  there  is  immobility  at  the  hip-joint ; 
the  limb  cannot  be  restored  to  its  proper  length  by 
the  application  of  ordinary  force,  and  when  the  de- 
formity is  once  reduced  it  does  not  tend  to  recur.  In 
fracture  of  the  neck  of  the  femur  the  trochanter  is 
not  prominent,  the  foot  is  everted,  the  knee  is  not 
adducted,  and  the  limb  is  not 
flexed  ;  crepitus  can  often  be 
obtained,  and  there  is  preter- 
natural mobility  at  the  hiji- 
joint.  Extension  restores  the 
limb  to  its  proper  length,  but 
upon  the  removal  of  the  ex- 
tending force  the  shortening- 
reappears. 

Everted  Dorsal  Disloca- 
tion.— This  is  a  form  of  dorsal 

T .  ,         , .  ,  .   ,      .  .  Iliac  dislocation  of  the  head  of 

dislocation    which    is    occasion-  thefemur.   (After Tillmanns.) 

ally  seen  and  is  characterized 

by  eversion  of  the  limb  in  j)lace  of  inward  rotation, 
which  is  marked  in  the  ordinary  dorsal  dislocation. 
This  symptom  is  due  to  rupture  of  the  outer  branch 
of  the  Y  ligament. 

Dislocation  of  the  Hip  Backward  (Ischiatic) . 

— In  this  dislocation  the  head  of  the  bone  is  dislocated 

near  to  the  sacro-sciatic  notch,  and  may  occupy  the 

following  positions :   (1)  the  head  of  the  bone  may 

rest  below  and  behind  the  obturator  internus ;   (2) 

between  the  obturator  internus  and  the  j)yriformis 

^  muscle  ;  (3)  below  the  tendon  of  the  obturator  inter- 

isohiatic  dislocation  of  the  uns.     This  dislocation  results  from  force  applied  to 

Tinman ns )  ^    ^™"^         "^"^  ^^®  kuce,  foot,  Or  pelvis  when  the  thigh  is  flexed  upon 

the  pelvis. 

Symptoms. — In  this  dislocation  the  limb  is  slightly  or  markedly  flexed, 

inverted,   and  adducted,  and  the  knee  is  turned  towards  its  fellow  and 

touches  the  thigh  at  the  inner  margin  of  the  patella.     (Fig.  518.)     The 

shortening  is  rarely  more  than  half  an  inch  :  the  hip  is  less  prominent,  and 

38 


594  DISLOCATIONS  OF  THE  HIP. 

the  troelianter  is  farther  from  the  anterior  superior  spinous  process  of  the 
ilium,  thau  in  the  iliac  dislocation.  The  bone  is  less  movable  aucl  its  head 
is  lower  than  in  the  iliac  variety. 

Treatment. — Eeduction  of  the  iliac  and  ischiatic  dislocations  may  be 
accomplished  by  manipulation  or  by  extension  and  counterextension.  The 
patient  being  ansesthetized  and  placed  upon  his  back,  the  surgeon  grasps 
the  leg  at  the  ankle  and  knee,  flexes  the  leg  upon  the  thigh,  and  the  thigh 
upon  the  pelvis  in  the  position  of  adduction  ;  he  then  abducts  the  limb  and 
rotates  it  outward,  bringing  it  in  a  broad  sweej)  across  the  abdomen,  and  by 
bringing  it  down  to  its  natural  position  the  head  of  the  bone  will  slip  into 
the  acetabulum.  (Fig-  519.)  The  manipulations 
Fig.  519.  recommended  by  Kocher  are  as  follows  :  The  patient 

is  placed  upon  his  back  wpon  a  firm  mattress  and 
anaesthetized :  1,  the  surgeon  then  grasps  the  ankle 
of  the  injured  limb  Avith  one  hand  and  the  front  of 
the  knee  with  the  other  and  rotates  the  thigh  inward 
to  relax  the  capsule  and  lift  the  head  of  the  bone 
from  the  posterior  surface  of  the  pelvis  ;  2,  the  thigh 
is  next  flexed  to  ninety  degrees,  preserving  the  exist- 
ing adduction  and  inward  rotation ;  3,  traction  is 
then  made  in  the  line  of  the  femur  to  make  the  cap- 
sule tense ;  4,  external  rotation  is  then  j)ractised, 
which  makes  the  posterior  part  of  the  capsule  and 
Eeduction  of  backward    the  T  ligament  tensc  and  returns  the  head  of  the  bone 

dislocation    of    the    femnr.     ^     ^^     acetabulum. 
(Bryant.) 

Traction  Method. — Stimson  recommends  the  fol- 
lowing method  :  The  patient  is  placed  face  downward  upon  a  table  with  his 
legs  projecting  so  far  beyond  the  edge  that  the  injured  thigh  hangs  directly 
downward,  while  the  surgeon  grasps  the  ankle,  the  knee  being  flexed  at  a 
right  angle.  The  other  limb  is  held  horizontally  by  an  assistant.  The 
weight  of  the  limb  makes  traction  in  the  desired  direction,  or  a  small  sand- 
bag may  be  added  at  the  knee,  and  by  a  slight  rocking  motion  or  rotation 
of  the  limb  the  head  of  the  bone  slips  into  the  acetabulum. 

Allis  in  the  reduction  of  dorsal  dislocations  recommends  that  while  the 
patient  is  supine  the  surgeon  kneel  beside  him,  and,  in  the  case  of  the  right 
hip,  grasp  the  ankle  with  the  right  hand  and  place  the  bent  elbow  of  the 
left  arm  beneath  the  knee.  He  then  turns  the  bent  leg  outward  by  means 
of  the  ankle  and  lifts  upward,  and  next  turns  the  leg  inward  and  brings  the 
femur  down  in  extension. 

Reduction  by  Extension  and  Counterextension. — Eeduction  by 
extension  and  counterextension  by  the  use  of  the  pulley  and  extending 
bands  was  formerly  frequently  practised  for  the  reduction  of  dislocations  of 
the  head  of  the  femur.  This  method  is  not  often  practised  at  the  present 
time,  as  by  its  use  much  greater  violence  is  done  to  the  parts,  and  on  the 
whole  it  is  not  so  satisfactory  as  the  treatment  by  manipulation.  It  may, 
however,  be  required  in  some  cases  of  old  dislocation  of  the  femur. 

Dislocation  of  the  Hip  Downward  and  Forward  (Thyroid). — 
In  this  dislocation  the  head  of  the  bone,  after  escaping  from  the  acetabulum, 


DISLOCATIONS   OF  THE   HIP. 


595 


Fig.  521. 


lodges  over  the  thyroid  foramen  upon  the  obturator  externus  muscle.     It  is 
produced  by  force  acting  upon  the  limb  while  it  is  in  a  state  of  abduction. 

Symptoms. — The  limb  is  lengthened  about  an  inch  and  a  half,  the  heel 

is  raised,  and  the  foot  may  be  slightly  everted  ;  the  hip  is  flattened,  and  the 

limb  is  flexed  and  abducted.     (Fig.  520. )    The  head 

Fig.  520.  ^f  ^-^^  bone  may  be  felt  below  the  horizontal  ramus  of 

the  pubis,  and  may  lie  far  enough  inward  {perineal 

dislocation)  to  press  upon  the  urethra. 

Treatment. — The  reduction  of  downward  and  for- 
ward dislocations  of  the  head  of  the  femur  is  eifected 
by  flexing  the  leg  and  thigh  and  bringing  the  limb 
into  a  i^osition  of  abduction ;  it  is  then  adducted  and 
rotated  inward  in  a  broad  sweep  across  the  abdomen 
and  brought  down  to  its  natural  position,  when  the 
head  of  the  bone  slips  into  the 
acetabulum  (Fig.  521),  or 
Kocher's  method  may  be  em- 
ployed :  1.  The  leg  should  be 
flexed  upon  the  thigh,  and 
the  thigh  carried  up  to  a  right 
angle  with  the  pelvis,  main- 
taining abduction  and  exter- 
nal rotation  to  relax  the  Y 
ligament.  2.  Traction  should 
next  be  made  in  the  line  of 
the  shaft  of  the  femur,  to  ren- 
der the  ijosterior  part  of  the 
capsule  tense.  3.  External 
rotation  is  then  made,  which,  twisting  the  tense  posterior  j)art  of  the  capsular 
ligament  and  the  outer  branch  of  the  Y  ligament,  brings  the  head  of  the  bone 
upward  and  backward  into  the  acetabulum.  During  attempts  at  the  reduction 
of  thyroid  dislocations  it  is  quite  common  for  the  head  of  the  bone  to  pass 
below  and  behind  the  acetabulum  and  convert  the  thyroid  into  an  ischiatic 
or  an  iliac  dislocation,  in  which  event  the  reduction  may  be  accomijlished 
by  adopting  the  manixjulations  for  the  reduction  of  iliac  or  ischiatic  dis- 
placements. 

Dislocation  of  the  Hip  Upward  and  Forward  (Pubic). — In  this 
form  of  dislocation,  which  is  the  least  frequently  seen,  the  head  of  the  bone 
after  escaping  from  the  acetabulum  rests  upon  the  pubis  internal  to  the 
pubic  eminence.  (Fig.  522.)  It  is  produced  by  falls  upon  the  foot  or  ujion 
the  knee,  when  the  thigh  is  thrown  behind  the  perjjendicular,  or  may  be 
produced  by  violent  twists  of  the  limb. 

Symptoms. — The  limb  is  shortened  and  abducted,  the  thigh  is  flexed, 
the  foot  is  everted,  the  head  of  the  bone  can  be  felt  in  front  of  the  pubis, 
and  the  trochanter  is  not  j)rominent.  This  form  of  dislocation  is  also  apt  to 
be  confounded  with  fracture  of  the  neck  of  the  femur.  In  fracture  of  the 
neck  of  the  femur  there  are  crepitus  and  mobility  ;  the  thigh  is  not  flexed 
nor  abducted.     In  pubic  dislocation  there  are  absence  of  crej)itus,  immo- 


Thyroid   dislocation   of   the 
femur.  (After  Tillmanns.) 


Reduction  of  tliyroid  disloca- 
tion of  the  femur. 


596 


DISLOCATIONS  OF  THE  HIP. 


Fig.  522, 


bilifcy,  abduction  and  flexion  of  the  thigh,  and  the  head  of  the  bone  can  be 
felt  in  front  of  the  pubis. 

Treatment. — The  thigh  being  flexed,  the  head  of  the  bone  is  drawn 
down  from  the  pubis ;  it  is  then  semi- abducted  and  rotated  inward  to  dis- 
engage the  bone  comjiletely.  While  rotating  inward 
and  drawing  on  the  thigh  the  knee  should  be  carried 
inward  and  downward  to  its  place  by  the  side  of  its 
fellow,  and  the  head  of  the  bone  will  usually  slip  into 
the  acetabulum. 

Kocher's  method  is  as  follows  :  1.  Tractiou  should 
first  be  made  in  the  axis  of  the  limb  to  bring  the  head 
of  the  bone  over  the  brim  of  the  pelvis.  2.  Pressure 
should  next  be  made  with  the  hand  upon  the  head  of 
the  femur  to  i^revent  its  passing  uj)ward  during  flexion 
of  the  thigh.  3.  The  thigh  should  next  be  flexed  to 
less  than  a  right  angle  to  relax  the  Y  ligament.  4. 
Inward  rotation  is  next  made  which  directs  the  head  of 
the  bone  into  the  acetabulum. 

AUis,  in  the  reduction  of  anterior  or  inward  dislo- 
cations, recommends  flexing  the  thigh,  then  adducting 
it,  carrj'ing  the  knee  obliciuely  inward  and  downward, 
and  then  rotating  outward. 

Anomalous  Dislocations  of  the  Hip. — As  before 
stated,  anomalous  or  atypical  dislocations  are  likely  to 
result  where  both  branches  of  the  ilio-femoral  or  Y  liga- 
Puijic  dislocation  of  ment  have  been  ruptured.  In  these  the  head  of  the  bone 
assumes  a  number  of  different  positions.  Anomalous 
dislocations  of  the  hij)  are  classified  as  those  which  occuj)y 
a  position  above  the  level  of  the  acetabulum,  upward,  and  these  below  the 
level  of  the  acetabulum,  either  downward  or  forward,  suhpuhic. 

Dislocations  of  the  Hip  directly  Upward  (Supracotyloid), — In 
this  dislocation  the  head  of  the  bone  is  displaced  upward,  and  rests  a  little 
to  the  side  of  the  anterior  suioerior  spine  of  the  ilium.  Seduction  is  effected 
by  traction  and  inward  rotation. 

Dislocation  Downward  upon  the  Tuberosity  of  the  Ischium 
(Infracotyloid). — This  dislocation  is  rare.  The  limb  is  flexed,  and  may  be 
somewhat  abducted  and  everted.  Beduction  is  accomplished  by  traction  and 
flexion  aided  by  direct  pressure  upon  the  head  of  the  femur  from  behind. 

After- Treatment  of  Dislocations  of  the  Hip. — After  reduction  of 
dislocations  of  the  femur  it  is  usually  well  to  apply  a  sand- bag  or  long  splint 
to  the  outer  side  of  the  limb,  or  to  seciu'e  the  limbs  together  by  a  bandage, 
and  the  patient  should  be  kept  in  bed  and  not  allowed  to  use  the  limb  for 
two  or  three  weeks,  luitil  a  sufi&cieut  time  has  elapsed  to  have  the  rent  in 
the  capsular  ligament  firmly  healed. 

Complications  in  Dislocations  of  the  Hip, — Dislocations  of  the  hip 
may  be  complicated  by  fracture  of  the  lip  of  the  acetabulum,  which  renders 
reproduction  of  the  dislocation  likely  after  reduction,  Fractm-e  of  the  neck 
or  shaft  of  the  femiir  may  also  occur  in  connection  with  these  dislocations. 


the  femur, 
manns.) 


DISLOCATIONS   OF  THE  PATELLA.  597 

In  the  event  of  such  an  accident  efforts  should  be  made  to  replace  the 
head  of  the  bone  in  the  acetabulum  by  maniijulation,  but  this  is  not  likely 
to  be  successful,  and  the  case  should  be  treated  as  one  of  fracture  of  the 
femur,  when  a  fairlj'  useful  limb  maj^  result,  or  excision  of  the  head  of  the 
bone  may  be  jpractised.  Injury  of  the  femoral  vessels  is  not  common  in 
dislocation  of  the  femur,  but  has  occurred  in  pubic  dislocations. 

Compound  dislocations  of  the  femur  are  rare  accideuts,  and  are  usu- 
ally produced  by  great  violence.  In  such  a  case  an  attempt  should  be  made 
to  reduce  the  displaced  bone,  and  if  this  cannot  be  successfully  done,  the 
head  of  the  bone  should  be  excised. 

Old  Dislocations  of  the  Femur. — The  reduction  of  old  dislocations 
of  the  femur  is  usually  a  matter  of  the  greatest  difficulty.  After  the  head 
of  the  bone  has  been  dislocated  for  a  few  weeks  it  is  often  impossible  to 
replace  it.  An  old  ischiatic  or  obturator  dislocation  is  less  amenable  to 
treatment  than  a  pubic  or  an  iliac  dislocation.  In  old  dislocations  of  the 
femur  the  head  of  the  bone  may  undergo  changes,  or  the  acetabulum  may 
become  more  shallow  from  filling  up  or  from  the  absorption  of  the  edges,  so 
that  it  will  be  difficult  for  the  bone  to  remain  in  place  in  case  of  its  reduction. 
Attemi)ts  to  reduce  dislocations  of  the  femur  are  usually  not  successful  after 
several  months,  but  cases  of  months'  or  even  years'  standing  have  been 
reduced.  The  reduction  of  old  dislocations  of  the  femur  should  be  attempted 
if  the  displacement  causes  great  disability  or  pain. 

Treatment. — The  patient  should  be  anaesthetized,  and  motion  made  to 
break  up  adhesions  as  far  as  possible  ;  then  the  proper  manixjulations  for  the 
reduction  of  particular  dislocations  should  be  practised.  If  these  fail,  exten- 
sion and  counterextension  may  be  employed  by  the  use  of  the  pulley  and 
extending  bands,  or  the  method  of  angular  extension  suggested  by  Bigelow 
may  be  employed  :  we  succeeded  in  reducing  a  dorsal  dislocation  of  the 
femur  of  six  weeks'  standing  by  the  use  of  this  method.  Where  reduction 
cannot  be  accomjilished,  excision  of  the  head  of  the  bone  has  been  prac- 
tised with  good  results,  and  this  operation  should  be  considered  in  suitable 
cases.  Should  fracture  occur  near  the  head  of  the  bone  during  attempts 
at  reduction  of  an  old  dislocation,  further  manijjulations  should  be  aban- 
doned, and  the  limb  dressed  in  such  a  position  as  to  diminish  the  deformity, 
with  the  chance  that  a  false  joint  may  occur  at  the  seat  of  fractiu'e,  giving 
the  patient  a  more  useful  limb. 

Dislocations  of  the  Patella. — These  occur  from  blows  or  falls  upon 
the  side  of  the  bone,  especially  when  the  knee  is  slightly  flexed,  or  may 
result  from  muscular  violence.  The  patella  may  be  dislocated  outward, 
inward,  rotatory,  upward,  or  downward. 

Outward  Dislocation. — The  outward  or  external  dislocation  of  the 
patella  is  the  most  common,  because  the  bone  lies  in  the  tendon  of  the  quad- 
riceps extensor  cruris  muscle,  and  the  tendo  patellfe  is  attached  at  an  angle 
the  vertex  of  which  is  directed  towards  the  internal  condyle.  Forcible  con- 
traction of  the  quadriceps  muscle  has  a  tendency  to  convert  the  angle  into  a 
straight  line,  and  the  patella  is  thrown  outward.  The  bone  may  also  be 
displaced  by  direct  violence.  Symptoms. — The  breadth  of  the  knee  is 
increased,  the  internal  condyle  becomes  unusually  prominent,  the  limb  is  a 


598 


DISLOCATIONS   OF  THE  PATELLA. 


little  flexed,  aud  the  joint  is  fixed.  (Pig.  523.)  The  borders  of  the  patella 
may  be  felt,  one  anteriorly,  the  other  posteriorly.  Treatment. — Reduction 
is  effected  by  placing  the  patient  on  his  back  and  relaxing  the  quadriceps 
extensor  cruris  muscle  by  elevating  the  leg,  when  the  patella  can  usually 
be  pressed  back  into  place  with  the  fingers. 

Fig.  525. 
Fic    524 


Out^v  ard  dislocation  of  the 
patella.    (Agnew. 


In«  ird  dielooation  of  the 
patella.    (Agnew.) 


Eotatory  dislocation  of 
the  patella.  (Agnew.) 


Inward  Dislocation  of  the  Patella. — This  luxation  is  an  extremely 
rare  one.  Symptoms. — The  knee  is  slightly  flexed,  and  the  patella  is  found 
resting  against  the  articular  surface  of  the  internal  condyle.  (Fig.  524.) 
Treatment. — This  dislocation  is  reduced  by  the  same  manipulation  as  that 
for  the  reduction  of  external  dislocation  of  the  patella,  except  that  th6  patella 
is  pressed  outward. 

Rotatory  Dislocation  of  the  Patella.  -  Here  the  ijatella  rests  upon 
its  edge  in  the  groove  between  the  condyles  (Fig.  525),  or  there  may  be  a 
partial  or  complete  revolution  of  the  bone  on  its  axis.  Symptoms. — The 
leg  is  extended,  and  the  edge  of  the  patella  can  be  recognized  under  the 
skin  in  front  of  the  knee.  The  extensor  muscles  are  in  a  state  of  ten- 
sion. Treatment. — Reduction  is  accomplished,  after  aufesthetizing  the 
patient,  by  flexing  the  thigh  high  upon  the  abdomen,  and  while  the  limb 
is  held  in  this  position  an  assistant  alternately  flexes  and  extends  the  leg, 
while  the  surgeon  manipulates  the  bone  with  his  fingers  until  it  slips  into 
place. 

Upward  and  Downw^ard  Dislocations  of  the  Patella. — These 
dislocations  can  result  only  from  elongation  or  rupture  of  the  ligamentum 
patellae  or  the  tendon  of  the  quadriceps  extensor.  Symptoms. — The  symp- 
toms of  either  of  these  dislocations  are  similar  to  those  of  fracture  of  the 
patella.  Treatment. — This  consists  in  the  use  of  a  posterior  splint  aud 
adhesive  straps  to  draw  the  fragments  into  position,  the  dressing  being  very 
similar  to  that  employed  in  fractures  of  the  patella  ;  or  a  more  satisfactory 


DISLOCATIONS  OF  THE   KXEE. 


599 


Fig.  527 


Fig.  526. 


treatment  is  to  exx^ose  the  ruptured  tendon  and  suture  the  divided  ends 
together  with  silk  or  catgut  sutures  ;  or,  if  it  has  been  torn  loose  from  the 
bone,  to  drill  the  bone  and  pass  sutures  through  the  drill-holes,  and  secure 
them  to  the  ruptured  end  of  the  tendon.  Fixation  of  the  joint  should  be 
maintained  for  six  ■n^eeks. 

After  the  reduction  of  dislocations  of  the  patella  the  knee-joint  should 
be  fixed  in  the  extended  position  for  three  weeks  by  the  application  of  a 
posterior  splint  or  a  plaster-of- Paris  bandage. 

Congenital  displacements  of  the  patella  have  been  observed  in  a  few 
cases.     The  treatment  consists  in  the  application  of  a  brace. 

In  cases  of  displacement  of  the  patella  from  pathological  causes,  such  as 
relaxation  of  the  ligaments,  the  treatment  consists  in  the  use  of  a  comjiress 
and  a  bandage,  or  the  application  of  a  brace,  which  limits  the  motion  of  the 
knee  and  at  the  same  time  prevents  displacement  of  the  patella. 

Dislocations  of  the  Knee. — Dislocations  of  the  knee  are  infrequent 
injuries,  and  result  only  from  the  apijlication  of  great  force.  The  ligaments 
are  very  strong,  and  occupy  the  internal,  external,  and  posterior  aspects  of 
the  joint,  while  in  front  the  patella  with  its  tendon  gives  additional  strength 
to  the  articulation.  Dislocations  of  the  knee-joint  may  be  backward,  for- 
ward, lateral,  or  rotatory. 

Forward  Dislocation  of  the  Knee. — This  may  be  complete  or 
incom]3lete,  and  may  result  from  hyperextension  of  the  knee,  or  from  direct 
violence  received  upon  the  front 
of  the  thigh  or  the  back  of  the 
leg.  Symptoms. — In  this  dis- 
location, if  complete,  the  leg  is 
shortened  from  one  to  three 
inches,  and  may  be  extended  or 
slightly  flexed.  Two  promi- 
nences are  observed,  one  in 
front  of  the  knee,  caused  by  the 
head  of  the  tibia,  and  the  other 
behind  the  knee,  produced  by 
the  lower  extremity  of  the 
femur.  (Fig.  526.)  The  patella 
may  rest  in  front  of  the  tibia  or 
in  the  depression  above  the 
latter.  Treatment. — The  pa- 
tient, having  been  anaesthetized, 
is  placed  upon  his  back ;  ex- 
tension is  made  iipon  the  leg 
and  counterextension  upon  the 

thigh,    and   the    surgeon's   arm  Forward  dislocation  of  the 
1     ■  ,         1  1  ii    J.1       •    •    J.      knee.    (After  Tillmanns.) 

being  placed  beneath  the  joint, 

the  leg  is  gradually  flexed.     Under  this  manipulation  the  bones  usually 

slip  into  place. 

Backward  Dislocation  of  the  Knee. — This  dislocation  may  be  com- 
plete or  incomplete,  and  is  generally  due  to  violence  received  upon  the 


Backward  dislocation  of  the 
knee.    (After  Tillmanns.) 


600 


DISLOCATIONS  OF  THE   KNEE. 


Fig.  528. 


frout  of  the  ]eg  or  the  back  of  the  thigh.  The  patella  is  usually  dislocated 
outward  at  the  same  time,  and  the  leg  is  in  a  position  of  hyperextension. 
(Pig.  527.)  In  this  dislocation  the  posterior  ligament  is  ruptured,  and  the 
heads  of  the  gastrocnemius,  popliteus,  and  quadriceps  muscles,  together 
with  the  popliteal  vessels,  are  placed  upon  the  stretch.  Symptoms. — The 
leg  is  shortened  and  bent  forward  or  extended  ;  a  depression  exists  in  front 
of  the  joint,  the  condyles  of  the  femur  can  be  felt  anteriorly,  and  the  head 
of  the  tibia  projects  posteriorly.  Treatment. — The  reduction  is  accom- 
l^lished  by  traction  with  pressure  upon  the  ends  of  the  tibia  and  femur 
with  flexion  of  the  knee. 

Lateral  Dislocations  of  the  Knee. — These  may  be  either  external 
or  internal,  and  are  generally  incomplete.  In  internal  lateral  dislocation 
the  head  of  the  tibia  is  carried  inward,  so  that  the  internal  condyle  of  the 
femur  rests  upon  the  outside  of  the  internal  articular  surface  of  the  head  of 
the  tibia.     (Fig.  528.)     In  external  lateral  dislocation  the  tibia  is  carried 

externally,  and  the  external  condyle 
of  the  femur  rests  upon  the  inner  por- 
tion of  the  outer  articular  surface  of 
the  head  of  the  tibia.  (Fig.  529.)  In 
either  of  these  dislocations  the  patella 
is  displaced,  and  there  is  a  laceration 
of  the  lateral  ligaments  as  well  as  of 
the  crucial  ligaments,  and  more  or  less 
rotation  of  the  tibia.  Symptoms. — 
When  the  displacement  is  internal,  the 
knee-joint  presents  a  marked  increase 
iu  its  transverse  diameter,  and  the 
internal  tuberosity  of  the  tibia  can  be 
felt  upon  the  inner  aspect  of  the  joint ; 
upon  the  outer  side  a  prominence  can 
be  detected,  which  is  the  external  con- 
dyle of  the  femur.  In  external  dis- 
locations two  prominences  can  also  be 
felt,  composed  of  the  internal  condyle 
of  the  femur  and  the  outer  side  of  the  external  tuberosity  of  the  tibia. 
Treatment.— Eeduction  is  usually  accomplished  without  difficulty,  by 
making  extension  and  counterextensiou  and  j)ressing  the  displaced  bones 
back  into  their  normal  position. 

Rotatory  Dislocation  of  the  Knee. — This  is  a  rare  displacement, 
in  which  the  head  of  the  tibia  is  twisted  either  inward  or  outward.  In  the 
external  variety  the  bones  of  the  leg  are  twisted,  so  that  the  internal  angle 
of  the  tibia  is  directed  forward  and  externally,  the  fibula  is  directed  back- 
ward, a  marked  prominence  of  the  patella  is  seen  externally,  and  the 
internal  condyle  of  the  femur  is  also  prominent,  while  the  inner  border  of 
the  calf  of  the  leg  presents  anteriorly.  (Fig.  530.)  Treatment. — Eeduc- 
tion is  accomj)lished  by  making  extension  and  couuterextension  and  at  the 
same  time  twisting  the  leg  either  externally  or  internally,  according  to  the 
direction  of  the  displacement. 


Incomplete  internal 
dislocation  of  the  knee. 

(Agnew.) 


Incomplete  external 
dislocation  of  the  l;nee. 
(Agnew.) 


DISLOCATIONS  OF  THE  KNEE. 


601 


The  after-treatment  of  all  dislocations  of  the  knee  consists  in  fixation  of 
the  joint  by  the  application  of  a  posterior  padded  splint ;  the  region  of  the 
joint  should  also  be  covered  for  a  few  days  with  lint  saturated  with  lead 
water  and  laudanum.  As  soon  as  the  swelling  has  subsided  the  knee-joint 
should  be  fixed  in  the  extended  position  by  the  application 
of  a  plaster-of- Paris  bandage,  which  should  be  removed 
after  ten  days  for  the  daily  use  of  massage  and  passive 
motion.  The  bandage  should  be  retained  for  about  three 
weeks,  after  which  the  patient  may  be  allowed  to  use  the 
limb,  but  the  joint  motions  should  be  restricted  for  some 
weeks  by  some  form  of  splint  or  brace. 

Compound  Dislocations  of  the  Knee. — These  re- 
sult from  the  application  of  great  force,  and  are  often 
accompanied  by  laceration  of  important  vessels  and  nerves 
in  the  popliteal  space.  When  accompanied  by  extensive 
destruction  of  the  soft  tissues  and  laceration  of  the  popli- 
teal blood-vessels,  primary  amputation  is  usually  j'equired. 
If,  however,  the  injury  to  the  soft  parts  is  not  extensive 
and  the  vessels  have  escaped  injury,  the  wound  should  be 
thoroughly  sterilized,  drainage  should  be  introduced,  and 
after  reduction  of  displaced  bones  the  wound  should  be 
closed,  a  gauze  dressing  applied,  and  the  knee  fixed  in  the 
extended  position  by  the  application  of  splints  or  a 
plaster-of- Paris  bandage.  Compoimd  dislocations  of  the  knee, 
complicated  with  comminution  of  the  head  of  the  tibia  or 
the  condyles  of  the  femur,  the  vessels  being  uninjured,  are  cases  in  which 
primary  excision  of  the  joint,  either  partial  or  complete,  may  be  employed 
with  advantage. 

Congenital  Dislocations  of  the  Knee. — These  have  occasionally  been 
observed,  affecting  one  or  both  knees.  The  reduction  of  the  dislocation  in 
these  cases  is  soon  followed  by  its  reappearance.  The  most  satisfactory 
treatment  consists  in  the  application  of  a  brace  which  limits  the  motion  of 
the  joint  and  is  provided  with  pads  which  prevent  the  bones  from  slipping 
out  of  place. 

Displacement  of  the  Semilunar  Cartilages  of  the  Knee. — A  semi- 
lunar cartilage  may  become  loosened  from  its  capsular  attachment  and 
move  in  between  the  tibia  and  the  femur,  becoming  wedged  between  the 
articular  surfaces.  This  may  occur  in  a  healthy  joint,  or  in  one  in  which 
synovitis  or  osteoarthritis  exists.  The  cartilage  may  be  entirely  detached 
from  the  tibia,  and  may  become  wedged  between  the  articular  ends  of  the 
bones,  causing  locking  of  the  joint.  A  patient  who  has  once  suffered  from 
this  displacement  is  likely  to  have  a  recurrence  of  the  accident. 

Symptoms. — When  this  displacement  occurs  the  leg  becomes  sud- 
denly partially  flexed  and  the  knee-joint  locked  ;  the  patient  complains  of 
severe  pain  in  the  knee,  and  is  unable  to  bear  his  weight  upon  it ;  at  the 
same  time  he  may  suffer  from  nausea  and  vomiting.  Some  swelling  of  the 
joint  may  follow  the  accident,  but  quickly  subsides  after  the  cartilage  is 
replaced. 


Rotatory  disloca- 
tion of  the  knee.  (Af- 
ter Agnew. ) 


602  DISLOCATIONS   OF  THE  FIBULA. 

Treatment. — The  replacement  of  the  cartilage  can  usually  be  accom- 
plished by  flexing  and  extending  the  knee-joint,  at  the  same  time  making 
rotation.  As  the  muscles  hold  the  knee  very  rigidly  and  the  manipulations 
are  painful,  it  may  be  necessary  to  give  an  anaesthetic.  Patients  who  fre- 
quently suffer  from  this  accident  soon  learn  to  replace  the  cartilage  them- 
selves, by  bearing  their  weight  upon  the  flexed  knee  and  suddenly  transfer- 
ring the  weight  of  the  body  to  the  other  leg  and  extending  the  knee  of  the 
injured  leg.  If,  however,  it  is  impossible  to  replace  the  detached  cartilage, 
or  if  the  accident  is  of  such  frequent  occurrence  as  to  cause  constant  dis- 
ability, operative  treatment  should  be  instituted.  The  joint  should  be 
opened  by  an  incision,  the  greatest  care  being  taken  to  make  the  operation 
an  aseptic  one,  and  the  detached  cartilage  exposed  and  removed,  or  sutured 
again  to  the  edge  of  the  tibia  with  silk  or  catgut  sutures,  the  wound  in  the 
capsule  of  the  joint  being  closed  with  sutures,  as  well  as  the  external  wound. 
After  dressing  the  wound  the  leg  should  be  placed  upon  a  posterior  splint 
to  fix  the  knee-joint,  or  a  plaster-of-Paris  dressing  applied.  After  ten  days 
the  splint  should  be  removed  daily  for  the  application  of  massage  and  pas- 
sive motion,  and  worn  for  several  weeks. 

Dislocations  of  the  Fibula. — The  fibula  may  be  displaced  from  the 
tibia  at  its  upper  or  at  its  lower  extremity. 

Dislocation  of  the  Head  of  the  Fibula. — The  upper  end  of  the 
fibula  may  be  dislocated  forward  or  backward,  or  upward ;  all  of  these 
displacements  are  rare.  The  anterior  and  posterior  tibio-fibular  ligaments 
are  torn.  The  symptoms  are  inability  to  bear  any  weight  upon  the  limb, 
and  mobility  of  the  head  of  the  fibula.  Treatment. — Reduction  is  accom- 
l^lished  by  flexing  the  leg  upon  the  thigh,  to  relax  the  biceps  muscle,  when 
the  head  of  the  bone  can  usually  be  pressed  into  its  normal  position .  The 
limb  should  then  be  fixed  upon  a  moulded  binder's  board  splint,  with  a 
compress  over  the  head  of  the  fibula,  or  a  plaster-of-Paris  dressing  may  be 
applied. 

Dislocation  of  the  Lower  E:^treniity  of  the  Fibula. — A  few  cases 
of  this  dislocation  have  been  recorded,  in  which  the  lower  end  of  the 
fibula  has  been  torn  from  its  attachments  to  the  tibia  and  the  foot,  and  has 
been  displaced  backward.  Treatment. — Eeduction  is  accomplished  by 
making  extension  and  manipulation  at  the  same  time,  and  after  the  bone 
has  been  returned  to  its  proper  place  the  foot  and  leg  should  be  fixed  with 
a  moulded  binder's  board  splint,  or  by  the  application  of  a. plaster-of-Paris 
bandage. 

Dislocations  of  the  Ankle.— Dislocation  of  the  ankle  unaccom- 
panied by  fracture  of  the  malleoli  is  an  uncommon  accident.  The  displace- 
ment may  be  either  forward,  backward,  or  lateral. 

Forward  Dislocation  of  the  Ankle. — This  displacement  is  very  rare, 
only  ten  cases  having  been  recorded.  It  may  result  from  force  applied 
to  the  front  of  the  leg  when  the  foot  is  flexed  or  from  falls  on  the  heel  when 
the  tarsus  is  flexed,  and  is  apt  to  be  accompanied  by  a  fracture  of  one  or 
both  malleoli.  The  lateral  and  anterior  ligaments  are  ruj)tured,  the  astrag- 
alus escapes  from  the  cavity  between  the  tibia  and  the  fibula,  and  the 
articular  surface  of  the  tibia  rests  upon  the  upper  surface  of  the  calcaneum. 


DISLOCATIONS   OF  THE  ANKLE. 


603 


(Fig.  531.)  Symptoms. — These  are  lengtheuing  of  the  foot  and  shorteniug 
of  the  heel,  the  malleoli  may  be  felt  lower  down  than  usual,  and  the  tendo 
Achillis  is  uot  prominent  and  rests  against  the  tibia. 

Backward  Dislocation  of  the  Ankle. — This,  which  is  the  more 
common  displacement,  is  caused  by  the  foot  being  driven  backward  while  in 
the  extended  position.  The  lateral  and 
anterior  ligaments  are  ruj)tured,  and  the 
bones  of  the  leg  occupy  a  position  in  front 


Fig.  532. 


Backward  dislocation  of  tlie  unkle.    (.Vguew.) 


of  the  asti-agalus.  (Fig.  532. )  The  tibia  may  rest  in  contact  with  the  scaphoid 
bone,  or  upon  the  neck  or  the  head  of  the  astragalus.  In  this  dislocation,  as 
well  as  in  the  forward  variety,  fracture  of  the  external  or  internal  malleolus 
may  be  associated  with  the  injury.  Symptoms. — The  symptoms  are  short- 
ening of  the  foot  and  lengthening  and  elevation  of  the  heel ;  the  tendo 
Achillis  stands  out  i^rominently  upon  the  posterior  portion  of  the  leg. 
Treatment. — Eeduction  in  forward  dislocations  is  accomplished  by  flexing 
the  leg  upon  the  thigh,  in  order  to  relax  the  gastrocnemius  and  soleus  mus- 
cles, and  making  extension  from  the  foot,  with  counterextension  from  the 
knee ;  the  bones  of  the  leg  should  be  drawn  forward  by  an  assistant  at  the 
same  time  that  the  foot  is  forced  backward ;  this  manijiulation  should  be 
reversed  in  posterior  dislocations.  It  is  usually  necessary  to  administer  an 
anaesthetic,  and  in  difficult  cases  the  reduction  may  be  facilitated  by  subcu- 
taneous division  of  the  tendo  Achillis.  After  reduction  the  leg  and  foot 
should  be  fixed  by  the  application  of  moulded  binder' s  board  splints,  and  as 
soon  as  the  swelling  has  diminished,  a  plaster-of-Paris  bandage  should  be 
applied.     Massage  and  passive  motion  should  be  employed  after  ten  days. 

Outward  Dislocation  of  the  Ankle. — This  dislocatiou  is  very  rare, 
and  is  produced  by  force  which  drives  the  foot  into  a  state  of  extreme  abduc- 
tion, and  is  usually  associated  with  rupture  of  the  internal  lateral  ligament 
and  fracture  of  the  external  malleolus.  (Fig.  533.)  The  symptoms  are 
marked  eversion  of  the  foot,  prominence  of  the  internal  malleolus,  and  a 
depression  over  the  lower  jjortion  of  the  fibula,  which  marks  the  site  of  the 
fracture  of  that  bone.  Treatment. — Eeduction  is  accomplished  by  making 
extension  and  counterextension  and  at  the  same  time  bringing  the  foot  into 
a  position  of  adduction.  After  reduction  lateral  moulded  binder's  board 
splints  should  be  fitted  to  the  leg,  and  held  in  position  by  the  turns  of  a 
roller  bandage.     In  a  few  days,  after  the  swelling  has  subsided,  a  plaster-of- 


604 


DISLOCATIONS   OF  THE  ANKLE. 


Paris  dressing  should  be  applied  to  the  foot  and  leg,  the  foot  being  held  in 
an  inverted  position  until  the  plaster  has  become  firm. 


Fig.  5.33. 


Fig.  534. 


Outward  dislocation  of  the  ankle  i\  ith  Sim  ture  ol  the 
fibula.     (Agnew.) 


Inward  dislocation  of  the  ankle. 
(Agnew.) 


Inward  Dislocation  of  the  Ankle. — This  dislocation  results  from 
falls  sustained  upon  the  outer  border  of  the  foot,  causing  forcible  adduction 
or  inversion  of  the  foot.  Symptoms. — The  foot  is  very  much  inverted, 
and  the  superior  surface  of  the  astragalus  can  be  felt  below  the  external 
malleolus  (Fig.  534),  or  the  foot  is  adducted  with  much  less  inversion. 
Treatment. — Eeduction  is  accomxjlished  by  making  extension  upon  the 
foot  and  counterestension  upon  the  leg,  and  by  manipulation,  bringing  the 
foot  into  its  normal  position.  The  after-treatment  consists  in  fixing  the  foot 
in  a  slightly  everted  position  by  the  use  of  binder's  board  splints  or  the 
plaster-of- Paris  bandage. 

Subastragaloid  Dislocation  of  the  Foot. — This  is  extremely  rare, 
and  consists  in  the  separation  of  the  calcaneum  and  the  scaphoid  from 
the  astragalus.  The  displacement  of  the  bones  may  be  backward,  forward, 
outward,  or  inward.  Fractures  of  the  astragalus  and  of  the  external  malle- 
olus have  been  observed  in  connection  with  it.  Symptoms. — The  foot  is 
inverted  or  everted,  according  as  the  disiDlacement  is  outward  or  inward, 
and  the  head  of  the  astragalus  is  prominent  in  front  of  the  ankle.  Shorten- 
ing of  the  foot  would  be  observed  in  forward  and  lengthening  in  backward 
dislocation.  Treatment. — The  iDatient  should  be  anesthetized,  and  exten- 
sion and  counterextension  made,  with  manipulation  at  the  same  time  to 
reduce  the  deformity. 

Compound  Dislocations  of  the  Ankle. — These  are  the  most  fre- 
quent compound  dislocations  met  with,  and  the  results  following  this  injury 
were  formerly  so  unsatisfactory,  as  regarded  the  loss  of  life  from  septic 
infection  and  the  loss  of  function  in  the  limb,  that  the  majoiity  of  cases 
were  subjected  to  primary  amputation.      At  present  more  conservative 


DISLOCATIONS  OF  THE  ANKLE.  605 

methods  of  treatment  are  adopted,  with  most  gratifying  results.  In  these 
dislocations  the  foot  is  nsually  everted,  and  the  articular  surface  of  the 
tibia  is  driven  through  a  wound  in  the  soft  parts  (Fig.  535),  or  occasionally 
the  compound  dislocation  may  consist  in  an  inward  displacement  of  the 
foot,  with  protrusion  of  the  astragalus  through  a 
wound  at  the  outer  aspect  of  the  ankle,  audfrac-  Fig.  .53.5. 

ture  of  the  external  malleolus.  Compound  dis- 
locations of  the  ankle-joint,  particularly  those  in 
which  the  tibia  or  the  astragalus  escapes  from  a 
wound  at  the  inner  aspect  of  the  joint,  are  often 
associated  with  a  rupture  of  the  posterior  tibial 
artery  or  nerve. 

Treatment. — The  greatest  care  should  be 
exercised  to  render  the  wound  and  the  surround- 
ing parts  aseptic.  The  skin  should  be  sterilized 
and  the  wound  irrigated  with  a  1  to  2000  bichlo- 
ride solution.  If  the  i:)Osterior  tibial  artery  has 
been  injured,  it  should  be  secured  by  liga-  com^S^d  dislocation  of  the  an kie- 
tures,  and  free  drainage  provided  by  passing  joint.   (Agnew.) 

a  large  drainage-tube  through  the  wound  and 

bringing  it  out  through  a  counter-opening  upon  the  opposite  side  of  the 
joint.  Having  reduced  the  displacement,  the  foot  should  be  brought 
into  position, — that  is,  at  a  right  angle  to  the  leg.  In  some  cases  where 
the  lower  end  of  the  tibia  projects  from  the  wound,  it  is  often  difficult  to 
reduce  the  dislocation.  Here  resection  of  the  tibia  or  excision  of  the 
astragalus  renders  the  reduction  easy.  If  the  case  is  complicated  by  a  frac- 
ture of  the  lower  portion  of  the  tibia,  it  is  better  to  excise  a  portion  of  the 
bone  before  attempting  reduction,  which  facilitates  the  latter  and  at  the  same 
time  relieves  tension  and  favors  free  drainage.  We  have  seen  the  most  satis- 
factory results  in  these  cases  follow  xsartial  excision.  If  the  wound  is  an 
extensive  one,  a  few  sutures  may  be  introduced  at  each  extremity,  but,  as 
the  greatest  safety  is  in  free  drainage,  it  is  wise  to  allow  the  wound  practically 
to  remain  an  open  one.  A  sterilized  or  antiseptic  gauze  dressing  should 
next  be  applied  to  the  wound,  and  over  this  a  number  of  layers  of  sterilized 
or  bichloride  cotton.  If  there  is  much  difficulty  in  reducing  the  deformity, 
or  if  there  is  a  tendency  to  redisplacement  after  reduction,  by  the  muscles 
acting  through  the  tendo  Achillis,  this  tendon  may  be  divided  subcutane- 
ously.  After  applying  a  gauze  dressing,  lateral  splints  of  binder's  board, 
moulded  to  the  foot  and  leg,  holding  the  foot  at  a  right  angle  to  the  leg, 
should  be  applied,  the  foot  and  leg  being  placed  in  a  fracture-box.  An 
equally  satisfactory  dressing  consists  in  the  application  of  a  plaster- of- Paris 
bandage  including  the  foot  and  leg  and  extending  a  little  distance  above  the 
knee.  At  the  end  of  three  or  four  days  the  splints  should  be  removed,  or 
the  plaster-of-Paris  bandage  should  be  fenestrated  and  the  wound  inspected, 
and  if  it  has  remained  aseptic  the  drainage-tube  may  be  removed  and  the 
dressing  reapplied.  If  suppuration  occurs,  the  drainage-tube  should  be 
allowed  to  remain  in  place  for  some  time,  and  irrigation  and  more  frequent 
dressings  of  the  wound  will  be  required.     In  cases  in  which  the  wound  runs 


606  DISLOCATIONS  OF  THE  ASTRAGALUS. 

an  aseptic  course  and  healing  talses  place  promjDtly,  very  good  functional 
results  may  be  exijected.  Where,  however,  suppuration  occurs,  the  time  of 
repair  is  very  much  prolonged,  and  more  or  less  fixation  of  the  ankle-joint 
is  apt  to  result. 

Dislocation  of  the  Bones  of  the  Foot.— Dislocation  of  the 
Astragalus. — The  astragalus  may  be  dislocated  forward,  backward,  or 
laterally,  or  rotated  on  its  axis. 

Forward  and  Outward. — This  may  be  complete  or  incomplete,  and 

usually  results  from  a  fall  from  a  height  upon  the  foot.     In  this  dislocation 

there  is  an  irregular-shaped  prominence  in 

Fig.  536.  front  of  the  ankle,  the  foot  is  usually  inverted, 

and  the   external   malleolus  is  prominent. 

(Fig.  536.) 

Backward. — In  this  rare  dislocation  the 
astragalus  is  forced  posteriorly  from  its  posi- 
tion between  the  malleoli,  and  separated  from 
the  OS  calcis  and  the  scaphoid.  The  displace- 
ment is  produced  by  force  acting  upon  the 
anterior  part  of  the  ankle  when  the  tarsus  is 
strongly  flexed  upon  the  bones  of  the  leg. 
In  this  dislocation  there  is  a  prominence 
above  the  heel,  the  foot  is  shortened,  and 
^      ,  ,  ,. ,  ,  ,      there  is  undue    prominence  of   the    tendo 

Forward  and  outward  dislocation  of  the 

astragalus.  Achillis  over  the  displaced  bone. 

Lateral. — Lateral  dislocations  of  the  as- 
tragalus maj'  be  associated  with  fracture  of  either  the  external  or  the  internal 
malleolus.     In  these  dislocations  the  foot  may  be  inverted  or  everted. 

Dislocation  by  Rotation. — This  is  a  rare  form  of  dislocation  of  the 
astragalus.  It  is  produced  by  the  patient  falling  from  a  height  upon  the 
foot,  the  foot  rotating  while  the  leg  is  fixed.  The  astragalus  occupies  its 
position  between  the  malleoli,  but  the  relations  of  its  articular  surface  are 
changed.  The  bone  may  be  turned  vertically  or  transversely.  There  is 
fixation  at  the  ankle,  with  more  or  less  change  in  shape,  produced  by  the 
rotation  of  the  astragalus. 

Treatment. — In  reducing  these  dislocations  the  leg  should  be  flexed 
upon  the  thigh,  to  relax  the  gastrocnemius  and  soleus  muscles,  extension'  and 
counterextension  should  be  made  from  the  foot  and  leg,  and  the  surgeon 
should  endeavor  by  manipulation  to  press  the  astragalus  back  into  its 
normal  position ;  if  this  cannot  be  accomplished,  it  may  be  necessary  to 
divide  the  tendo  Achillis,  which  will  often  facilitate  the  reduction  of  the 
displaced  bone.  If  reduction  cannot  be  accomplished  by  these  means,  the 
displaced  bone  should  be  exi^osed  by  incision  and  reduced  or  excised.  After 
the  reduction  or  excision  of  the  bone  a  moulded  pasteboard  splint  shoiild 
be  applied  for  a  few  days,  and  when  the  swelling  has  subsided  a  plaster-of- 
Paris  bandage  should  be  applied. 

Compound  Dislocations  of  the  Astragalus. — These  result  from  falls 
from  a  height,  the  weight  of  the  body  striking  upon  one  foot.  The  astraga- 
lus may  be  comj)letely  driven  from  between  the  malleoli,  or  may  be  only 


DISLOCATIONS  OF  THE  TARSAL  BONES.  607 

partially  displaced.  Treatment. — In  these  dislocations  the  most  satis- 
factory method  of  treatment  consists  in  enlarging  the  wound  and  reducing 
or  excising  the  disj)laced  bone,  and  after  the  removal  of  the  bone  the  foot 
should  be  placed  at  a  right  angle  to  the  bones  of  the  leg,  a  copious  antiseptic 
or  steiilized  gauze  dressing  should  be  applied,  and  the  ankle  fixed  for  a 
few  weeks  by  the  apiilication  of  a  binder's  board  sj^lint  or  a  plaster-of- Paris 
dressing. 

Dislocation  of  the  Os  Calcis. — This  bone  is  very  rarely  dislocated, 
but  may  be  separated  from  the  astragalus  above  and  from  the  cuboid  bone 
in  front.  This  dislocation  usually  results  from  falls  upon  the  heel,  or  from 
force  applied  to  the  bone  at  the  side  of  the  foot.  The  symptoms  are  distor- 
tion of  the  heel  and  inability  to  abduct  or  adduct  the  foot.  Dislocation 
of  the  Scaphoid. — This  dislocation  is  also  extremely  rare,  and  can  be 
recognized  by  its  projection  on  the  anterior  surface  of  the  foot.  Disloca- 
tion of  the  Cuboid. — The  cuboid  bone  has  been  dislocated  in  connection 
with  displacements  of  other  bones  of  the  tarsus  ;  only  one  case  of  independent 
luxation  of  this  bone  has  been  recorded.  Dislocation  of  the  Cuneiform 
Bones. — The  cirneiform  bones  may  be  dislocated  separately,  or  the  three 
bones  may  be  dislocated  together.  The  internal  cuneiform  bone  is  the  one 
most  liable  to  dislocation.  There  is  a  prominence  on  the  inner  border  of 
the  foot,  consisting  of  one  or  more  of  the  bones.  Treatment. — The  reduc- 
tion of  displacements  of  individual  bones  of  the  tarsus  is  accomplished  by 
manipulation ;  if,  however,  it  is  found  impossible  to  reduce  the  dislocated 
bone,  and  it  causes  pain  or  disability,  it  should  be  excised.  After  reduc- 
tion, the  foot  and  ankle  should  be  fixed  with  a  moulded  splint  or  plaster- 
of-Paris  bandage. 

Dislocation  of  the  Metatarsal  Bones. — These  are  not  common,  but 
are  occasionally  seen.  The  direction  of  the  dislocation  may  be  upward, 
downward,  or  lateral.  They  may  result  fi-om  falls  or  from  the  foot  being- 
caught  and  twisted  between  heavy  weights.  Symptoms. — The  symptoms 
in  these  dislocations  are  a  prominence  upon  either  the  dorsal  or  the  palmar 
aspect  of  the  foot,  and  shortening  of  the  toes  corresponding  to  the  displaced 
bones.  Treatment. — The  reduction  is  effected  bj^  making  traction  upon 
the  displaced  bone  from  the  toe  and  at  the  same  time  pressure  over  the  end 
of  the  bone.  After  reduction  a  compress  should  be  applied  over  the  seat  of 
the  displacement,  and  the  foot  fixed  by  a  splint  or  a  plaster-of- Paris  bandage. 

Dislocations  of  the  Phalanges  of  the  Toes. — These  dislocations 
are  not  so  common  as  dislocatiojis  of  the  phalanges  of  the  fingers,  but  are 
occasionally  seen,  and  result  from  twists  and  extreme  flexion.  Symptoms. 
— These  are  a  prominence  at  the  articulation  and  shortening  of  the  injured 
toe.  Treatment. — The  reduction  of  dislocation  of  the  phalanges  of  the 
toes  is  accomplished  by  extension  aud  counterextension  with  manipulation. 
After  the  reduction  the  part  should  be  fixed  by  the  application  of  a  moulded 
binder's  board  gutter,  which  should  be  retained  for  several  weeks. 

DISEASES    OF    JOINTS. 

Synovitis. — Synovitis  consists  in  an  inflammation  of  the  synovial  mem- 
brane of  a  joint,  and  may  arise  from  local  causes,  such  as  sj)rains,  contusions. 


608  DISEASES   OF  THE  JOINTS. 

and  -wouuds,  or  from  infective  or  tubercular  inflammation  of  the  bones  and 
cartilages  of  the  joints,  or  fi'om  constitutional  causes,  such  as  gout  or  rheu- 
matism.    It  may  exist  as  an  acute  or  as  a  chronic  affection. 

Acute  Synovitis. — This  affection  may  result  from  contusions,  sprains, 
twists,  wounds,  exposure  to  cold  or  dampness,  infective  processes,  or  rheu- 
matism. The  synovial  membrane  becomes  injected  and  cedematous,  and  its 
secretion  is  increased  in  amount,  and  may  be  thin  and  watery  or,  from 
excess  of  fibrous  exudations  or  infection,  flocculent  or  purulent:  the  joint 
at  the  same  time  becomes  distended  from  the  excess  of  secretion. 

Symptoms. — These  are  pain,  increased  by  motion  of  the  joint  or  by 
pressure  upon  the  articulation,  and  swelling,  which  changes  the  normal 
shape  of  the  joint ;  there  may  also  be  more  or  less  flexion  of  the  joint  as  a 
result  of  the  intra-articular  effusion.  Fluctuation  is  usually  marked  in  the 
region  of  the  joint  in  which  the  caj)sule  is  thinnest.  The  skin  is  hot  to  the 
touch,  but  is  often  unchanged  in  color.  Elevation  of  temperatui-e  is  usually 
J) resent,  the  degree  of  elevation  depending  ujDon  the  size  of  the  joint,  the 
acuteness  of  the  attack,  and  its  cause.  In  acute  suppurative  synovitis  chills 
occur,  and  are  accompanied  by  a  septic  temperature ;  the  swelling  of  the 
joint  increases,  and  the  skin  becomes  cedematous  and  red,  pointing  to  the 
presence  of  pus  within  the  joint. 

Treatment. — The  first  indication  in  the  treatment  of  acute  synovitis  is 
to  place  the  joint  at  rest  by  the  application  of  a  splint,  and  it  is  often  more 
comfortable  to  the  patient  if  the  joint  is  fixed  in  a  semiflexed  position. 
Cold  should  then  be  applied  by  means  of  an  ice-bag,  and  this  may  be 
followed  by  the  use  of  a  lotion,  such  as  lead  water  and  laudanum.  If  the 
distention  of  the  joint  is  great,  and  it  is  likely  that  the  vitality  of  the 
synovial  membrane  and  cartilages  is  threatened,  the  joint  should  be  aspi- 
rated with  full  antiseptic  precautions.  This  procedure  quicklj^  relieves  the 
distention,  and  hastens  the  cure  of  the  case.  When  the  acute  symptoms 
have  subsided,  the  use  of  elastic  pressure  by  means  of  a  rubber  bandage,  or 
the  application  of  tincture  of  iodine  or  massage,  will  often  be  followed  by 
good  results.  Aciite  synovitis  in  healthy  subjects  rarely  terminates  in 
suppuration,  but  in  debilitated  subjects  such  a  termination  may  occur.  If, 
due  to  infection,  acute  synovitis  runs  on  to  suppuration,  the  joint  should 
be  opened  by  incisions  and  washed  out  with  a  1  to  2000  bichloride  solution, 
free  drainage  being  secured  by  the  introduction  of  drainage-tubes.  Even 
if  suppuration  has  occurred,  if  free  drainage  is  secured  before  the  surfaces 
of  the  cartilages  have  become  ulcerated,  recovery  may  take  place  with  little 
loss  of  function. 

Chronic  Synovitis. — This  may  result  from  acute  synovitis,  or  may 
arise  from  repeated  slight  injui-ies  and  occupy  a  considerable  time  in  its 
develoiiment.  There  is  usually  more  or  less  involvement  of  the  other 
structures  of  the  joint,  giving  rise  to  arthi-itis.  The  synovial  membranes 
become  cedematous  and  thickened,  and  may  be  thrown  into  folds  or  may  be 
fastened  together  by  adhesions  from  organization  of  the  exudations  between 
their  surfaces.  Fluid  in  variable  quantity  may  exist  in  the  joint,  and 
patches  of  membrane  undeigo  degeneration  and  softening,  or  may  become 
studded  with  villous  growths,  or  suppuration  may  eventually  occur. 


ARTHRITIS.  609 

Symptoms. — In  chronic  synovitis  there  is  generally  marked  limitation 
in  the  motion  of  the  joint ;  pain  is  usually  absent  unless  jjressure  is  made 
upon  the  joint  or  motion  of  the  joint  is  attempted.  The  shape  of  the  joint 
is  changed,  depending  upon  the  amount  of  effusion  and  the  thickening 
of  the  tissues.  If  the  amount  of  effusion  is  large,  the  condition  known  as 
hydrops  articuli  is  present.  In  dry  cases  motion  of  the  joint  will  develop 
crepitation  or  crackling.  Wasting  of  the  muscles  in  the  region  of  the  joint 
from  disuse  is  iisually  very  marked. 

Treatment. — This  consists  in  fixation  of  the  joint  and  the  adoption  of 
means  which  favor  the  absorption  of  the  plastic  exudates  and  fluid.  The 
use  of  tincture  of  iodine  or  pressure  over  the  joint  is  followed  by  good 
results.  The  application  which  we  have  seen  give  the  best  results  is  one 
comxDosed  of  unguentum  iodi,  3ii;  unguentum  belladonnse,  3iv;  unguentum 
hydrargyri,  3  ii.  This  should  be  spread  uj)on  *lint  and  applied  over  the  sur- 
face of  the  joint,  which  should  be  fixed  by  the  application  of  a  splint  or  a 
plaster-of- Paris  dressing.  After  the  swelling  has  subsided,  passive  motion 
and  massage  should  be  employed.  In  cases  in  which  a  large  amount  of 
effusion  is  present,  aspiration  of  the  joint  may  be  of  service.  In  long- 
standing cases  aspiration  and  irrigation  with  a  five  per  cent,  solution  of 
carbolic  acid,  of  which  from  five  to  ten  cubic  centimetres  are  allowed  to 
remain  in  the  cavity,  may  be  practised  with  good  results.  Many  months 
of  treatment  are  often  required  before  the  patient  regains  fair  use  of  the 
joint.  If  infection  occurs  and  abscesses  form  they  should  be  opened  and 
drained,  and  in  cases  of  extensive  disorganization  of  the  articulation  excision 
or  amputation  may  ultimately  be  required. 

Arthritis. — This  consists  in  an  acute  or  a  chronic  inflammation  of  the 
joint,  involving  the  synovial  membranes,  the  cartilages  and  ligaments,  and 
the  articular  surfaces  of  the  bones.  The  affection  may  arise  from  a  traumatic 
synovitis  or  from  the  presence  of  pyogenic  cocci,  or  may  be  due  to  infection 
from  special  organisms,  such  as  the  bacilli  of  tuberculosis,  or  the  micro- 
organisms of  gonorrhoea  or  typhoid  fever,  or  may  develop  as  a  complication 
■of  rheumatism,  gout,  syphilis,  or  diseases  of  the  nervous  system. 

The  varieties  of  arthritis  are  :  1,  simple  acute  ;  2,  suppurative  ;  3,  gonor- 
rhoeal ;  4,  syphilitic  ;  5,  rheumatic  ;  6,  osteoarthritis  ;  7,  neuropathic  arthri- 
tis ;  8,  tuberculous  arthritis. 

Simple  Acute  Arthritis. — This  affection  arises  from  traumatisms  of 
joints,  and  is  characterized  at  first  by  the  same  symptoms  as  acute  synovitis, 
but  the  steady  extension  of  the  process  to  the  surrounding  structures  gives 
evidence  of  a  wider  area  of  involvement  of  the  tissues.  Pain,  swelling, 
lieat,  and  loss  of  function  are  marked.  If  i^yogenic  infection  does  not  occur, 
resolution  may  take  place  and  recovery  follow  with  little  impairment  of 
function  of  the  joint.  Treatment. — The  joint  should  be  immobilized  by  a 
splint  and  a,nodyne  lotions,  such  as  lead  water  and  laudanum,  with  an  ice- 
bag,  applied  to  the  surface  of  the  joint.  After  inflammatory  symptoms  have 
subsided  massage  and  passive  motion  should  be  employed. 

Acute  Suppurative  Arthritis. — Abscess  of  a  Joint. — This  may 
result  from  a  penetrating  wound  of  a  joint,  the  pyogenic  oi-ganisms  gaining 
access  to  the  joint  through  the  wound,  or  in  cases  of  osteomyelitis  by  exten- 

39 


610  ACUTE  SUPPURATIVE  ARTHRITIS. 

sion  of  the  infective  process  througli  the  artioular'ends  of  the  bone  or  j)ei'i- 
articular  structures,  or  in  patients  suffering  from  pyaemia  through  the 
infection  of  the  synovial  membrane  by  the  micro-organisms  in  the  blood. 
An  extra-articular  abscess  may  rupture  into  a  joint  and  cause  this  affection. 
It  may  also  arise  in  the  course  of  acute  infective  diseases,  such  as  typhoid 
or  scarlet  fever,  measles,  and  small-pox,  and  is  due  to  a  mixed  infection  of 
the  joint  by  pyogenic  cocci,  and  the  specific  micro-organisms  of  the  par- 
ticular disease  or  their  ptomaines.  The  pathological  lesions  consist  in  exu- 
dation into  the  synovial  sac,  the  subsynovial  connective  tissue,  and  the 
capsule  and  ligaments  of  the  joint,  and  the  formation  of  pus.  The  articular 
cartilages  become  softened  and  broken  down,  or  may  be  separated  in  masses 
from  the  bone.  The  ligaments  may  also  become  softened  and  eroded,  so 
as  to  permit  of  undue  motion  or  displacement  of  the  bones. 

Symptoms. — The  joint  becomes  swollen  and  painful,  the  pain  being 
increased  by  motion  and  being  worse  at  night.  The  skin  becomes  hot,  red, 
and  cedematous,  fluctuation  may  be  obtained,  and  intra- articular  tension  is 
shown  by  flexion  of  the  joint.  Arthritis  occuri-ing  in  the  course  of  acute 
infectious  diseases  presents  redness  and  swelling  of  the  joints,  but  sup- 
puration may  not  result  unless  the  infection  be  a  mixed  one.  In  cases  of 
suppurative  arthritis  due  to  pysemia  a  number  of  joints  are  usually  involved, 
and  the  swelling  of  the  joints  is  preceded  by  the  constitutional  symptoms  of 
pytemia ;  there  may  be  no  pain,  and  swelling  of  the  joints  may  be  the  most 
prominent  symjDtom.  Constitutional  symptoms  are  manifested  by  a  chill  or 
chilliness  ;  fever  is  present,  the  temj)erature  often  being  as  high  as  lO-i"  to 
106°  P.  (40°  to  41°  C.)  ;  the  pulse  becomes  rapid,  the  patient  presents  the 
constitutional  sj'mj)toms  of  sei^tic  intoxication,  and  death  may  result  in 
three  or  four  days  from  septictemia. 

Treatment. — This  consists  in  making  free  incisions  into  the  joint,  fol- 
lowed by  thorough  disinfection  of  the  joint-cavity.  This  is  best  accom- 
plished by  antiseptic  irrigation  with  a  1  to  2000  bichloride  solution  and  the 
introduction  of  drainage-tubes.  A  copious  antiseiitic  gauze  dressing  should 
next  be  applied,  and  the  joint  immobilized  by  the  application  of  a  splint. 
After  disinfection  and  free  drainage  of  the  joint  have  been  accomplished, 
the  constitutional  disturbance  usually  subsides  rapidly,  and  the  discharge 
from  the  joint  gradually  diminishes.  If  the  joint  has  been  opened  early, 
recovery  with  more  or  less  restoration  of  function  may  take  place.  In  other 
cases,  where  extensive  disorganization  of  the  joint  has  occurred,  sinuses 
may  persist,  and  necrosis  or  caries  of  the  articular  ends  of  the  bones,  with 
relaxation  of  the  ligaments,  may  be  present.  In  such  instances  the  joint  is 
useless,  and  an  arthrectomy  or  excision  may  be  required,  and  rarely  ampu- 
tation is  called  for.  In  pysemic  cases  the  prognosis  is  not  so  favorable,  as 
the  patient  often  succumbs  to  the  septic  infection ;  but  even  in  these, 
incision  and  drainage  of  the  joint  are  sometimes  followed  by  recovery. 

In  arthritis  occurring  in  the  course  of  infective  diseases,  if  there  is  no 
evidence  of  suppuration,  lead  water  and  laudanum  or  an  ice- cap  should  be 
applied  over  the  surface  of  the  joint,  or  it  may  be  enveloped  in  cotton 
wadding,  and  a  bandage  applied  firmly  over  this  dressing,  the  part  being- 
fixed  by  the  application  of  a  splint.     Under  this  treatment  in  many  cases 


GONOERHCEAL  ARTHRITIS.  611 

resolution  takes  place  lu  a  few  days,  and  recovery  follows  with  a  good  func- 
tional result. 

Gronorrhoeal  Arthritis. — Gonorrhoeal  Septicaemia. — During  the 
course  of  acute  or  chronic  gonorrhoea  there  may  develop  a  synovitis  or  an 
arthritis,  with  effusion  into  the  joints,  due  to  infection  by  the  gonococcus  of 
Neisser,  or  to  a  mixed  infection  from  gonorrhoeal  and  pyogenic  organisms. 
Men  are  more  apt  to  suffer  from  the  affection  than  women.  All  of  the  joints 
may  be  affected,  but  those  most  commonly  involved  are  the  knee  and  the 
ankle  ;  occasionally  the  intervertebral,  sterno- clavicular,  temijoro-maxillary, 
and  sacro-iliac  articulations  are  affected.  The  presence  of  gonococci  cannot 
always  be  demonstrated,  and  in  such  cases  the  infection  may  possibly  be 
due  to  their  ptomaines. 

Symptoms. — In  acute  cases  one  or  more  joints  become  painful  and 
swollen  ;  the  pain  is  usually  in  excess  of  the  apparent  involvement  of  the 
joint,  the  skin  becomes  red,  and  the  joint  assumes  the  position  which 
relieves  intra-articular  tension.  Tenosynovitis  of  the  wrist  is  often  observed. 
There  are  usually  present  more  or  less  elevation  of  temperature  and  accel- 
eration of  the  pulse.  In  subacute  or  chronic  cases  the  joint  becomes 
swollen  and  distended  with  fluid,  but  pain  is  not  a  prominent  symptom. 
Suppuration  rarely  occurs,  and  when  this  accident  takes  place  it  is  probably 
due  to  a  mixed  infection  from  i3yogenic  and  specific  organisms.  The  inflam- 
mation usually  terminates  in  resolution,  and  is  apt  to  result  in  more  or  less 
ankylosis  of  the  joint  from  organization  of  the  articular  and  periarticular 
exudations.  In  subacute  or  chronic  cases  the  effusion  in  the  joint  is 
absorbed  very  slowly,  weeks  or  months  often  being  required. 

Treatment. — Attention  should  be  given  to  the  cure  of  the  coexisting 
urethritis.  While  there  is  any  evidence  of  inflammatory  symptoms  the 
joint  should  be  immobilized  by  the  use  of  a  splint  or  a  plaster-of-Paris 
dressing.  If  pain  is  a  prominent  symptom,  a  lotion  of  lead  water  and  lauda- 
num may  be  applied  with  good  results,  or  a  solution  of  guaiacol,  twenty-five 
to  fifty  per  cent.,  in  olive  oil  will  be  found  most  efficient  in  relieving  pain. 
The  use  of  an  ointment  of  belladonna  and  mercury,  equal  parts,  or  of 
ichthyol  is  often  satisfactory.  Hot-air  baths  or  baking  may  be  followed  by 
good  results.  If  the  joint  becomes  very  tense  in  the  acute  stage,  it  should 
be  aspirated  or  drained.  As  soon  as  the  pain  has  disappeared,  massage 
and  gentle  passive  motion  should  be  practised,  but  if  this  is  followed  by 
pain  and  swelling  it  is  an  evidence  that  immobilization  of  the  joint  should 
again  be  resorted  to,  and  passive  motion  and  massage  should  be  postponed 
for  a  time.  In  chronic  cases  with  large  effusion  into  the  joint,  aspiration 
and  irrigation  with  a  five  per  cent,  carbolic  solution,  with  full  antiseptic 
precautions,  may  be  practised,  and  followed  by  massage.  If  ankylosis 
results,  the  adhesions  may  be  broken  up  under  an  anesthetic,  but  there  is 
always  the  risk  that  forcible  motions  of  the  joint  may  set  up  fresh  inflam- 
matory action,  so  that  we  are  disposed  to  think  it  is  better  to  leave  the 
patient  with  an  ankylosed  limb  in  good  position,  if  not  painful,  than  to 
attempt  to  restore  motion  by  violent  manipulations,  which  may  be  followed 
by  extensive  inflammation  of  the  joint.  The  administration  of  iodide  of 
mercury,  one-third  grain,  combined  with  extract  of  hyoscyamus,  one-half 


612 


RHEUMATIC  ARTHRITIS. 


Fig.  537. 


grain,  tliree  or  four  times  a  day,  is  often  followed  by  good  results.  Internally 
opium  may  be  required  to  relieve  pain,  and  salol,  the  salicjdates,  oil  of 
wintergreeu,  iodide  of  potassium,  and  quinine  may  be  employed. 

Syphilitic  Arthritis. — Synovitis  or  arthritis  may  develop  as  the 
result  of  syphilis,  either  in  the  early  secondary  stages,  when  it  may  be  of 
the  nature  of  a  subacute  septic  synovitis,  or 
in  the  later  secondary  stages  of  the  disease, 
either  in  acquired  or  in  congenital  syphilis. 
In  the  later  form  the  pathological  change 
consists  in  a  small- celled  iniiltration  or  a 
diffused  gummatous  formation.  Symptoms. 
— Pain  is  not  usually  a  prominent  symptom, 
even  when  the  joint  disease  is  marked ; 
muscular  spasm  may  be  well  developed. 
The  joint  is  not  uniformly  swollen,  but  is 
apt  to  present  several  points  of  enlargement, 
which-  give  an  elastic,  doughy  feeling ;  the 
skin  is  not  red  or  inflamed,  but  later  the 
skin  covering  the  swelling  may  become 
purple  or  brown.  (Fig.  537. )  When  these 
conditions  of  the  joints  are  associated  with 
other  signs  of  syphilis,  the  diagnosis  of  the 
character  of  the  joint-lesion  is  not  difficult ; 
but  in  other  cases  the  diagnosis  of  this 
aifection  from  tuberculosis  of  the  joints  is 
often  difficult  or  imj)ossib]e.  Treatment. 
— The  results  of  treatment  in  syphilitic 
synovitis  and  arthritis  are  usually  satisfac- 
tory ;  immobilization  of  the  joint  is  seldom 
necessary,  and  the  patient  may  be  allowed 
to  use  the  part  moderately.  The  local  use 
of  mercurial  ointment  or  plaster  over  the 
joint  is  often  followed  by  good  results.  In 
young  subjects,  and  especially  in  congenital 
cases,  biniodide  of  mercury  or  the  bichloride  in  appropriate  doses,  continued 
for  some  time,  is  often  followed  by  the  best  results.  In  older  subjects,  or  even 
in  young  subjects,  after  mercurials  have  been  used  for  sometime,  the  admin- 
istration of  iodide  of  potassium  alone,  or  the  mixed  treatment,  biniodide  of 
mercury,  one-twenty-fourth  grain,  iodide  of  potassium,  five  to  ten  grains, 
will  often  be  followed  by  rapid  diminution  of  the  j  oint  affection.  As  anaemia 
is  usually  associated  with  this  condition,  iron  in  some  form  should  be  admin- 
istered, the  iodide  being  especially  useful. 

Rheumatic  Arthritis. — This  form  of  arthritis  may  be  acute  or  chronic. 
Acute  rheumatic  E^rthritis  usually  attacks  a  number  of  joints  at  the  same 
time,  and  is  characterized  by  the  same  symi^toms  as  acute  synovitis, — pain, 
tenderness  on  pressure  or  motion,  heat,  swelling,  elevation  of  temperatoi-e, 
and  increase  in  the  pulse-rate.  This  form  of  arthritis  is  a  local  manifestation 
of  a  general  disease,  which  usually  ends  in  resolution  without  producing  any 


Syphilitic  arthritis  of  the  elbow. 


OSTEOAETPIRITIS.  613 

marked  structural  change  in  the  joints  involved  or  any  loss  of  function,  and 
is  more  likely  to  come  under  the  care  of  the  physician  than  of  the  surgeon. 
Monarticular  rheumatism  is  most  likely  to  be  confounded  with  acute  suppu- 
rative arthritis. 

Chronic  Rheumatic  Arthritis. — This  affection  may  result  from 
repeated  attacks  of  acute  rheumatism,  or  may  occur  in  persons  who  are 
constantly  exposed  to  cold  or  dampness.  There  ai'e  marked  alterations  in 
the  joint  structures,  the  synovial  membranes  and  periarticular  structures 
becoming  thickened,  and  the  secretion  of  synovial  fluid  is  diminished  :  the 
cartilages  are  occasionally  eroded,  and  the  joint  becomes  stiff  and  painful. 
Upon  motion  of  the  joint  crackling  or  crepitation  may  be  elicited.  In  some 
cases  plastic  exudation  binds  together  the  articular  and  periarticular  struc- 
tures, so  that  restriction  of  motion  or  ankylosis  results.  Wasting  of  the 
muscles  is  very  marked.  Treatment. — This  is  dii-eoted  to  promoting  the 
absorjjtion  of  the  exudations  and  adhesions,  and  then  as  far  as  j)ossible 
restoring  the  function  of  the  affected  joints.  The  patient  shoxild  wear 
woollen  clothing,  and  avoid  exposure  to  cold  and  dampness.  The  admin- 
istration of  salicylates,  iodide  of  potassium,  and  the  salts  of  lithium  should 
be  resorted  to,  and  iron,  arsenic,  and  strychnine  may  be  employed  with 
advantage.  Massage  and  electricity  are  of  service,  and  ankylosis  may  be 
overcome  by  motions  of  the  joint  under  an  auEesthetic.  When  there  is 
marked  contraction  of  the  joints,  tenotomy  may  be  required  to  correct  the 
deformity. 

Gouty  Arthritis. — This  form  of  arthritis  occurs  in  patients  of  a  gouty 
.  diathesis,  and  attacks  especially  the  smaller  articulations,  such  as  those  of 
the  fingers  and  toes  and  the  metacarpal  and  metatarsal  joints.  There  is  a 
deposit  of  urate  of  sodium  in  the  connective  tissue  of  the  joint  and  the 
periarticular  tissues,  which  results  in  destruction  of  the  cartilages,  alter- 
ation in  the  shape  of  the  joint,  and  impairment  of  motion.  The  irritant 
action  of  the  urate  of  sodium  results  in  overgrowth  of  the  connective  tissue 
and  the  jproduction  of  fibrous  tissue,  which  contracts  and  causes  deformity 
of  the  joint.  Prom  its  accumulation  in  the  joints  chalk-stones  form,  which 
may  cause  ulceration  of  the  skin  over  them.  In  gouty  subjects  acute  exacer- 
bations occur,  and  the  affection  usually  involves  one  or  more  joints,  which 
become  hot,  swollen,  and  jDainful,  the  metatarso-phalangeal  joint  of  the 
great  toe  being  the  one  most  commonly  involved.  Gouty  arthritis  is  simply 
the  local  manifestation  of  a  general  disease  which  comes  under  the  province 
of  the  physician,  but  the  occurrence  of  sui)puration  or  contraction  and 
deformities  of  the  joints  may  require  surgical  treatment. 

Osteoarthritis. — Arthritis  Deformans. — This  is  a  disease  of  later 
life,  and  is  rarely  seen  in  subjects  under  fifty  years  of  age,  although  it  occa- 
sionalljf  develops  in  feeble  individuals  under  this  age  ;  it  is  more  common 
in  women  than  in  men.  It  appears  to  arise  from  loss  of  vitality  of  the  tis- 
sues, possibly  dependent  upon  trophic  nerve-changes,  which  lead  to  defective 
innervation.  In  the  early  stage  of  this  affection  the  articular  cartilages 
appear  roughened  and  iibrillated,  and  finally  there  is  an  actual  loss  of  sub- 
stance in  the  cartilage  ;  later  there  is  swelling  of  the  edges  of  the  cartilage, 
with  the  formation  of  nodules,  and  masses  of  cartilage  may  become  detached. 


614 


NEUROPATHIC  ARTHRITIS. 


Fig.  538. 


Osteoarthritis  of  the  shoulder-joint.   (Aguew.) 


forming  loose  bodies  in  the  joint ;  still  later  the  bone  becomes  hypersemic, 
and  osseous  tissue  is  thrown  out  around  the  periphery  of  the  joint,  the  latter 

condition  pi'oducing  great  deformity  and 
interfering  seriously  with  its  motions. 
(Fig.  538.)  Symptoms. — The  symptoms 
which  distinguish  this  affection  from  other 
varieties  of  arthritis  are  slowness  in  the 
development  of  the  articular  changes,  ab- 
sence of  pain  or  of  elevation  of  tempera- 
ture, grating  ujDon  movement,  enlarge- 
ment and  distortion  of  the  joints,  and 
muscular  atrophy.  In  young  persons  the 
disease  may  present  a  more  acute  type. 
In  some  cases  one  joint  only  is  affected, 
especially  in  elderly  persons,  in  whom  the 
hip  may  be  involved,  giving  rise  to  the 
affection  known  as  morbus  coxce  senilis,  or 
the  vertebral  articulations  may  be  in- 
volved, jjroducing  stiffness  and  deformity 
of  the  spine.  Treatment. — The  treatment  of  this  affection  is  unsatisfactory, 
although  in  the  early  stage  of  the  disease  it  may  retard  the  development. 
All  depressing  influences  should  be  removed,  and  the  nutrition  of  the  patient 
should  be  improved  by  the  administration  of  cod-liver  oil  and  arsenic  ;  iodide 
of  potassium  and  iodide  of  iron  may  often 
be  employed  with  good  results.  Anky- 
losis of  the  joints  should  be  j)  re  vented  by 
careful  passive  motion,  and  massage  is  of 
great  service  in  hastening  the  absorption 
of  effusions  and  in  improving  the  nutri- 
tion of  the  muscles  and  tissues  in  the 
region  of  the  diseased  joints. 

Neuropathic  Arthritis.  —  Spinal 
Arthropathy. — Charcot's  Disease. — 
This  is  a  peculiar  form  of  osteoarthritis, 
which  has  been  described  by  Charcot, 
presenting  many  of  the  symptoms  of  ar- 
thritis deformans,  and  occurring  in  pa- 
tients suffering  from  locomotor  ataxia, 
and  syringomyelia.  (Fig.  539.)  The 
disease  is  more  acute  in  its  course  than 
the  ordinary  osteoarthritis,  and  affects 
the  larger  joints,  particularly  the  knee- 
joint.  The  essential  cause  of  this  affec- 
tion is  degeneration  of  the  spinal  cord 
with  secondary  nutritive  changes  in  the  articulations.  Symptoms. — 
The  disease  begins  acutely  with  au  effusion  into  the  joint,  which  is  unac- 
companied by  pain  or  elevation  of  temj)erature,  and  soon  undergoes  absorp- 
tion or  organization ;   later,  degeneration  of  the  articular  cartilages,  peri- 


FiG.  5.S9. 


Neuropathic  arthritis  of  the  knee-joint. 
\\ilham  J.  Taylor.) 


NEURALGIA  OF  JOINTS.  615 

articular  structures,  and  bone  occurs,  and  there  is  often  great  enlargement 
of  the  ends  of  the  bones  by  osteophytes,  very  similar  to  those  seen  in  osteo- 
arthritis. Grating  of  the  joint  upon  motion  is  present,  and  i-elaxation  and 
degeneration  of  the  ligaments  often  give  rise  to  great  mobility  or  partial 
or  complete  dislocation  of  the  joint.  Eapid  muscular  atrophy  is  observed 
at  the  same  time.  Degeneration  of  the  bones  in  the  region  of  the  joint  may 
cause  fracture  upon  slight  provocation.  Treatment. — The  treatment  of 
this  condition  is  that  appropriate  for  the  nervous  condition,  the  joint  at  the 
same  time  being  protected  by  the  application  of  a  splint  or  apparatus  which 
serves  to  limit  the  motion  and  prevent  displacement. 

Hysterical  Affections  of  Joints. — This  consists  in  a  disabled  or  pain- 
ful condition  of  the  joints,  and  is  most  commonly  seen  in  young  women ; 
the  joints  most  frequently  aifected  are  the  hip  and  the  knee.  It  may  arise 
after  a  slight  injury  or  sprain  of  the  joint,  or  without  apparent  cause. 
Symptoms. — The  patient  complains  of  pain  in  the  joint  and  refuses  to 
move  it ;  the  overlying  skin  is  hypertesthetic,  there  is  no  marked  swelling, 
and  the  joint  may  be  maintained  in  a  position. of  flexion  or  extension, 
although  it  is  generally  observed  that  the  amount  of  flexion  or  extension  is 
changed  from  day  to  day,  and  the  flexion  is  not  like  that  which  is  common 
in  arthritis.  Muscular  atrophy  is  present  from  disuse.  Superficial  pressure 
produces  evidence  of  extreme  pain,  while  deep  pressure  is  often  painless. 
Irregular  areas  of  ansesthesia  and  hypersesthesia,  not  corresponding  with  the 
anatomical  distribution  of  the  nerves,  can  sometimes  be  found  upon  the 
limb.  Fixation  of  the  joint  is  usually  quickly  overcome  if  the  patient  is 
anaesthetized  ;  the  patient  at  the  same  time  often  exhibits  other  symptoms  of 
hysteria.  Treatment. — The  treatment  of  this  affection  often  requires  the 
greatest  judgment  and  skill  upon  the  part  of  the  surgeon.  The  constitu- 
tional condition  of  the  patient  should  receive  as  much  attention  as  the 
affected  joint.  The  general  health  should  be  carefully  looked  after,  tonics 
often  being  indicated,  and  the  surgeon  should  endeavor  to  make  the  patient 
understand  that  the  condition  is  one  which  will  soon  improve  under  treat- 
ment. We  have  found  in  these  cases  the  best  results  follow  the  use  of 
Paquelin's  cautery,  the  point  being  lightly  passed  over  the  skin  of  the 
joint  at  a  number  of  points,  and  after  a  few  applications  of  this  nature 
massage  and  passive  motion  should  be  employed ;  at  the  same  time  the 
patient  is  encouraged  to  make  use  of  the  joint ;  no  dressing  further  than  a  ' 
simple  flannel  bandage  is  indicated.  In  obstinate  eases,  in  addition  to  the 
remedies  above  recommended,  the  removal  of  the  patient  from  her  surround- 
ings and  from  the  attention  of  sympathizing  friends  is  advisable.  The  rest 
treatment  of  Weir  Mitchell  will  often  be  followed  bj'  a  rapid  improvement, 
both  in  the  local  and  in  the  constitutional  condition  of  the  patient. 

Neuralgia  of  Joints. — The  joints  are  occasionally  the  seats  of  pain 
which  appears  to  be  independent  of  a  change  in  the  structure  of  the  joint. 
Such  neuralgic  j)ain  may  arise  from  neurasthenia,  from  malaria,  from  disease 
of  tlie  brain  or  of  the  spinal  cord,  or  from  injury  of  or  pressure  uj)on  the 
trunks  of  nerves  supplying  the  joint.  Symptoms. — The  pain  is  usually 
intermittent,  and  is  often  observed  in  joints  which  have  received  a  previous 
injury,  such  as  a  sprain  or  contusion,  although  the  function  may  have  been 


616  LOOSE  BODIES  IN  JOINTS. 

completely  restored.  The  patient  complains  of  burning  or  lancinating 
pain,  wliich  is  apt  to  be  most  severe  at  tlie  end  of  the  day,  when  he  is  more 
or  less  exhausted.  There  is  no  swelling  or  deformity  of  the  joint,  and  the 
overlying  skin  appears  normal.  Treatment. — When  neuralgia  of  a  joint 
follows  an  injury  and  there  is  more  or  less  fixation,  the  patient  should  be 
anaesthetized  and  passive  movements  made  to  break  up  articular  or  periar- 
ticular adhesions,  and  the  subsequent  use  of  the  joint  should  be  encouraged. 
This  is  usually  followed  by  complete  relief  of  the  painful  symptoms.  If 
the  condition  can  be  traced  to  injury  of  or  pressure  upon  a  nerve-trunk 
supplying  the  joint,  nerve-stretching  or  neurectomy  should  be  practised. 
When  no  tangible  cause  for  the  painful  condition  of  the  joint  can  be  deter- 
mined, the  patient  should  be  placed  upon  tonic  treatment,  and  at  the  same 
time  the  use  of  Paquelin's  cautery  may  be  followed  by  good  results,  the 
point  being  lightly  passed  over  the  joint ;  massage  and  electricity  may  also 
be  employed  with  advantage. 

Neoplasms  of  Joints. — The  joints  are  rarely  the  seats  of  primary 
growths,  such  as  sarcomata,  carcinomata,  or  choudromata.  Secondary  in- 
vasion of  the  joints,  however,  sometimes  occurs.  Carcinoma  as  a  secondary 
affection  of  joints  is  among  the  rarest  of  diseases.  Sarcoma  originating  in 
the  head  of  a  bone  may  extend  towards  the  joint  and  stretch  or  .distort  the 
articular  cartilages,  or  rupture  them  and  invade  the  joint.  Cliondromata 
growing  from  the  bones,  the  periosteum,  or  the  soft  parts  may  also  involve 
the  joints  secondarily.  Treatment. — In  cases  of  malignant  neoplasms  of 
joints  the  only  treatment  which  offers  the  patient  relief  is  amj)utation. 

Cysts  of  Joints. — These  are  usually  connected  with  synovial  sacs  in  or 
about  the  joints,  and  result  from  the  dilatation  of  normal  bursse  by  exces- 
sive secretion.     The  treatment  of  cysts  of  joints  is  con- 
sidered under  Bursitis.     (See  page  421.) 

Loose  Bodies  in  Joints. — Loose  bodies,  consisting 
of  fibrocartilage,  bone,  or  fibrous  material,  are  occasion- 
ally observed  in  the  larger  joints,  the  knee-joint  being- 
most  frequently  affected,    and  next  in  frequency  the 
elbow-joint.     They  may  be  loose  in  the  joint,  or  attached 
by  a  long  or  a  short  pedicle.     They  vary  in  size  from 
that  of  a  Ilea  to  an  inch  or  more  in  diameter.    (Fig.  540.) 
These  bodies  originate  from  the  synovial  fringes  of  the 
joint  becoming  detached  and  remaining  free  in  the  joint, 
or  from  detached  osteophytes,  or  portions  of  bone  or 
cartilage,  resulting  from  injury,  or  from  quiet  necrosis, 
°°^^  knee-ioin  °™  *  ^'^    ^^  which  process  a  portion  of  cartilage  is  detached  from 
the  subjacent  bone  without  suppuration.    Fibrous  bodies 
probably  result  from  the  organization  of  blood-clot  which  has  been  j)resent 
in  the  joint. 

Symptoms. — A  patient  who  has  never  received  an  injury  to  his  knee 
may  suddenly  be  seized  with  severe  pain  in  the  joint  and  feel  that  he  is 
unable  to  move  it  in  anj^  direction  ;  at  the  same  time  he  may  complain  of 
nausea,  and  may  even  voinit ;  the  joint  becomes  fixed  and  soon  shows  evi- 
dence of  synovitis.     The  disability  may  last  for  a  few  days,  and  usually 


ANKYLOSIS.  617 

suddenly  disappears  as  the  loose  body  changes  its  position.  The  patient 
often  experiences  no  further  difficulty  for  months,  but  is  likely  to  have  a 
repetition  of  the  same  symptoms  if  the  body  again  becomes  wedged  between 
the  articular  surfaces  of  the  joint.  During  the  interval  he  may  be  conscious 
of  the  body  .slipping  about  in  the  joint  or  in  the  burste  connected  with  the 
joint,  and  it  can  often  be  felt  at  certain  points,  but  usually  quickly  disappears 
if  pressure  is  made  upon  it.  Flexion  and  extension  of  the  joint  may  again  dis- 
lodge it.  Patients  are  often  able,  by  certain  motions  of  the  joint  combined 
with  pressure  and  manipulation,  to  dislodge  the  body,  when  it  can  be  felt  under 
the  skin  in  the  region -of  the  joint.  Sooner  or  later  synovitis  develops,  and 
as  a  result  of  the  stretching  of  the  ligaments  the  joint  becomes  weak. 

Treatment. — The  body  may  be  kept  in  place  by  the  use  of  a  bandage 
hrmly  applied  over  the  joint,  or  by  wearing  a  close-fitting  laced  knee-cap. 
If,  however,  the  patient  experiences  pain  and  frequent  attacks  of  dis- 
ability, if  the  body  can  be  located  the  most  satisfactory  treatment  is  its 
excision.  As  the  body  often  slips  out  of  view  before  the  incision  is  made, 
it  should  be  transfixed  with  a  needle  and  the  incision  made  directly  down 
upon  it.  The  risk  of  this  operation,  if  proi^er  care  is  taken  as  regards 
asepsis,  is  small.  After  the  removal  of  the  body  the  wound  should  be  closed 
by  deep  sutures  uniting  the  edges  of  the  wound  in  the  capsule,  and  finally 
by  a  layer  of  superficial  sutures  approximating  the  skin  and  connective 
tissue,  a  gauze  dressing  applied,  and  the  joint  kept  at  rest  for  a  few  weeks 
upon  a  splint  or  by  a  plaster-of- Paris  dressing. 

Ankylosis. — This  consists  in  the  partial  or  complete  obliteration  of  the 
motions  of  a  joint,  and  results  from :  1.  Alteration  of  the  surfaces  of  the 
joint  from  disease.  2.  Contraction  of  soft  parts,  skin,  tendons,  and  liga- 
ments. 3.  The  presence  of  tumors  or  foreign  bodies  in  the  joint.  4.  Deform- 
ities following  displacements  of  the  fragments  in  fractures.  Disuse  in  the 
larger  joints  is  not  capable  of  producing  comiilete  ankylosis. 

Ankylosis  may  be  either  fibrous  or  bony  ;  the  former  arises  from  the 
removal  of  the  superficial  layer  of  the  articular  cartilages  by  ulceration  and 
the  deposit  of  plastic  material ;  while  the  latter  always  results  from  the 
complete  destruction  of  the  articular  cartilages,  so  that  the  ends  of  the  bones 
come  in  contact  and  unite.  Ankylosis  of  a  joint  may  also  result  from 
adhesions  in  the  capsule  or  extra  capsular  adhesions. 

Ankylosis  of  a  joint  may  result  from  wounds  involving  a  joint  followed 
by  suj)purative  arthritis,  or  from  the  organization  of  effused  blood  in  the 
joint,  the  latter  producing  only  fibrous  ankylosis,  or  from  acute  or  chronic 
arthritis  accompanied  by  destruction  of  the  articular  cartilages,  producing 
bony  ankylosis.  Ankylosis  of  joints  may  occur  in  such  positions  that  the 
limb  is  absolutely  useless,  or  may  take  place  with  the  limb  in  such  a  position 
that  the  part  can  be  of  use  to  the  patient.  In  fibrous  ankylosis  there  is 
always  a  fair  chance  that  the  motions  of  the  joint  may  be  regained  ;  in  cases 
of  bonj'  ankylosis  it  is  imi)ossible  to  have  restoration  of  joint  motion. 

Treatment. — In  cases  of  stiffness  of  joints  from  disuse,  such  as  is  fre- 
quently found  after  prolonged  fixation  in  the  treatment  of  fractures,  where 
there  is  no  true  ankylosis,  passive  motion  and  massage  should  be  employed, 
and  will  usually  be  followed  by  the  lestoration  of  function. 


618  TUBERCULOUS  AETHEITIS. 

In  fibrous  ankylosis  witli  the  limb  in  bad  position,  following  contu- 
sions or  wounds  of  joints,  where  the  ankylosis  is  due  to  intra-  and  peri- 
articular fibrous  bands,  an  anaesthetic  should  be  administered  and  forcible 
movements  of  the  joint  made  to  break  up  adhesions,  and,  after  putting 
the  joint  at  rest  for  a  few  days,  passive  motion  should  be  carefully  j)rac- 
tised.  If  the  cases  are  of  long  standing  and  the  contraction  is  marked,  the 
surgeon  should  remember  the  possibility  of  contracture  of  the  important 
blood-vessels  and  nerves,  which  may  be  torn  if  forcible  movements  of  the 
joint  are  made  in  straightening  the  limb.  In  such  cases  excision  of  the  joint 
is  preferable.  In  cases  of  fibrous  ankylosis  of  joints  in  good  position  as 
regards  their  usefulness,  and  of  fibrous  ankylosis  resulting  from  tubercular 
arthritis,  no  forcible  movements  should  be  practised,  as  fresh  inflammation 
may  be  excited  and  subsequent  destruction  of  the  joint  may  occur.  In  bony 
ankylosis  with  the  joint  in  good  position,  the  treatment  depends  upon  the 
joint  involved  ;  at  the  knee-joint  ankylosis  with  the  limb  nearly  straight  is 
a  condition  which  cannot  be  improved  upon  by  operation  ;  the  same  may  be 
said  of  the  hip-  and  ankle-joints.  Here  attempts  to  restore  joint  motion  by 
forcible  movements  are  useless,  and  may  result  in  fracture'  of  the  bone,  which 
may  occur  at  the  position  of  the  former  articulation  or  at  other  points. 

In  the  joints  of  the  upper  extremity,  the  shoulder  and  elbow,  for  instance, 
the  loss  of  motion  interferes  so  much  with  the  patient's  means  of  livelihood 
and  comfort  that  operative  treatment  is  indicated.  In  these  cases  excision 
of  the  ankylosed  joint  may  be  undertaken  with  the  idea  of  obtaining  a  false 
joint  which  will  increase  the  usefulness  of  the  part.  In  bony  ankylosis  in 
bad  position,  when  the  limb  is  useless,  excision  of  the  ankylosed  joint 
should  be  practised,  or  the  deformity  may  be  corrected  by  an  osteotomy  of 
the  bones  above  and  below  the  joint.  After  excision,  if  it  is  desirable  to 
have  a  movable  joint,  as  soon  as  the  wound  has  healed  motion  should  be 
encouraged,  so  that  a  false  joint  shall  result.  If  fixation  is  desired,  the 
splints  should  be  retained  until  firm  fibrous  or  bony  union  has  occurred. 

Tuberculous  Arthritis. — The  majority  of  cases  of  chronic  joint 
disease  arise  from  infection  by  the  bacillus  tuberculosis.  The  disease  may 
originate  in  the  bone,  the  synovial  membrane,  the  capsule  of  the  joint,  or  the 
periarticular  structures.  The  predisposing  cause  of  tuberculous  arthritis  may 
in  many  cases  be  traced  to  sprains,  blows,  twists,  or  exposure  to  cold  ;  in  other 
cases  the  disease  develops  without  apj)arent  cause  ;  the  exciting  cause  is  the 
bacillus  tuberculosis.  Tuberculosis  of  synovial  membranes  is  more  frequent 
in  adults,  while  tuberculosis  of  bone  is  more  common  in  children.  When  the 
synovial  membrane  is  the  seat  of  the  disease  from  direct  infection  of  a  joint 
by  tuberculous  matter,  there  are  active  hypersemia  of  the  membrane  and 
external  swelling,  but  when  the  invasion  of  the  disease  is  slower  the  joint 
shows  little  evidence  of  active  inflammation,  the  synovial  membrane  becomes 
congested,  hypertrophied,  and  cedematous,  and  there  is  an  abundant  devel- 
opment of  granulation-tissue.  The  tubercular  infection  produces  a  pulpy 
condition  of  the  entire  synovial  sac,  with  usually  little  or  no  effusion  into 
the  joint,  the  swelling  being  entirely  due  to  a  thick  layer  of  granulation- 
tissue.  In  this  form  of  tuberculosis  great  deformity  of  the  joints  results 
early  in  the  disease,  such  as  flexion,  rotation,  and  in  some  cases  partial 


TUBERCULOUS  ARTHRITIS.  619 

luxation.  More  rarely  the  fungous  granulations  are  less  marked,  and  free 
effusion  takes  place  into  the  joint.  If  the  primary  infection  takes  place  in 
the  bone,  the  disease  by  direct  extension  of  the  process  soon  involves  the 
structures  of  the  joint,  a  portion  of  the  articular  cartilage  is  destroyed,  and 
the  joint  is  opened.  Tuberculosis  of  bone  in  the  region  of  a  joint  usually 
involves  the  synovial  structure  of  the  joint,  and,  on  the  other  hand,  f)rimary 
tuberculous  synovitis  and  arthritis  are  apt,  by  extension,  later  to  implicate 
the  subjacent  bone. 

Symptoms. — In  a  case  of  tuberculous  arthritis  the  marked  swelling  of 
the  joint  is  due  to  the  production  of  excessive  granulation-tissue,  which  may 
undergo  degeneration,  becoming  softened  and  oedematous,  and  the  appear- 
ance of  the  joint  changes,  becoming  spindle-shaped,  as  the  softened  liga- 
ments offer  little  resistance  to  the  growing  granulations.  The  skin  over  the 
joint  is  white  and  thickened,  and  palpation  will  often  elicit  a  sensation  of 
fluctuation,  when  the  synovial  sacs  are  distended  with  effusion  or  pus.  Pain 
in  synovial  tuberculosis  is  usually  slight,  but  may  be  more  marked  in  the 
joint  tuberculosis  which  originates  in  the  bone  ;  it  may  be  elicited  by  press- 
ure or  by  certain  motions.  The  temperature  of  the  patient  may  be  slightly 
elevated,  and  the  joint  may  feel  hot  to  the  touch.  Deformity  is  iiresent  in 
all  cases  to  a  greater  or  less  degree,  depending  upon  the  joint  involved,  the 
extent  of  softening  and  degeneration  of  the  ligaments,  the  tendency  to 
assume  certain  attitudes  to  secure  relief  from  pain,  and  muscular  spasm 
induced  by  reflex  irritation.  Muscular  spasm  is  one  of  the  first  and  most 
important  symptoms  of  joint  tuberculosis,  and  is  reflex,  resulting  in  uncon- 
scious automatic  contraction  of  the  muscles,  producing  rigidity  and  fixation 
of  the  joint.  Impairment  of  joint  motion  may  be  slight  at  first,  but  as  the 
disease  advances  it  becomes  a  prominent  symptom.  Caseation  and  lique- 
faction of  the  granulations  covering  the  synovial  membrane  may  occur,  and 
the  pus,  so-called,  accumulates  in  the  cavity  of  the  joint,  and  finally  per- 
foi-ates  the  capsule,  forming  abscesses  and  sinuses.  During  this  process  the 
granulations  are  destroyed,  the  tubercle  bacilli  penetrate  the  deeper  tissues, 
and  the  patient  is  exjiosed  to  the  risks  of  general  tubercular  infection.  If, 
upon  spontaneous  or  intentional  opening  of  such  a  joint,  infection  occurs, 
there  is  aggravation  of  the  local  condition  of  the  diseased  joint  and  of  the 
patient's  constitutional  condition. 

Pannus  Synovitis. — In  this  form  of  synovitis  or  arthritis  the  tuber- 
cles are  present  in  great  numbers  widely  disseminated  over  the  synovial 
membranes,  but  are  rarely  visible  to  the  naked  eye.  Prom  the  border  of 
the  articular  cartilages  a  thin  layer  of  granulations  approaches  the  centre 
of  the  joint,  the  vascularity  of  the  membrane  is  marked,  and  the  ligaments 
and  periarticular  structures  are  but  slightly  affected.  There  is  sometimes  a 
large  serous  effusion  in  the  joint. 

Diagnosis. — The  diagnosis  between  primary  osteal  and  primary  synovial 
tuberculosis  is  often  a  matter  of  difficulty.  In  cases  of  the  fungous  variety 
of  the  disease  involving  superficial  joints,  if  well  advanced,  and  if  it  has 
gone  on  to  the  formation  of  abscess  or  sinus,  the  recognition  of  the  disease 
is  not  difficult.  This  affection  may  be  confounded  with  syphilitic  arthritis, 
with  which  it  has  some  points  in  common,  but  the  latter  affection  is  quite 


620  TUBERCULOUS  AETHKITIS. 

rare,  except  in  children,  and  careful  examination  will  often  show  other 
evidences  of  syphilis.  In  i^rimary  tubercnlosis  of  joints,  aside  from  the 
circumscribed  points  of  tenderness  over  certain  parts  of  the  joint,  if  the 
disease  is  not  far  advanced,  the  loss  of  function,  swelling,  and  muscular 
resistance  may  be  so  little  marked  that  it  will  be  difficult  to  say  that  the 
affection  exists.  If,  however,  any  of  the  symx)toms  are  present,  the  patient 
should  be  treated  as  if  joint  tuberculosis  were  actually  present. 

Prognosis. — This  depends  largely  upon  the  general  condition  of  the 
patient  and  the  extent  of  the  local  disease,  as  well  as  the  treatment  adopted 
and  the  time  of  beginning  treatment.  When  the  disease  involves  only  a 
small  portion  of  a  joint,  recovery  may  take  place  with  only  partial  anky- 
losis and  impairment  of  joint  function.  Where  there  is  marked  involve- 
ment of  the  joint,  the  destruction  may  be  so  extensive  that  recovery  can 
take  place  only  with  marked  restriction  of  motion  or  ankylosis,  the  fixation 
resulting  from  firm  fibrous  or  bony  union.  The  development  of  abscess  or 
sinus  may  result  in  caries  or  necrosis  of  the  articular  ends  of  the  bones. 
Many  cases  of  joint  tuberculosis  run  a  course  of  years  and  finally  recover, 
with  more  or  less  impairment  of  motion.  In  tuberculosis  of  joints  there 
are  three  distinct  stages  which  are  recognized  during  the  course  of  the  affec- 
tion,— 1,  musciilar  spasm  or  rigidity  ;  2,  effusion  or  granulation  ;  3,  abscess. 
Caseation,  if  extensive,  is  accomi>anied  by  constitutional  disturbance  of  more 
or  less  severity,  and  if  septic  infection  occurs  it  involves  additional  risks  to 
the  patient.  During  the  course  of  the  disease  the  patient  is  also  in  danger 
of  the  develox^ment  of  general  or  visceral  tuberculosis,  and,  in  cases  of 
prolonged  suppuration,  of  amyloid  disease. 

Treatment. — A  spontaneous  cure  in  cases  of  joint  tuberculosis  is  rare, 
and  if  it  does  occur  it  usually  results  in  such  marked  deformity  of  the  joint 
that  a  subsequent  operation  has  to  be  undertaken  to  render  the  part  useful. 
The  most  important  point  in  the  treatment  is  to  secure  complete  rest  or 
immobilization  and  favor  ankylosis,  as  the  disease  is  always  aggravated  by 
movements  of  the  joint.  Early  immobilization  secures  perfect  rest,  and  at 
the  same  time  tends  to  prevent  subsequent  deformity.  Immobilization  may 
be  accomplished  by  the  use  of  orthoi^sedic  apparatus  or  by  the  application  of 
a  plaster-of- Paris  dressing.  The  plaster  bandage  is  often  incorrectly  applied, 
so  that  it  does  not  completely  immobilize  the  joint.  In  aj^plying  the  jalaster- 
of-Paris  dressing  to  fix  the  knee-joint  the  bandage  should  extend  from  the 
toes  to  the  groin  ;  for  the  ankle,  the  bandage  should  extend  from  the  toes  to 
the  knee.  To  secure  fixation  of  the  hip-joint,  the  patient  should  stand  with 
his  sound  limb  upon  a  low  stool,  so  that  extension  of  the  diseased  joint  is 
made  by  the  weight  of  the  limb,  and  the  bandage  should  envelop  the  limb 
from  the  toes  to  the  pelvis,  which  should  be  surrounded  by  turns  of  the  band- 
age, or  the  patient's  pelvis  should  be  supported  ujion  an  apparatus  (Fig.  81), 
extension  at  the  same  time  being  made  upon  the  limb  while  the  bandage  is 
carried  around  the  iielvis.  In  immobilizing  the  shoulder-joint  the  arm  should 
be  fastened  to  the  side,  and  in  the  elbow  the  bandage  is  applied  to  the  arm, 
which  is  flexed  to  a  right  angle,  from  the  wrist  to  the  shoulder. 

In  fixing  tuberculous  joints  the  surgeon  should  always  bear  in  mind  the 
possibility  of  ankylosis,  and  see  that  the  joint  is  fixed  in  such  a  position 


DISEASES  OF  SPECIAL  JOINTS.  621 

that  it  will  be  most  useful  if  this  result  should  occur.  Fixation  of  the 
diseased  joint  may  also  be  secured  by  the  use  of  moulded  splints  of  binder's 
board  or  of  felt,  and  by  the  use  of  mechanical  apparatus,  which  can  be  so 
constructed  that  it  fixes  the  joint  and  at  the  same  time  makes  traction  upon 
it  so  as  to  separate  the  diseased  joint  surfaces.  The  latter  form  of  splint  is 
one  which  is  largely  employed  in  the  treatment  of  tuberculous  arthritis  of 
the  hip,  knee,  and  ankle.  Fixation  of  the  joint  should  be  maintained  for  a 
considerable  time,  even  after  the  evidences  of  active  disease  have  disap- 
peared, fixation  for  months  or  5-ears  often  being  required.  If  deformity  has 
occurred  before  the  case  comes  iinder  the  surgeon's  care,  this  should  be 
corrected  by  the  apijlication  of  weight  extension  or  by  tenotomy  before  the 
fixation  apparatus  is  applied.  Aspiration  may  be  required  in  cases  in 
which  there  is  a  large  effusion  in  the  joint  or  when  a  tuberculous  abscess 
has  formed.  The  treatment  of  tubercular  joints  by  the  injection  of  agents 
which  favor  the  cicatrization  of  the  new  tissue  and  bring  about  destruction 
or  encapsulation  of  the  bacilli  has  recently  been  employed  with  most  encour- 
aging results.  (See  page  66.)  When,  in  spite  of  rest  or  injection,  the 
disease  progresses  and  destruction  of  the  tissues  of  the  joint  begins,  operative 
treatment,  such  as  arthrectomy,  excision,  or  amputation,  is  often  required. 

The  operative  treatment  of  tuberculosis  of  the  joints,  arthrectomy  or 
excision,  in  children  may  be  deferred  to  a  later  period  than  in  adults,  for 
in  the  former  subjects  recovery  with  ankylosis  is  more  likely  to  occur,  while 
in  adults  early  operation  is  usually  required.  Amputation  in  tuberculosis 
of  joints  is  rarely  demanded,  but  is  occasionally  required  as  a  life-saving 
measure  in  cases  where  there  is  extensive  disease  of  the  joints  as  well  as  of 
the  periarticular  structures,  or  in  cases  of  multiple  affection  of  the  joints  of 
the  same  limb,  or  where  the  patient  presents  marked  exhaustion  from  pro- 
fuse suppuration  or  shows  evidence  of  beginning  visceral  disease.  Ampu- 
tation is  sometimes  required  after  excision  where  no  improvement  follows 
this  operation. 

In  tuberculous  arthritis,  in  addition  to  the  local  treatment  just  described, 
the  patient's  constitutional  condition  should  receive  most  careful  attention. 
He  should  be  given  a  nutritious  and  easily  assimilated  diet,  and  should  be  in 
the  fresh  air  as  much  as  possible ;  sea  air  is  often  very  beneficial.  The 
drugs  which  are  most  serviceable  are  iron,  which  may  be  given  in  the  form 
of  the  iodide  of  iron,  cod-liver  oil,  and  syrup  of  hydriodic  acid. 

DISEASES  OP  SPECIAL  JOINTS. 

Diseases  of  the  Hip-Joint.— Simple  Acute  Synovitis  of  the 
Hip-Joint. — This  affection  is  occasionally  seen  in  the  hip-joint,  although, 
from  the  depth  of  the  joint  and  its  protection  by  muscles  and  fascia,  it  is  not 
so  much  exposed  to  the  causes  producing  it  as  some  other  joints.  The  con- 
dition may  result  from  exi^osure  to  cold  or  from  strains.  Symptoms. — 
These  are  heat  and  stiffness,  accompanied  with  pain,  which  is  often  referred 
to  the  knee,  from  the  connection  between  the  two  joints  by  the  obturator 
nerve  ;  swelling  may  be  noticed  over  the  front  and  back  of  the  capsule,  caused 
by  effusion  into  the  synovial  sac  and  by  oedema.  Flexion,  abduction,  and 
eversion  of  the  thigh  are  also  present.      In  the  early  stages  of  the  affection 


622  ACUTE  SEPTIC  SYNOVITIS   OF  THE   HIP. 

the  patient  has  a  well-marked  limp  in  walking,  and  later  the  pain  and  ten- 
derness may  be  so  great  that  he  cannot  use  the  limb.  Diagnosis. — In  young 
subjects  it  is  often  difficult  to  differentiate  this  affection  from  tuberculous 
arthritis  of  the  hip  or  coxalgia,  but  the  diagnosis  can  be  made  in  most  cases 
by  observing  that  it  comes  on  soon  after  a  strain  or  exposure  to  cold,  and 
when  proper  treatment  is  instituted  recovery  soon  takes  place.  We  are 
inclined  to  think  that  many  of  the  cases  of  coxalgia  which  have  been  reported 
as  being  cured  in  a  short  time  by  the  use  of  splints  or  special  apparatus,  in 
which  recovery  followed  without  deformity  and  impairment  of  function  of 
the  joint,  were  really  cases  of  acute  simple  or  rheumatic  synovitis  of  the  hij). 

Treatment. — The  first  indication  in  treatment  is  to  put  the  joint  at  rest. 
This  may  be  accomplished  by  confining  the  patient  to  bed  and  applying 
extension  by  means  of  a  weight  and  pulley  attached  to  an  extension  appa- 
ratus applied  to  the  leg,  such  as  is  used  to  make  extension  in  fractures  of  the 
femur  ;  lateral  support  may  also  be  given  to  the  limb  by  the  use  of  sand-bags. 
The  same  object  may  be  accomplished  by  the  use  of  Thomas's  or  Taylor's 
splint,  or  modifications  of  the  same,  in  case  it  is  desirable  to  allow  the 
patient  to  go  about  during  the  course  of  treatment.  In  infants  and  young 
children  fixation  may  be  secured  by  the  aj)plication  of  a  splint  of  felt  or 
binder's  board  moulded  to  the  leg,  thigh,  and  pelvis.  If  pain  is  marked,  the 
local  application  of  hot  fomentations  or  lead  water  and  laudanum  will  often 
be  of  service.  The  patient  should  be  carefully  fed  and  given  tonics.  Fixa- 
tion of  the  joint  should  be  maintained  for  some  weeks,  and  not  until  after  all 
pain,  swelling,  and  tenderness  have  subsided  should  the  splint  be  removed 
and  the  patient  allowed  to  use  the  limb. 

Acute  Septic  Synovitis  and  Arthritis  of  the  Hip.— This  condition 
may  result  from  pyaemia,  from  infected  wounds,  or  by  extension  from  an 
acute  epiphysitis,  or  may  occur  as  a  complication  of  tj'phoid  or  scarlet 
fever,  or  measles.  Symptoms. — The  disease  runs  a  rapid  course,  the  limb 
soon  becomes  abducted,  flexed,  and  everted,  and  the  distended  capsule  of 
the  joint  is  apt  to  rupture,  allowing  the  pus  to  escape  into  the  surrounding- 
tissues  ;  the  head  of  the  bone  may  also  become  dislocated  from  distention  of 
the  capsule.  Pain  and  fever  are  present.  Treatment. — As  soon  as  there 
is  evidence  of  purulent  effusion  in  the  joint,  it  should  be  opened  by  incision, 
irrigated  with  normal  salt  or  bichloride  solution,  and  thoroughly  drained, 
and  an  extension  apj^aratus  or  si3lint  should  be  applied  to  fix  the  joint.  The 
patient's  constitutional  condition  should  receive  attention,  stimulants,  qui- 
nine, and  iron  being  administered  freelj\  In  many  cases  of  acute  septic 
arthritis  of  the  hip  recovery  follows  with  a  useful  joint  after  incision  and 
free  drainage  ;  in  some  cases,  however,  after  the  wounds  have  healed,  more 
or  less  fixation  of  the  joint  results.  If  dislocation  of  the  head  of  the  bone 
has  occurred,  its  reduction  may  often  be  accomplished  by  maniijulation. 

Tuberculous  Arthritis  of  the  Hip,  Coxalgia,  Hip-Joint  Dis- 
ease.— This  is  one  of  the  most  frequent  joint-affections  which  come  under 
the  care  of  the  surgeon,  and  is  most  common  in  children,  but  is  occasionally 
seen  in  adults.  The  disease  may  be  osteal  or  synovial  iu  its  origin.  The 
tubercular  deposit  in  the  majority  of  cases  takes  place  at  the  femoral 
epiphysis  or  in  the  head  of  the  femur  under  the  articular  cartilage,  but  it 


TUBERCULOUS   ARTHRITIS   OF  THE   HIP.  623 

may  also  occur  in  the  acetabulum  or  in  the  synovial  membrane  of  the  joint. 
Primary  infection  of  the  synovial  membrane  is  probably  much  more  frequent 
than  is  generally  supposed.  In  children  the  starting-point  of  the  disease  is 
almost  without  excei^tion  in  the  bone,  at  the  epiphj^seal  line,  or  in  the  head 
of  the  femur  ;  while  in  adults  the  synovi^al  membrane  is  most  frequently  the 
seat  of  the  primary  infection.  In  some  cases  the  predisposing  cause  of  the 
affection  can  be  traced  to  slight  traumatisms,  but  in  others  the  disease 
apparently  develops  without  exciting  cause. 

Clinical  History. — The  symptoms  which  first  attract  attention  are  a 
slight  limp,  pain  in  the  hip,  or  more  commonly  at  the  inner  side  of  the  kuee, 
with  a  tendency  soon  to  grow  tired  upon  slight  exertion,  and  starting-pains 
at  night  caused  by  muscular  spasm.  The  child  while  asleep  will  suddenly 
cry  out  and  become  awakened,  but  soon  drop  off  to  sleep  again.  These 
symptoms  the  parent  is  apt  to  attribute  to  some  fall  or  injury  which  the 
child  has  received,  but  upon  careful  questioning  it  is  rarely  found  that 
a  satisfactory  connection  between  an  injury  and  the  development  of  the 
symptoms  can  be  established.  The  symptoms  may  be  gradually  aggravated, 
so  that  the  nature  of  the  disease  cannot  be  mistaken,  or  there  may  be  a 
remission  of  some  weeks  or  months,  followed  by  the  return  of  the  same 
symptoms,  the  pain  in  the  hip  and  knee,  the  limp,  and  the  starting-pains  at 
night  being  more  marked  than  in  the  first  instance. 

In  the  development  of  tuberculous  disease  of  the  hip  three  stages  are 
recognized,  each  accompanied  with  distinctive  symptoms.  1.  The  stage  of 
deposition  of  bacilli,  causing  irritation  and  new  growth.  2.  The  stage  of 
fully  developed  arthritis,  with  the  formation  of  embryonic  tissue-masses  and 
effusion  into  the  joint.  3.  The  stage  of  caseation  or  abscess,  with  breaking 
down  of  the  infected  tissues,  disorganization  of  the  joint,  and  destruction  of 
the  periarticular  tissues. 

Ssonptoms. — First  Stage. — There  is  slight  lameness  or  stiffness  in  the 
articulation,  the  knee  is  slightly  flexed,  and  the  limb  is  abducted  ;  stiffness 
may  be  more  marked  in  the  early  part  of  the  day  than  later,  when  consider- 
able exercise  has  been  taken .  The  patient  is  disinclined  to  play,  and  soon 
becomes  tired.  Eigidity  of  the  muscles  about  the  joint  is  observed, 
especially  of  the  adductors.  Pressure  upon  the  trochanter  or  the  sole  of  the 
foot  causes  pain  in  the  hip-joint.  Pain  in  this  stage  is  not  often  marked, 
but  may  be  complained  of  in  the  hip,  or  more  frequently  at  the  inner  side  of 
the  kuee,  because  of  the  relation  of  the  obturator  nerve  to  these  articula- 
tions. Starting-pains  at  night  may  be  present.  The  amount  of  pain  depends 
largely  uj)on  the  extent  and  rapidity  of  involvement  of  the  bone  ;  when  the 
epiphysis  and  osseous  tissue  beneath  the  articular  cartilage  are  involved, 
l^ain  is  apt  to  be  a  prominent  symptom.  The  muscles  may  be  slightly 
atrophied,  and  there  may  be  some  fulness  over  the  joint  in  front  of  and 
behind  the  trochanter. 

Second  Stage. — This  is  characterized  by  the  occurrence  of  marked 
deformity,  caused  by  inflammation,  with  softening  and  partial  destruction 
of  the  ligaments,  and  by  changes  in  the  bone-substance,  and  muscular  con- 
traction. The  patient  limps  decidedly,  the  adductor  muscles  are  rigid,  the 
muscles  of  the  thigh  are  atrojihied,  and  effusion  into  the  cajisule  may  cause 


624 


TUBERCULOUS  ARTHRITIS   OF  THE  HIP. 


Fig.  541. 


swelling  in  the  region  of  the  joint.  The  limb  is  abducted  and  everted,  the 
buttock  on  the  affected  side  is  flattened,  the  gluteal  muscles  being  wasted, 
and  the  gluteo-femoral  crease  is  obliterated.  (Fig.  541.)  The  affected  limb 
appears  lengthened,  but  this  is  only  an  apparent  lengthening,  due  to  tilting 
of  the  pelvis  from  the  efforts  of  the  patient  to  throw 
the  weight  of  the  body,  in  walking  and  standing, 
upon  the  sound  limb,  and  to  preserve  parallelism 
of  the  limbs.  The  accompanying  diagram  will  illus- 
trate these  conditions.  (Fig.  542.)  Actual  lengthen- 
ing may  occur  in  this  stage  of  the  disease  from  disten- 
tion of  the  capsule  with  effusion.  Pain  is  usually 
present,  and  may  be  referred  to  the  biij  or  to  the  knee. 

Fig.  542. 


Obliteration  of  the  gluteo- 
femoral  crease. 


Apparent  elongation  of  left  limb 
due  to  adduction  of  the  sound  limb 
and  tilting  of  the  pelvis  on  the 
sound  side,  to  allow  the  abducted 
limb  to  be  brought  into  a  line  with 
the  body.    (Bryant.) 


Abducted  position  of  the 
diseased  left  limb  when  the 
pelvis  is  at  right  angles  to 
the  spine.    (Bryant.) 


Motions  of  the  joint  are  much  restricted,  full  extension  and  complete  adduc- 
tion are  not  possible,  and  the  deformity  cannot  be  corrected  even  by  the 
application  of  considerable  force.  During  this  stage  the  effusion  may  be 
absorbed,  or  may  escape  from  the  joint  into  the  surrounding  tissues,  or 
abscess  may  occur. 

Third  Stage.— This  is  the  stage  of  shortening  and  deformity.  There 
are  marked  adduction  of  the  limb  and  flexion  of  the  thigh  upon  the 
pelvis,  with  prominence  of  the  buttock  upon  the  affected  side.  (Fig. 
543.)  The  shortening  results  from  adduction  and  from  the  change  in  the 
relation  of  the  neck  of  the  femur  to  the  shaft,  the  obtuse  angle  becoming 
very  nearly  a  right  angle.  The  latter  deformity  occurs  from  muscular  spasm 
and  from  bearing  the  weight  upon  the  inflamed  and  softened  bone.  The 
deformed  head  and  neck  of  the  femur  are  also  pushed  upward  and  outward, 
so  that  the  upper  part  of  the  trochanter  may  occupy  a  position  above 
E^elaton's  line.  The  flexion  of  the  thigh  upon  the  pelvis  and  the  fixation  of 
the  joint  are  sometimes  very  marked.  (Fig.  544.)  There  is  usually  wasting 
of  the  muscles  of  the  gluteal  region  and  thigh.  In  this  stage  abscesses  which 
open  upon  the  skin  in  the  region  of  the  joint  are  very  common.     Separation 


TUBERCULOUS  ARTHRITIS   OF  THE  HIP. 


625 


of  the  head  of  the  bone  from  the  neck  may  occur  at  the  epiphyseal  line,  or 
there  may  be  absorption  of  the  head  and  neck  of  the  bone.    The  acetabulum 


Fig.  543. 


Fig   544 


Deformity  in  the  third  stage  of  hip-disease. 


Flexion  and  fixation  of  the  thigli  in  hip-disease. 


may  be  perforated  and  pus  may  find  its  way  through  it  to  the  surface, 
ox^ening  just  below  Poupart's  ligament,  upon  the  perineum  or  into  the 
rectum  or  bladder.  When  an  abscess  opens  spontaneously  upon  the  surface, 
or  becomes  infected  after  opening,  by  pyogenic  organisms,  pain,  heat,  tender- 
ness, and  profuse  suppuration  are  added  to  the  existing  symptoms  of  the 
disease,  and  the  patient  presents  the  general  symptoms  of  the  hectic  state. 
A  certain  number  of  cases  of  hip- disease  j)ass  through  the  various  stages  of 
the  disease  and  recover  without  the  formation  of  abscess,  but  usually 
present  more  or  less  deformity  and  impairment  of  function  of  the  joint. 

Dislocation  of  the  head  of  the  femur  occasionally  occurs  during  the 
course  of  the  disease,  ijarticularly  in  those  cases  which  have  not  been  ti-eated 
and  in  which  there  is  great  adduction,  forcing  the  altered  head  of  the  bone 
against  the  upper  rim  of  the  acetabulum.  In  such  cases  very  little  absorp- 
tion of  the  acetabulum  will  allow  the  head  of  the  bone  to  slip  out  upon  the 
dorsum  of  the  ilium. 

When  recovery  takes  place  in  a  case  of  advanced  hip-disease  there  always 
result  more  or  less  deformity  and  loss  of  function  in  the  joint ;  if  free  suppu- 
ration has  occurred,  the  discharge  from  the  sinuses  may  diminish,  and  after 
a  time  they  may  close,  or  they  may  i^ersist  for  years  after  the  disease  is 

40 


626  DIAGNOSIS  OF  HIP-DISEASE. 

apparently  cured.  The  amount  of  deformity  and  loss  of  function  of  the 
joint  depend  largely  upon  the  stage  of  the  disease  at  which  the  treatment 
was  begun  and  the  character  of  the  treatment  employed.  Partial  or  com- 
plete ankylosis,  which  may  be  fibrous  or  bony,  always  takes  place.  Anky- 
losis in  good  position  does  not  prevent  the  patient  from  having  a  fairly 
useful  limb  ;  the  shortening  can  be  overcome  by  the  use  of  a  raised  shoe. 

Complications. — Abscess. — This  is  a  very  common  complication  of 
hip-disease,  occurring  in  about  fifty  per  cent,  of  all  cases.  In  cases  in  which 
appropriate  treatment  is  emjjloyed  early  in  the  disease  probably  not  more 
than  twenty  ijer  cent,  suffer  from  abscess,  according  to  Gibney.  Abscess 
usually  results  in  sinuses,  which  may  continue  to  discharge  for  some  time 
-and  eventually  heal.  A  very  common  seat  of  abscesses  in  hip-disease  is 
upon  the  ujaper  and  anterior  portion  of  the  thigh,  external  to  the  femoral 
vessels,  but  they  may  occur  at  many  other  points,  in  the  gluteal  region,  or  on 
the  inner  aspect  of  the  thigh,  or,  in  cases  in  which  the  acetabulum  is  iierfo- 
rated,  above  Poupart's  ligament,  in  the  perineum,  or  open  into  the  bladder  or 
bowel.  In  cases  of  hip-disease  in  which  there  is  long-standing  suppuration, 
the  patient  may  develop  progressive  emaciation  and  amyloid  changes  in  the 
liver  and  kidneys,  attended  with  albuminuria  and  anasarca,  which  are 
usually  soon  followed  by  death.  Tubercular  meningitis  is  a  complication 
which  not  infrequently  occurs  during  the  course  of  hip-disease,  and  is  almost 
always  fatal.  Visceral  tuberculosis  is  also  a  complication  which  usually 
manifests  itself  after  the  joint-lesion  is  apparently  cured. 

Diagnosis. — This  is  sometimes  difficult  in  the  very  early  stages  of  the 
affection,  but  if  the  surgeon  will  bear  in  mind  the  characteristic  symptoms 
of  the  disease, — limping,  pain  in  the  region  of  the  knee,  flattening  of  the 
buttock,  loss  of  the  gluteo-femoral  crease,  atrophy  of  the  limb,  loss  of  motion 
or  fixation  in  the  movements  of  the  joint,  and  starting-pains  at  night, — he 
will  seldom  fail  to  recognize  the  true  nature  of  the  affection.  In  every  case 
of  suspected  hip-disease  a  systematic  examination  should  be  made,  the 
patient  being  stripjjed  and  examined  standing,  to  observe  the  position 
of  the  limbs ;  he  should  next  be  placed  upon  his  back  upon  a  flat  sur- 
face, such  as  a  table,  and  the  length  of  the  limbs  should  be  comijared 
and  any  change  in  their  position  noted.  The  condition  of  the  joint  as 
regards  motion  or  fixation  should  next  be  carefully  examined  ;  arching  of 
the  lumbar  spine  due  to  contraction  of  the  psoas  muscle  when  the  leg  and 
thigh  are  depressed  is  a  most  valuable  diagnostic  sign.  When  the  thigh 
upon  the  sound  side  is  flexed  and  then  brought  down  so  that  the  limb  rests 
upon  the  table,  no  change  in  the  lumbar  spine  occurs,  but  if  the  same  manipu- 
lation is  practised  upon  the  affected  side  a  marked  lumbar  curve  is  devel- 
oped, which  disappears  as  soon  as  the  knee  is  raised.  (Fig.  545.)  The  joint 
should  also  be  examined  for  swelling,  and  tenderness  on  pressure.  Careful 
inquiry  will  elicit  the  history  of  limping  and  starting-pains. 

Hip-disease  may  be  confounded  with  tuberculosis  of  the  spine,  synovitis 
of  the  hip,  periarthritis,  perinephric  or  appendicular  abscess,  hysteria,  infan- 
tile paralysis,  malignant  disease,  and  congenital  dislocation. 

Hip-disease  may  be  differentiated  from  tuberculosis  of  the  spine  by  the 
facts  that  in  the  latter  the  limp  is  different,  the  spine  is  rigidly  fixed,  and 


DIAGNOSIS  OF  HIP-DISEASE. 


627 


upon  examination  spinal  deformity  can  usually  be  observed  ;  the  motions  of 
abduction  and  adduction  are  restricted  in  hip-disease,  while  in  spinal  caries 
they  are  usually  not  impaired  ;  extension  may  be  limited  from  involvement 
of  the  psoas  and  iliacns  muscles  ;  in  spinal  tubeiculosis  palpation  will  often 
reveal  an  inflammatory  mass  or  abscess  in  the  region  of  the  psoas  muscle. 
Acute  synovitis  of  the  hip  is  a  rare  affection,  and  occurs  after  injury 
or  exjjosure  to  cold.  The  deformity,  which  is  noticed  early,  consists  of  ful- 
ness in  the  region  of  the  joint,  and  the  p)ain  is  referred  to  the  joint ;  in 

Fig.  545. 


Arching  of  the  spine  when  the  diseased  limb  is  brought  down  to  the  table. 


Position  of  the  spine  when  the  diseased  limb  is  Hexed. 

hip-disease  the  symj)toms  develop  more  slowly,  and  do  not  yield  so  readily 
to  treatment.  Periarthritis  is  a  phlegmonous  inflammation  of  the  cellular 
tissue  over  the  hip,  and  is  accompanied  by  fever,  pain,  and  redness  of  the 
skin  ;  an  abscess  soon  forms,  and  uj)on  opening  this  recovery  takes  place 
promptly.  Appendicular  and  perinephric  abscess  may  cause  flexion  of 
the  thigh  and  limping  from  pressure  of  the  collection  upon  the  psoas  muscle, 
but  upon  examination  it  will  be  found  that  adduction  and  abduction  of  the 
joint  are  not  interfered  with,  and  extension  only  is  limited  ;  abdominal  or 
lirmbar  fulness,  due  to  the  presence  of  the  abscess,  can  also  be  demonstrated. 
Hysterical  affections  of  the  hip-joint  may  simulate  hip-disease,  but  in  such 
cases  many  of  the  symptoms  of  the  latter  disease  are  wanting,  and  an  exami- 
nation of  the  patient  under  an  angesthetic  will  show  that  the  motions  of  the 
joint  are  absolutely  unrestricted ,  and  other  symptoms  of  hysteria  can  usually 
be  demonstrated.  Infantile  Paralysis. — In  this  disease  the  history  of  the 
invasion  is  different  from  that  in  hii)-disease  ;  there  is  no  pain,  but  paralysis 
with  marked  muscular  atrophy,  and  there  is  also  no  fixation  of  the  hip-joint. 
Malignant  disease  of  the  hip  is  rare,  and  is  more  apt  to  be  seen  in 
adults,  while  hip-disease  is  more  common  in  children.  Sarcoma  of  the  thigh 
in  children  is  more  apt  to  involve  the  shaft  or  the  lower  extremity  of  the 


628  TREATMENT  OF  HIP-DISEASE. 

femur,  but  may  occur  in  the  upper  extremity  of  the  bone.  We  have  seen  a 
case  of  sarcoma  of  the  upper  extremity  of  the  femur  in  which  at  first  the 
symptoms  closely  resembled  hip-disease.  Congenital  dislocation  cannot 
be  confounded  with  hip-disease  if  the  surgeon  notes  the  waddling  gait  in 
the  former  affection,  the  absence  of  pain,  and  the  fact  that  the  deformity 
and  peculiar  gait  were  noticed  as  soon  as  the  patient  began  to  walk. 

Prognosis. — This  depends  largely  upou  the  surroundings  of  the  patient 
and  the  treatment.  In  children  who  are  well  treated  and  well  taken  care  of 
a  large  proportion  of  cases  will  recover,  with  more  or  less  deformity  or  dis- 
ability of  the  affected  joint.  In  many  cases,  and  especially  the  ill  fed  and 
poorly  nourished  children  who  are  admitted  to  hospitals,  in  spite  of  the  most 
careful  treatment,  disorganization  of  the  affected  joint  occurs,  abscesses  form, 
followed  by  profuse  suppuration,  amyloid  changes  in  the  liver  and  kidneys 
occur,  or  tubercular  meningitis  or  visceral  tuberculosis  develops  and  causes  a 
fatal  termination.  In  well-to-do  patients  the  prognosis  is  good  ;  but  the  treat- 
ment may  have  to  extend  over  a  jieriod  of  months  or  years,  and  long  after  the 
case  has  apparently  recovered  a  recurrence  of  the  disease  may  take  place. 

Treatment. — This  is  both  local  and  constitutional,  and  the  earlier  it  is 
instituted  the  better  is  the  prospect  of  recovery  with  the  least  impairment 
of  function  in  the  joint.  The  local  treatment  consists  in  securing  as  nearly 
as  possible  absolute  rest  of  the  affected  joint,  at  the  same  time  correcting 
any  deformity  which  exists,  and  using  such  appliances  as  will  prevent  sub- 
sequent deformity.  The  constitutional  treatment  of  the  case  consists  in  the 
employment  of  all  the  means  to  improve  the  patient's  general  condition  and 
nutrition  which  would  be  indicated  in  an  enfeebled  and  tubercular  state, 
such  as  fresh  air,  sea  air,  if  possible,  and  nutritious  diet,  and  at  the  same 
time  tonics,  as  cod-liver  oil  and  iodide  of  iron,  may  be  used  with  good  results. 

The  two  methods  of  treatment  which  are  most  practised  at  the  present 
time  are  prolonged  recumbency  with  extension,  and  the  use  of  fixation 
or  traction  splints,  which  allow  the  patient  to  walk  about  during  the  course 
of  treatment.  Each  of  these  methods  has  its  advantages,  and  the  surgeon 
often  has  to  be  governed  in  his  decision  as  to  which  method  he  will  emj)loy 
in  any  indi\adual  case  by  the  duration  of  the  disease  and  the  age  and  social 
condition  of  the  patient.  Among  the  poorer  classes  the  cost  of  fixation  and 
traction  splints  and  the  lack  of  judicious  care  in  their  management  prevents 
satisfactory  results.  Complete  rest  in  bed  in  this  class  of  jiatieuts  is  also 
very  difficult  to  secure.  In  many  cases  a  combination  of  the  two  methods 
is  followed  by  the  best  results.  In  the  early  stage  of  the  disease  recumbency 
and  extension  may  be  employed,  and  after  a  time  the  patient  be  allowed  to 
go  about  with  some  form  of  fixation  or  traction  splint. 

Prolonged  Recumbency  and  Extension. — This  method  is  especially 
applicable  in  the  early  stages  of  the  disease  and  in  young  children,  in  whom 
a  walking  splint  cannot  be  used  with  satisfaction.  It  is  remarkable  how 
well  children  stand  confinement  to  bed  for  a  long  time  if  they  are  jiroperly 
fed  and  have  good  hygienic  surroundings.  In  this  method  of  treatment 
an  extension  apparatus  made  of  adhesive  plaster  or  swans'  -down  plaster — 
either  of  which  is  preferable  to  rubber  plaster,  which  is  apt  to  irritate 
the  skin — is  applied  to  the  leg  and  the  lower  part  of  the  thigh,  secured  by 


TREATMENT  OF  HIP-DISEASE. 


629 


Fig.  547. 


transverse  strips  of  plaster,  and  held  in  place  by  a  gauze  or  muslin  band- 
age. The  patient  is  next  placed  upon  a  firm  mattress,  and  a  weight  of  from 
four  to  ten  pounds  is  attached  to  the  block  at  the  bottom  of  the  extension 
apparatus.  Lateral  support  may  be  given  to  the  limb  by  means  of  a  long 
padded  splint  extending  from  the  axilla  to  the  sole  of  the  foot,  or  by  sand- 
bags. Care  should  be  taken  to  make  extension  in  the  line  of  deformity, — 
that  is,  in  the  line  of  the  flexed  or  abducted  or  adducted  thigh, — and  as  the 
deformity  is  corrected  the  position  of  the  limb  can  be  gradually  changed  to 
the  normal  one.  The  amount  of  weight  necessary  to  produce  extension 
varies  in  individual  cases,  and  should  be  sufficient  to  overcome  muscular 
spasm.  If  starting-pain  at  night  is  not  relieved,  the  weight  should  be 
increased  ;  the  tendency  is  to  use  too  little  weight ;  we  often  employ  from 
six  to  twelve  pounds.  This  treatment  may  be  kept  vip  for  many  months ; 
if  abscess  does  not  occur  no  operative  treatment  is  required.  When  the  dis- 
ease has  been  arrested  the  patient  may  have  the  hip-joint  fixed  by  a  moulded 
binder's  board  splint,  or,  better,  by  some  form  of  hip-splint  with  a  high  shoe 
upon  the  sound  foot,  and  may  be  permitted  to  walk  with  crutches,  fixation 
being  maintained  for  a  long  time  after  all  symptoms  have  subsided,  and 
traumatism  being  carefully  guarded  against. 

Fixation  and  Traction  Splints. — In  cases  of  hip-disease  among  well- 
to-do  patients,  when  the  appliances  can  be  under  the  care  of  an  intelligent 
parent  or  nurse,  fixation  and  traction 
splints  are  often  most  satisfactory  ;  by 
their  use  patients  can  go  about  and  get 
change  of  air  and  scene,  and  the  joint 
treatment  can  be  carried  on  at  the  same 
time.  The  most  inexpensive  fixation 
apparatus  for  cases  of  hiij-disease  con- 
sists in  a  binder's  board  splint,  moulded 
to  the  uijper  part  of  the  leg,  the  thigh, 
and  the  pelvis,  and  secured  in  position 
by  a  bandage.  In  place  of  the  binder's 
board  splint  a  plaster- of-Par is  bandage 
may  be  applied  to  the  leg,  thigh,  pel- 
vis, and  abdomen  as  high  as  the  ribs. 
The  patient  should  be  fitted  with  a  high 
shoe  upon  the  sound  foot  and  should 
be  allowed  to  walk  with  crutches. 

Another  form  of  fixation  splint 
known  as  Thomas's  (Fig.  546)  is  very 
largely  used,  and  is  applied  as  shown  in  Fig.  547.  The  patient  wears  a  high 
shoe  upon  the  sound  foot  and  walks  by  the  aid  of  crutches.  This  splint 
may  be  made  of  sole-leather,  with  steel  braces,  and  is  convenient  in  appli- 
cation and  equally  satisfactory  in  its  results.  Various  forms  of  traction 
splints  may  also  be  applied.  In  these  extension  is  made  to  relieve  muscular 
spasm,  and  at  the  same  time,  in  many  of  them,  fixation  of  the  joint  is 
secured.  The  splints  of  Taylor,  Davis,  Lovett,  and  Wyeth  are  constructed 
with  this  end  in  view ;  the  extension  is  usually  made  by  a  ratchet  with  a 


Thomas's  splint. 


Thomas's  splint  applied. 


630 


ABSCESS  IN  HIP-DISEASE. 


movable  foot-j^iece.     (Fig.  548.)    An  extension  apparatus  of  adhesive  or 

swans' -down  plaster  is  apjjlied  to  the  leg  and  the  lower  part  of  the  thigh  ; 

buckles  are  fastened  to  the  extension  bands,  which  are  attached, to  striiis 

secured  to  the  foot-piece ;  after  being  applied,  extension  is  made  by  the  ratchet. 

During  the  course  of  treatment  by  any  of 
these  forms  of  splints  abscess  may  develop, 
which  will  interfere  with  their  use  while  the 
abscess  is  under  treatment.  The  length  of  time 
treatment  should  be  kept  up,  either  by  recum- 
bency and  extension  or  by  splints,  is  often  a 
matter  of  the  greatest  difficulty  to  decide,  and 
it  is  a  safe  rule  to  continue  it  even  after  it 
seems  not  to  be  absolutely  necessary,  rather 
than  to  remove'  the  fixation  or  traction  appa- 
ratus before  the  course  of  the  disease  is  ar- 
rested. ISTo  definite  time  can  be  given,  months 
or  even  years  of  treatment  being  often  required  ; 
and  when  the  disease  seems  to  be  arrested,  as 
indicated  by  the  absence  of 
the  characteristic  symptoms 
and  by  the  presence  of  firm 
ankylosis,  the  apparatus 
should  be  removed,  and 
some  simple  fixation  appa- 
ratus applied  for  a  few 
months,  after  which  this 
may  be  removed,  and  the 
patient  allowed  to  use  the 
limb  carefully  in  locomo- 
tion.    If  pain  or  tenderness 

returns,  it  is  evident  that  the  affection  has  not  been 

cured,  and  the  apparatus  should  be  resumed. 

Abscess  in  Hip-Disease. — This  is  one  of  the  most 

troublesome  complications  wliich  develop   during    the 

course  of  the  disease,  and  may  occur  at  any  time  except 

in  the  very  early  stage.     The  most  common  seat  of  ab- 
scess in  hip-disease  is  ujaon  the  anterior  aspect  of  the  joint 

(Fig.  549),  the  tuberculous  debris  finding  its  way  to  the 

surface  between  the  tensor  vaginae  femoris  and  sartorius 

muscles  ;  it  may  work  its  way  posteriorly  and  reach  the 

surface  in  the  gluteal  fold,  or  the  pus  may  open  into 

the  bursa  beneath  the  psoas  muscle  over  the  front  of  the 

femur  and  find  its  way  into  the  pelvis  under  Ponpart's 

ligament.     It  may  also  perforate  the  anterior  portion  of 

the  capsule  and  pass  down  the  inner  part  of  the  thigh 

beneath  the  adductor  muscles.     Abscess  which  starts  in 

the  acetabulum  is  apt  to  perforate  the  bone  and  form  a  collection  under  the 

iliacus  muscle ;  pelvic  abscess  may  ascend  under  the  muscles  and  point 


Traction  spliDt. 


Abvcess  in  hip-disease. 


OPERATIVE  TREATMENT  OF  HIP-DISEASE.  631 

under  Poupart's  ligament,  may  open  into  the  rectum,  or  may  enter  the 
bursa  under  the  tendon  of  the  psoas  muscle  and  make  its  way  to  the  inner 
aspect  of  the  thigh. 

Treatment. — Abscesses  may  form  slowly  or  rapidly,  and  sometimes 
assume  such  a  size  that  they  interfere  with  the  use  of  apparatus.  As  soon 
as  it  is  evident  that  pus  is  presetit,  this  should  be  removed  by  aspiration 
or  incision.  Gibney  holds  that  the  most  satisfactory  results  follow  repeated 
aspiration  or  small  incisions  ;  we  have,  however,  seen  the  best  results  from 
small  incisions  followed  by  injection  of  the  cavity  with  iodoform  emulsion 
and  closure  of  the  wound,  this  procedure  being  repeated  as  often  as  the  cavity 
refills.  It  often  happens  that  the  sinus  continues  to  discharge  for  some  time  ; 
this  will  persist  as  long  as  any  debris  is  cast  off  from  the  diseased  bone  and 
cartilages.  When  the  discharge  becomes  chronic,  opening  up  of  the  sinuses 
and  curetting  them  will  sometimes  be  followed  by  their  rapid  closure. 

Operative  Treatment  of  Hip-Disease. — In  cases  of  hip-disease  some 
surgeons  recommend  early  excision  of  the  diseased  head  and  neck  of  the 
femur,  while  others  postpone  operation  upon  the  bone  as  long  as  possible, 
merely  opening  and  draining  abscesses  if  they  form,  and  depending  upon 
ultimate  ankylosis  of  the  joint,  which  if  it  be  in  bad  position  can  be  cor- 
rected by  an  osteotomy  at  a  later  period.  There  are,  however,  many  cases 
of  hip-disease  which  do  badly  in  spite  of  the  most  careful  treatment ; 
abscesses  form,  infection  occurs,  the  patients  suifer  from  hectic,  and  exhaus- 
tion soon  supervenes.  In  such  cases  ojjerative  treatment  must  be  consid- 
ered, and  a  free  exposure  of  the  joint  and  excision  of  the  diseased  bone  in 
such  cases  are  often  followed  by  the  most  satisfactory  results.  The  special 
method  employed  in  excision  of  the  hij)  depends  upon  the  time  at  which 
the  case  is  seen.  Where  the  bulk  of  the  suppuration  is  in  the  gluteal  region 
or  the  posterior  aspect  of  the  thigh,  as  often  happens  in  long-standing  cases, 
we  prefer  the  posterior  incision  ;  while  where  abscess  forms  anteriorly,  as  is 
frequently  seen  in  early  cases,  we  prefer  the  anterior  incision.  The  anterior 
incision  is  also  to  be  preferred  in  cases  of  early  excision,  before  abscess  has 
occurred  or  much  destruction  of  the  joint-tissues  has  taken  place.  The 
methods  of  excising  the  hiji-joint,  as  well  as  the  correction  of  the  deformity 
following  hip-disease,  are  considered  in  the  chapter  upon  Excisions. 

After  excision  of  the  hip-joint  there  is  often  a  remarkable  improvement 
both  in  the  constitutional  and  in  the  local  condition  of  the  patient;  the 
wound  and  sinus  often  heal  promjitly,  and  the  patient  may  soon  regain  fair 
use  of  the  limb.  In  other  cases  sinuses  may  continue  to  discharge  for  some 
time,  new  abscesses  may  form  and  require  opening,  and  it  may  be  necessary 
to  reopen  the  wound  and  remove  more  diseased  bone  and  infected  soft  tissues. 
The  most  favorable  result  following  excision  of  the  hip  is  to  have  a  false 
joint  form,  allowing  more  or  less  motion  ;  shortening,  to  a  certain  extent, 
will  always  be  present,  and  can  be  overcome  by  the  wearing  of  a  high  shoe 
on  the  affected  limb.  We  have  seen  so  many  good  functional  results  follow 
excision  of  the  hip  that  we  are  disposed  to  recommend  the  oijeration  in 
cases  in  which  the  disease  runs  a  rapid  course  and  suppuration  is  free,  in 
which  hectic  is  well  developed,  and  where  the  limb  is  so  distorted  that  it 
would  be  useless  if  ankylosis  occurred  subsequently. 


632  DISExVSES   OF  THE  KNEE-JOINT. 

Amputation  in  Hip-Disease.— In  cases  of  advanced  hip-disease  in 
■wliicli  amyloid  clianges  liave  occurred  in  the  liver  and  kidneys,  and  suppu- 
ration is  very  profuse,  or  in  which,  in  spite  of  excision  of  the  joint,  suppu- 
ration, hectic,  and  exhaustion  continue,  amputation  of  the  limb  may  be 
required  as  a  life-saving  measure,  and  even  in  such  apparently  hopeless 
cases,  with  the  modern  methods  of  controlling  hemorrhage  during  the  opera- 
tion, a  fair  number  of  recoveries  take  place. 

Diseases  of  the  Knee- Joint. — The  knee-joiut  may  be  the  seat  of 
simple  or  acute  suppurative  synovitis  or  arthritis,  and  tuberculous  synovitis 
or  arthritis  ;  there  are  also  observed  cases  of  chronic  synovitis  with  marked 
effusion,  which  are  not  tuberculous. 

Simple  Synovitis. — This  may  result  from  traumatism,  from  exposure 
to  heat  or  cold,  or  from  over-exertion.  Symptoms. — In  this  disease  there 
are  pain  and  swelling  of  the  joint,  with  loss  of  function,  the  swelling  being 
due  to  effusion  in  the  joint  and  oedema  of  the  extra-articular  structures. 
The  tempei'ature  is  usually  elevated.  The  presence  of  effusion  in  the  joint 
can  usually  be  proved  by  the  floating  of  the  patella ;  when  this  is  pressed 
upon  it  can  be  made  to  touch  the  condyles  of  the  feinur  ;  when  the  pressure 
is  relieved  it  springs  back  into  place.  The  knee  is  flexed  if  the  effusion  is 
considerable,  this  position  being  assumed  to  relieve  tension  and  pain.  The 
only  condition  with  which  this  affection  can  be  confounded  is  hemorrhage 
into  the  joint,  which  occurs  earlier  than  synovial  effusion  and  is  much  more 
consistent  to  the  touch.  Treatment. — The  patient  being  put  at  rest  in 
bed,  the  knee-joint  should  be  fixed  by  the  application  of  a  posterior  splint, 
and  the  joint  covered  with  lint  saturated  with  lead  water  and  laudanum,  or 
an  ice-bag  applied  ;  compression  by  a  firm  bandage  is  also  useful.  Under 
this  treatment,  usually  in  a  few  days  the  active  symptoms  disappear.  The 
fixation  should  be  continued  until  the  effusion  has  disappeared,  and  when 
the  patient  begins  to  move  about  the  joint  should  be  supported  by  a  flannel 
bandage.  Massage  also  is  useful  in  hastening  the  absorption  of  the  effusion 
and  restoring  function. 

Acute  Suppurative  Synovitis  or  Arthritis. — This  may  result  from 
penetrating  wounds  of  the  knee-joint  or  infection  of  the  joint  from  extension 
in  epiphysitis  and  osteomyelitis,  and  by  the  localization  of  pyogenic  organ- 
isms from  the  blood-vessels,  as  seen  in  cases  of  pysemia.  Symptoms. — 
The  joint  becomes  red,  swollen  and  painful,  there  is  loss  of  function,  and 
the  position  of  the  articular  surfaces  is  changed  so  as  to  afford  relief  from 
distention.  There  are  also  symptoms  of  constitutional  infection,  elevation 
of  temperature,  rapid  pulse,  rigors,  and  sweating.  Treatment. — The  treat- 
ment which  affords  the  best  results  is  early  and  free  incision  of  the  joint, 
with  irrigation,  and  the  introduction  of  gauze  or  rubber  drainage ;  the 
joint  should  be  covered  with  a  copious  gauze  dressing,  and  put  at  rest  by 
the  application  of  a  splint  or  a  plaster-of- Paris  dressing.  If  incisions  are 
made  and  free  drainage  secured  before  the  articular  cartilages  have  been 
destroyed,  a  good  result  as  regards  function  of  the  joint  may  follow. 

Chronic  Synovitis. — This  affection  is  sometimes  seen  in  the  knee-joint 
following  acute  synovitis  and  gonorrhoeal  synovitis,  independently  of  the 
presence  of  tubercle,  and  may  consist  either  in  great  thickening  of  the 


TUBERCULOUS  ARTHRITIS   OF  THE   KNEE.  633 

structures  of  the  joint  or  in  a  large  effusion  into  it ;  the  latter  condition  is 
known  as  hydroi)s  articuli,  and  through  stretching  of  the  capsule  and  the 
ligaments  the  joint  is  rendered  weak  and  insecure.  Treatment. — In  many- 
cases  of  chronic  synovitis  of  the  knee  the  use  of  blisters  or  of  counter- 
irritation  by  other  means,  or  the  application  of  an  ointment  composed  of 
equal  parts  of  uuguentum  iodi,  unguentum  belladonnte,  and  unguentum 
hydrargyri,  combined  with  fixation  of  the  joint  by  sjaliuts  or  a  plaster-of 
Paris  dressing,  will  ultimately  effect  a  cure. 

In  other  cases,  in  which  the  effusion  is  not  large  and  the  swelliiig  depends 
upon  the  hj'pertrophy  of  the  synovial  fringes,  the  results  of  couuterirrita- 
tiou  and  fixation  are  not  so  satisfactory  ;  here  pressure,  applied  by  a  bandage 
or  by  strapping,  may  promote  the  absorption  of  the  inflammatory  material. 
When  in  spite  of  all  these  forms  of  treatment  the  condition  is  not  improved, 
it  is  justifiable  to  aspirate  the  joint  and  irrigate  it  with  a  five  per  cent. 
carbolic  solution,  or  to  open  it,  the  strictest  aseptic  details  being  observed, 
and  trim  away  the  hypertrophied  synovial  fringes.  The  wound  should 
afterwards  be  closed,  and  the  joint  immobilized  by  a  plaster-of-Paris  dress- 
ing. After  the  wound  is  solidly  healed,  massage  and  passive  motion  should 
be  emj)loyed  to  bring  about  restoration  of  function. 

Tuberculous  Arthritis  of  the  Knee.— This  disease  is  most  frequently 
met  with  in  childhood,  but  is  often  seen  in  young  adults,  and  in  xJoint  of 
frequency  is  next  to  hip-disease.  The  disease  is  usually  osteal  in  origin,  the 
articular  surface  of  the  femur  being  much  more  frequently  involved  than 
the  tibia.  It  is  extremely  rare  for  the  disease  to  originate  in  the  patella. 
lu  adults  the  synovial  membrane  of  the  joint  may  first  be  involved,  and  the 
bone,  ligaments,  and  periarticular  structures  involved  secondarily.  The 
changes  which  occur  in  the  tissues  are  similar  to  those  which  have  been 
already  described  as  typical  of  tuberculous  arthritis. 

Symptoms. — The  patient  complains  of  pain  in  using  the  limb,  favors  it 
in  walking,  and  walks  with  a  limp,  bearing  the  weight  upon  the  toes  and 
the  ball  of  the  foot.  Upon  examination  there  may  be  observed  some  heat 
in  the  joint,  and  reflex  muscular  spasm  may  be  noticed  upon  motions  of  the 
joint ;  stiffness  may  be  present.  Later  there  is  a  slight  flexion,  with  change 
in  the  shape  of  the  joint,  which  becomes  globular,  the  swelling  being  more 
marked  by  reason  of  the  atrophy  of  the  muscles  above  and  below  the  joint. 
(Fig.  550.)  As  the  disease  advances  the  limb  becomes  more  flexed,  and 
the  tibia  is  drawn  backward,  producing  a  subluxation.  (Fig.  551.)  The 
synovial  membrane  and  the  cartilages  may  be  broken  down  ;  the  tubercular 
masses  may  undergo  caseation  and  form  abscesses,  which  perforate  the 
capsule  and  escape  into  the  periarticular  structures,  and  finally  open  upon 
the  skin  in  the  region  of  the  joint.  In  other  cases  no  abscesses  form,  but 
disorganization  of  the  joint,  with  deformity,  occurs,  which  may  be  followed 
by  ankylosis. 

Diagnosis. — Tuberculous  arthritis  of  the  knee-joint  may  be  confounded 
with  acute  arthritis  of  the  knee  ;  the  latter  comes  on  soon  after  exposure 
to  cold  or  after  an  injury,  and  runs  a  rapid  course.  Cellulitis  of  this 
region  develops  rapidly,  and  is  usually  phlegmonous.  Rheumatic  arthritis 
is  generally  au  acute  aft'ection,  and  is  accomx^anied  with  marked  constitu- 


634 


TUBERCULOUS   ARTHRITIS   OF  THE  KNEE. 


tional  symptoms.  Chronic  bursitis  of  the  knee,  which  is  often  tubercular 
in  origin,  is  sometimes  difficult  to  distinguisli  from  tuberculous  arthritis, 
especially  if  the  bursa  involved  communicates  with  the  knee-joint,  but  may 
be  distinguished  from  the  latter  by  observing  that  the  bursa  is  distended, 
that  the  effusion  into-  the  knee-joint 
is  not  marked,  and  that  the  joint 
motions  are  not  much  affected. 
Neuroses  of  the  knee-joint  are  un- 
accompanied by  physical  signs  other 
than  flexion.     Sarcoma  in  this  loca- 


Fi(, 


Tuberculous  arthritis  of  the  knee. 


Skiagraph  oi  liibLH  iilo^i^  ni  tlie  knee-joint. 


tion  usually  involves  the  articular  end  either  of  the  tibia  or  of  the  femur,  and 
the  enlargement  extends  some  distance  above  or  below  the  joint.  The  pain 
in  sarcoma  is  of  a  boring  character,  and  pulsation  may  often  be  felt,  which 
is  a  most  valuable  diagnostic  sign. 

Treatment. — The  first  indication  in  the  treatment  is  to  put  the  joint  at 
absolute  rest.  This  may  be  accomplished  by  the  use  of  the  plaster-of- Paris 
bandage,  or  by  some  form  of  splint  which  furnishes  at  the  same  time  both 
fixation  and  traction.  The  patient  should  use  crutches,  and  wear  a  high 
shoe  on  the  sound  foot,  so  that  no  weight  can  be  borne  on  the  affected  leg, 
thus  securing  complete  physiological  rest  of  the  diseased  joint.  The 
patient's  constitutional  condition  should  also  receive  attention ;  the  diet 
should  be  nutritious,  and  such  remedies  as  tonics,  cod-liver  oil,  and  iron 
should  be  administered. 

When  the  plaster-of-Paris  bandage  is  employed  it  should  extend  from 
the  toes  or  the  lower  part  of  the  leg  to  the  upper  part  of  the  thigh,  or  a 
movable  splint  of  sole-leather,  made  to  fit  the  leg  accurately  by  moulding- 
leather  upon  a  cast  made  from  a  neatly  fitting  plaster  bandage,  may  be  used, 
which  has  the  advantage  that  it  can  be  removed  to  bathe  the  limb. 
Thomas's  splint  (Fig.  552),  or  that  of  Shaffer,  may  be  employed  with 
advantage ;  the  latter  is  so  constructed  that  traction  is  made  at  the  same 


DISEASES  OF  THE  ANKLE-JOINT. 


635 


Fig.  .5.52. 


,'i 


Thomas's  knee- 
3S  spliDt. 


time  that  fixation  of  the  joint  is  produced.  The  course  of  treatment  may 
extend  over  months  or  years.  In  many  cases  abscesses  form,  which  should 
be  opened  and  drained,  and  if  ankylosis  occurs  with  the  limb  in  good  posi- 
tion the  I'esult  will  be  as  favorable  as  that  obtained  by  operative 
means. 

Cases  often  come  into  the  hands  of  the  surgeon  in  which  the 
joint  is  so  much  flexed  that  a  splint  cannot  be  satisfactorily 
employed,  and  if  the  limb  should  become  ankylosed  it  would  be 
of  little  use  to  the  patient.  In  such  cases  the  use  of  extension 
by  weight  and  pulley  will  often  correct  the  deformity  ;  if  not, 
the  patient  should  be  etherized,  and  with  a  little  force,  and 
possibly  by  the  division  of  the  hamstring  tendons,  the  limb  can 
be  brought  into  a  nearly  straight  position,  after  which  it  can  be 
put  up  in  plaster  of  Paris,  or  a  splint  may  be  applied. 

By  the  use  of  some  of  these  various  forms  of  fixation  appa- 
ratus recovery  may  occur  with  more  or  less  loss  of  function  in 
the  joint.  The  amount  of  motion  remaining  depends  largely 
upon  the  extent  of  destruction  of  the  articular  cartilages.  In 
cases  where  the  disorganization  of  the  joint  is  extensive  and  the 
patient  suffers  from  hectic  and  is  losing  ground,  the  question  of 
operative  treatment  must  be  considered.  Excision,  arthrectomy 
or  erasion,  or  amj)utation  may  be  performed.  Arthrectomy 
or  erasion  is  to  be  preferred  to  excision  in  young  children, 
the  latter  operation  is  apt  to  damage  the  epiphyseal  cartilages 
and  interfere  with  the  subsequent  growth  of  the  limb.  In  adults  excision  is 
the  method  of  choice,  splints  being  of  little  use.  Amputation  is  reserved 
in  disease  of  the  knee-joint  for  cases  in  which  there  is  extensive  disorganiza- 
tion of  the  joint  with  involvement  of  the  contiguous  bones  and  soft  parts. 
The  special  operations  upon  the  knee-joint  are  considered  under  Excisions. 

Diseases  of  the  Ankle-Joint. — Simple  Acute  Synovitis. — 
This  usually  arises  from  traumatism,  and  is  characterized  by  the  symp- 
toms of  acute  synovitis, — limitation  of  motion,  pain,  and  swelling ;  the 
swelling  may  be  most  marked  in  front  of  the  joint  on  either  side  of  the 
extensor  tendons,  or  behind  the  joint  on  either  side  of  the  tendo  Achillis. 
Treatment. — This  consists  in  putting  the  joint  at  rest  by  the  ai)j)lication  of 
a  splint  and  the  use  of  such  lotions  as  lead  water  and  laudanum  or  muriate 
of  ammonium  and  laudanum.  After  a  few  days,  when  the  pain  has  dimin- 
ished and  the  swelling  has  subsided,  the  joint  should  be  fixed  by  the  appli- 
cation of  a  plaster-of-Paris  dressing  or  a  silicate  of  sodium  splint.  Care 
should  be  taken  not  to  keep  the  joint  immobilized  for  too  long  a  time,  and  after 
wearing  either  of  these  dressings  for  a  few  weeks  they  should  be  removed, 
and  the  patient  encouraged  to  use  the  joint.  Massage  in  the  latter  stages  of 
this  affection  is  often  most  useful  in  bringing  about  restoration  of  function. 

Tuberculous  Arthritis  of  the  Ankle-Joint. — This  may  be  either 
synovial  or  osteal  in  its  origin.  The  disease  is  more  apt  to  develop  in  the 
astragalus  than  in  the  articular  ends  of  the  bones  of  the  leg,  or  it  may  be 
secondary  to  disease  of  the  other  tarsal  bones  or  of  the  malleoli.  Symp- 
toms.— In  this  affection  there  is  stiffness  of  the  ankle,  and  more  or  less 


636 


DISEASES   OF  THE  TARSAJL  JOINTS. 


Tuberculous  arthritis  of  the  ankle. 


swe]]iiig  is  usually  observed  about  the  anterior  surface  of  tlie  ankle  or 
behind  the  joint  on  each  side  of  the  tendo  Achillis.  If  there  is  much 
intra- articular  effusion,  swelling  may  be  marked.  Pain,  characteristic  of 
osteitis,  is  also  present,  and  is  most  marked  when  attempts  are  made  to 

move  the  joint.     As  the 
^^°-  °53-  disease  advances,  the  foot 

is  held  in  the  extended 
position  and  the  contour 
of  the  joint  is  changed, 
so  that  a  globular  swelling- 
is  present  at  the  ankle. 
Abscesses  may  form, 
which,  when  opened,  are 
likely  to  leave  discharg- 
ing sinuses.  (Fig-  553.) 
The  prognosis  is  always 
grave  in  tuberculous  dis- 
ease of  the  ankle-joint,  and  depends  upon  the  age  and  constitutional  condi- 
tion of  the  patient.  Treatment. — As  in  other  tuberculous  joints,  fixation 
is  one  of  the  most  important  indications  in  treatment.  The  joint  should  be 
immobilized  by  a  plaster-of- Paris  dressing,  or  by  moulded  leather  or  binder's 
board  splints  ;  care  should  be  taken  that  the  foot  is  kept  at  a  right  angle 
to  the  leg,  so  that  if  ankylosis  occurs  it  will  be  in  a  useful  position.  The 
bandage  should  be  renewed  at  intervals  as  the  swelling  subsides,  and  a  fresh 
one  api^lied.  The  patient  should  also  use  crutches,  to  keep  the  weight  off 
the  diseased  joint.  The  injection  of  iodoform  emulsion  or  chloride  of  zinc, 
combined  with  fixation  of  the  joint,  may  often  be  used  with  good  results. 
When  the  disease  is  well  advanced  and  abscesses  have  formed,  these  should 
be  opened  and  drained ;  if  the  swelling  continues  and  the  discharge  from 
the  sinuses  is  profuse,  and  the  patient' s  constitutional  condition  shows  that 
he  is  suifering  from  the  profuse  discharge,  some  form  of  operative  treatment, 
such  as  erasion,  excision,  or  amputation,  should  be  adopted. 

Erasion  may  be  first  employed,  or  excision  may  be  preferred,  care  being 
taken  that  all  diseased  structures,  both  bony  and  of  the  soft  parts,  are  freely 
removed.  Extensive  removal  of  bone  is  often  demanded.  The  tarsal  bones 
are  sometimes  extensively  affected  and  require  removal,  as  well  as  the  lower 
ends  of  the  tibia  and  fibula.  Excision  of  the  ankle  in  children  for  tubercu- 
lous disease  is  followed  by  good  results,  but  in  adults  our  experience  has 
been  that  this  operation  is  not  so  satisfactory,  and  that  amputation  is  often 
subsequently  required. 

Diseases  of  the  Tarsal  Joints. — These  joints  may  present  simple 
acute  synovitis  following  traumatism,  as  well  as  tuberculous  sj'novitis  or 
arthritis. 

Acute  Synovitis. — This  disease  usually  follows  an  injury,  and  pre- 
sents the  symptoms  of  acute  synovitis,  pain,  swelling,  and  loss  of  function. 
Treatment. — This  consists  in  the  use  of  evaporating  lotions  and  fixation 
of  the  inflamed  articulation  by  a  splint.  Eecovery  generally  takes  place 
promptly  after  the  joint  is  put  at  rest. 


DISEASES  OF  THE  SHOULDER-JOINT.  637 

Tuberculous  Arthritis. — This  affection  is  characterized  by  swelling, 
which  comes  on  gradnally  and  causes  marked  change  in  the  shape  of  the 
foot ;  pain  may  not  be  a  jirominent  symptom,  except  in  the  later  stages  of 
the  affection  ;  there  is  loss  of  function,  and  the  patient  is  disinclined  to  use 
the  part.  The  disease  usually  runs  a  slo\y  course,  and  often  caseation  takes 
place,  and  tuberculous  abscesses  form,  which  open  upon  the  surface  of  the 
skin  and  leave  discharging  sinuses.  (Fig.  554.)  Treatment. — In  the  early 
stage  of  tliis  affection  fixation  of  the  articulation  should  be  obtained  by  the 
use  of  moulded  leather 

or  binders  board  splints,  Fig.  io4. 

or,  better,  by  a  plaster- 
of- Paris  bandage  applied 
from  the  toes  to  a  point 
above  the  ankle-joint. 
The  injection  of  iodoform 
emulsion  in  conjunction 
with  immobilization  may 
also  be  employed  with 

good  results.      After  ab-  Tuberculous  arthritis  of  tarsal  articulations. 

scesses  have  formed,   if 

the  swelling  persists  and  the  discharge  continues,  the  diseased  structures 
should  be  exposed  by  incision,  and  the  softened  and  carious  bones,  as  well 
as  the  diseased  soft  parts,  should  be  removed  by  a  gouge  or  curette.  It  is 
often  necessary  to  make  a  very  extensive  removal  of  the  tarsal  bones  in  these 
cases,  and  a  thorough  operation  is  much  more  likely  to  be  followed  by  good 
results  than  an  incomplete  one.  After  removing  all  the  diseased  structures 
the  wounds  should  be  thoroughly  irrigated  with  an  antiseptic  solution  and 
packed  with  iodoform  gauze.  The  foot  should  be  kept  in  ijosition  with 
moulded  splints  of  binder's  board  or  with  a  plaster-of- Paris  dressing,  fenes- 
tvee  being  cut  through  which  the  wounds  can  be  dressed.  After  free  removal 
of  the  diseased  structures  the  foot  is  often  very  much  shortened,  but  if  the 
parts  heal  satisfactorily  a  very  useful  member  results. 

Diseases  of  the  Shoulder-Joint. — This  articulation  may  be  the 
seat  of  acute  synovitis  or  of  tuberculous  synovitis  or  arthritis.  The  symp- 
toms of  acute  synovitis  are  similar  to  those  seen  in  other  joints,  and  the  treat- 
ment is  the  same. 

Tuberculous  Synovitis  or  Arthritis  of  the  Shoulder- Joint. — 
This  is  not  a  common  affection,  being  met  with  infrequently  as  comx^ared 
with  tubercular  disease  of  the  hip-,  knee-,  or  elbow-joints.  It  may  be 
synovial  or  osteal  in  origin.  Symptoms. — In  cases  of  synovial  origin, 
swelling,  effusion,  and  limitation  of  ^notion  are  observed  early  in  the  dis- 
ease ;  in  those  of  osteal  origin,  the  swelling  and  effusion  are  not  marked, 
and  thickening  of  the  bone,  with  considerable  pain  and  atrophy  of  the 
muscles,  is  observed.  The  deformity  in  this  affection  is  well  shown  in  Fig. 
555.  Abscesses  may  form,  which  point  either  in  front  of  or  behind  the 
deltoid  muscle.  Treatment. — This  consists  in  fixation  of  the  joint  by  the 
application  of  a  moulded  splint  to  the  shoulder  and  arm,  which  is  bound  to 
the  side  of  the  chest.     Injections  of  iodoform  emulsion  combined  with  fixa- 


638 


DISEASES  OF  THE  ELBOAV-JOINT. 


Fig.  555. 


Tuberculous  arthritis  of  the 
shoulder. 


tion  are  most  successfully  employed  in  this  joint,  and.  often  result  in  recovery 
witli  more  or  less  restoration  of  the  motions  of  the  joint.  Excision  of  the 
joint  may  be  required  if  abscesses  form,  and  the 
head  of  the  bone  or  the  articular  surface  of  the 
scapula  is  carious.  Very  excellent  functional  re- 
sults foUoM"  excision  of  this  joint. 

Dry  Tuberculous  Arthritis  of  the  Shoul- 
der-Joint (Caries  Sicca). — This  affection  attacks 
the  shoulder -joint  more  frecxuently  than  any  other 
joint  in  the  body,  and  is  most  common  in  young- 
adults.  There  is  often  very  extensive  desti'uction 
of  the  head  of  the  bone,  swelling  of  the  soft  parts 
is  not  marked,  as  in  ordinary  cases  of  tuberculous 
arthritis,  and  the  occurrence  of  abscess  is  rare. 
The  most  prominent  symptoms  are  i^ersistent  and 
severe  pain,  muscular  wasting,  and  loss  of  function 
of  the  joint.  It  is  not  likely  to  be  confounded 
with  monarticular  rheumatism,  which  is  generally 
observed  in  subjects  more  advanced  in  age. 
Treatment. — Counterirritation  and  early  fixation 
of  the  joint  are  often  followed  by  good  results. 
If  these  means  are  carefully  employed  operative 
treatment  is  seldom  required. 
Diseases  of  the  Elbow-Joint. — This  joint  may  be  the  seat  of  acute 
synovitis  or  of  tuberculous  synovitis  or  arthritis. 

Acute  SsTQCvitis. — This  affection  of  the  elbow  usually  follows  trauma- 
tisms, and  presents  the  following  symptoms  :  stiffness,  and  pain  upon  motion, 
soon  followed  by  more  or  less  effusion,  most  marked  posteriorly  on  each  side  of 
the  olecranon  ;  the  limb  is  held  in  a  semiflexed  and  semipronated  position. 
Treatment. — This  consists  in  fixation  by  the  use  of  a  splint  and  the  appli- 
cation of  evaporating  lotions.  The  acute  symptoms  usually  subside  rapidly 
under  treatment,  and  as  soon  as  the  swelling  and  tenderness  have  disap- 
peared, passive  motion  and  massage  should  be  practised  to  restore  the  func- 
tion of  the  joint. 

Tuberculous  Arthritis. — The  elbow  is  much  more  frequently  affected 
with  tuberculous  disease  than  any  of  the  joints  of  the  upper  extremity. 
The  disease  is  often  seen  in  childhood,  and  is  usually  of  synovial  origin,  but 
may  be  osteal,  the  seat  then  being  commonly  in  the  lower  articular  extremity 
or  in  the  lower  ej)iphysis  of  the  humerus.  Symptoms. — The  disease  usually 
develops  slowly  ;  there  are  stiffness  and  flexion  of  the  joint ;  pain  may  not 
be  a  prominent  symptom,  except  wheh  the  bone  is  the  starting-point,  when 
it  can  be  developed  by  pressure  upon  the  lower  end  of  the  humerus.  Effusion 
may  occur,  and  is  most  marked  at  the  posterior  surface  of  the  joint  on  each 
side  of  the  olecranon.  As  the  disease  progresses  the  swelling  becomes  greater 
and  the  muscles  atroi^hj^,  causing  the  joint  to  present  a  spindle-shajied 
appearance  ;  the  flexion  increases,  and  the  forearm  is  held  in  a  position  of 
pronation  or  semipronation.  (Fig.  556.)  If  caseation  occnrs,  abscesses  are 
apt  to  point  upon  the  posterior  and  lateral  aspects  of  the  joint.     Treat- 


DISEASES  OF  THE  AVRIST-JOINT. 


639 


Tuberculous  arthritis  of  the  elbow. 


ment. — As  soon  as  the  disease  is  recognized  the  joint  should  be  iixed  by 
the  application  of  a  splint  or  a  plaster- of- Paris  dressing.  The  flexed  posi- 
tion, at  an  angle  of  ninety  degrees  or  less,  is  that  which  is  most  comfortable 
to  the  patient,  and  also  that  in  which  the  arm  will  be  most  useful  if  anky- 
losis occurs.    Injections  of  iodoform 

emulsion  and  fixation  may  be  fol-  F^c^-  556. 

lowed  by  the  arrest  of  the  disease 
and  recovery  with  a  useful  arm  with 
a  moderate  amount  of  restriction 
in  the  motions.  If  abscesses  form, 
they  should  be  opened  and  drained, 
and  fi:xation  should  be  maintained. 
After  the  sinuses  have  healed,  anky- 
losis may  take  place,  and  the  arm 
may  be  useful  if  it  has  been  held 
at  a  right  angle.  If  the  disease  is 
j)rogressive  or  there  are  free  dis- 
charge and  other  evidences  that  disorganization  of  the  joint  has  occurred, 
erasion  or  excision  should  be  performed.  In  adults  early  operations  should 
be  practised  ;  in  children  it  is  better  to  wait  until  it  is  evident  disorganiza- 
tion of  the  joint  has  taken  place.  We  have  seen  many  very  useful  arms 
follow  the  excision  of  tuberculous  elbow-joints.  In  excising  such  joints  the 
diseased  structures  should  be  very  freely  removed,  but  less  extensive  opera- 
tions should  be  practised  in  children  than  in  adults,  to  avoid  injury  of  the 
epiphyses. 

Diseases  of  the  Wrist-Joint. — This  joint  may  be  the  seat  of  acute 
synovitis  or  of  tuberculous  synovitis  or  arthritis.  Acute  synovitis,  which 
arises  sometimes  from  injury,  but  more  commonly  from  general  septic  infec- 
tion, does  not  differ  in  its  symptoms  or  its  treatment  from  the  same  affection 
in  other  joints. 

Tuberculous  Synovitis  or  Arthritis  of  the  Wrist.— This  affection 
may  be  synovial  or  osteal  in  its  origin,  and  rarely  originates  in  the  articular 
surface  of  the  radius,  being  most  frequently  consequent  on  synovitis  of  the 

Fig.  557. 


Tuberculous  arthritis  of  the  wrist. 

carpal  articulations  or  osteitis  of  the  bones  of  the  carpus.  It  may  occur  in 
children  or  in  adults,  but  is  more  common  in  the  latter.  Symptoms. — 
The  joint  becomes  stiff,  and  swelling  occurs  upon  the  dorsal  surface  of  the 
wrist  on  each  side  of  the  extensor  tendons.  As  the  swelling  increases  the 
muscles  become  wasted,  so  that  the  region  of  the  wrist  j)resents  a  spindle- 
shaped  appearance  which  is  very  characteristic.  (Fig.  557.)  Pain  may  not 
be  a  marked  symptom  unless  the  joint  is  moved  ;  when  the  bones  are  exten- 


640  SACRO-ILIAC  DISEASE. 

sively  involved  it  is  often  severe.  Treatment. — This  consists  in  putting 
the  joint  at  rest  as  soon  as  the  disease  is  recognized.  Injections  of  iodoform 
emulsion  may  be  employed  with  good  results.  If  abscesses  form,  they 
should  be  opened  and  drained,  and  fixation  should  be  continued.  Even  in 
cases  of  extensive  disorganization  of  the  joint,  when  excision  would  seem 
to  be  indicated,  free  drainage  seems  to  us  to  offer  the  i)atient  a  better  chance 
of  recovery  than  excision.  A  good  result  may  follow  excision  of  the  wrist 
even  in  advanced  cases  of  tubercular  disease,  but  many  of  the  cases  in 
which  this  operation  had  been  done  required  amputation  later.  If,  how- 
ever, the  operation  is  not  j)osti3oned  until  extensive  disorganization  of  the 
joint  has  occurred,  more  favorable  results  may  be  obtained.  In  cases  in 
which  there  are  profuse  discharge  and  pain  and  evidences  of  visceral  tuber- 
culosis amputation  should  be  j)referred  to  excision. 

Metacarpo-phalangeal  or  interphalangeal  joints  may  be  the  seats 
of  tuberculous  arthritis,  and  the  treatment  is  similar  to  that  employed  in 
the  larger  joints. 

Tuberculosis  of  the  Sterno-Olavicular  and  Acromio-Clavicular 
Articulations. — These  articulations  are  occasionally  the  seats  of  tubercu- 
lous disease,  the  synovial  membranes,  cartilages,  or  bones  being  involved. 
The  pathological  conditions  are  similar  to  those  in  tuberculosis  of  other 
articulations.  Treatment. — This  is  similar  to  that  appropriate  for  other 
tuberculous  joints,— fixation  and  drainage  of  abscesses  and  the  removal  of 
the  diseased  structures  by  means  of  the  gouge  or  curette.  In  the  removal  of 
carious  bone,  care  should  be  taken  not  to  injure  the  costo-clavicular  or 
coraco-clavicular  ligaments,  which  prevent  displacement  of  the  clavicle. 

Sacro-Iliac  Disease. — Disease  of  the  sacro-iliac  articulation  is  a  com- 
paratively rare  affection,  and  is  usually  seen  in  young  adults,  rarely  in 
children.  It  may  arise  apparently  without  exciting  cause,  or  may  follow 
contusions  or  strains  of  the  pelvis  ;  here  a  traumatism,  as  in  other  articula- 
tions, may  be  the  localizing  cause  of  tuberculous  inflammation.  The  path- 
ological changes  are  similar  to  those  observed  in  tuberculous  inflammation 
in  other  localities.  The  abscesses  may  point  externally  in  the  region  of  the 
sacro-iliac  joint,  or,  jiassiug  internally,  may  enter  the  pelvis  and  be  dis- 
charged into  the  rectum,  or  follow  the  iliac  fascia  pointing  above  Poupart's 
ligament,  or  find  their  way  through  the  sacro-ischiatic  foramen  into  the 
buttock,  or  may  descend  between  the  obturator  and  levator  ani  fascise,  reach 
the  ischio-rectal  fossa,  and  point  at  the  side  of  the  anus. 

Sacro-iliac  disease  is  always  a  serious  affection,  and  is  especially  likely  to 
be  followed  by  an  unfavorable  termination  if  abscess  and  extensive  destruc- 
tion of  bone  occur.  In  cases  in  which  caseation  of  the  tuberculous  products 
does  not  occur,  the  prognosis  is  more  favorable. 

Symptoms. — In  the  early  stage  of  the  disease  the  iiatient  complains  of 
stiffness  and  occasional  pain  in  the  sacro-iliac  joint,  and  of  discomfort  in 
standing  or  walking.  Pain  may  also  be  noticed  in  coughing  or  sneezing, 
and  in  defecation.  As  the  disease  advances,  the  body  is  inclined  to  the 
sound  side,  and  the  weight  of  the  bodj''  is  supported  as  far  as  possible  upon 
the  sound  limb,  so  that  there  is  api^arent  lengthening  of  the  limb  upon  the 
affected  side.     Swelling  may  be  marked,  particularly  if  external  abscess  is 


SACRO-ILIAC  DISEASE.  641 

present.  This  disease  may  be  confounded  with  hip-disease,  from  which  it  is 
to  be  distinguished  by  the  facts  that  there  is  fulness  over  the  sacro-iliac 
joint,  that  there  is  no  fixation  of  the  hip-joint,  and  that  pain  is  referred  to 
the  region  of  the  sacrum.  In  sacro-iliac  disease,  pressing  the  ilia  together 
causes  marked  pain.  Gouorrhoeal  or  septic  synovitis  or  arthritis  may  also 
afiect  this  joint,  but  in  such  cases  the  disease  can  usually  be  traced  to  the 
original  infecting  cause,  and  it  runs  a  much  shorter  course. 

Treatment. — This  consists  in  putting  the  diseased  articulation  at  abso- 
lute rest,  and  supporting  the  i)atient  by  a  generous  diet  and  the  use  of  tonics 
and  stimulants.  Eest  of  the  joint  is  secured  by  confinement  to  bed,  with  a 
firm  binder  or  strips  of  plaster  applied  to  the  pelvis,  or  the  plaster-of- Paris 
bandage  may  be  used  to  secure  fixation,  being  applied  so  that  it  includes  the 
pelvis  and  fixes  the  hip-joint  at  the  same  time.  In  the  early  stage  of  the 
disease  the  actual  cautery  applied  to  the  affected  region  often  relieves  the 
pain  and  seems  to  check  or  limit  the  progress  of  the  tuberculous  inflamma- 
tion. The  injection  of  iodoform  emulsion,  even  after  caseation  has  occurred, 
is  often  of  service.  When  abscesses  have  formed,  they  should  be  opened 
with  aseptic  precautions  and  drained ;  intrapelvic  drainage  by  tubes  may 
be  required  in  some  cases,  and  is  often  of  value.  When  carious  bone  or 
sequestra  are  present,  their  removal  should  be  accomplished  by  the  use  of 
the  gouge  or  the  curette.  Extensive  removal  of  bone  may  be  required 
in  some  cases,  and  is  occasionally  followed  by  good  results. 


CHAPTEE  XXVI. 

OPERATIONS    UPON    THE    JOINTS    AND    BONES. 
By  Henry  E.  Whaeton,  M.D. 

EXCISIONS  OR  RESECTIONS. 

Excision  of  a  joint  imj)lies  tlie  partial  or  comj)lete  removal  of  the 
articular  surfaces  of  the  bones  making  up  the  articulation.  The  term 
resection  is  also  used  as  synonymous  with  excision,  but  is  employed  by 
some  authorities  to  indicate  the  removal  of  a  portion  or  the  whole  of  the 
shaft  of  one  of  the  long  bones. 

The  operation  of  excision  or  resection  is  employed  in  injuries  of  bones 
and  joints,  such  as  compound  fractures  and  dislocations,  or  in  the  case  of 
unreduced  dislocations  which  render  the  limb  useless  or  painful.  This  pro- 
cedure is  also  very  frequently  resorted  to  in  diseases  of  the  joints  in  which 
inflammation  resulting  from  pyogenic  or  specific  infection  has  so  seriously 
disorganized  the  joint  or  produced  so  much  deformity  that  great  impair- 
ment of  function  results.  The  operation  is  also  required  for  the  removal  of 
growths,  either  benign  or  malignant,  which  have  their  origin  in  the  bones. 

Excision  is  now  widely  employed  in  the  treatment  of  destructive  dis- 
eases of  the  joints  which  were  formerly  treated  by  amputation,  and  the 
former  operation  should,  if  possible,  always  be  preferred  to  the  latter. 
It  is,  however,  not  to  be  recommended  in  very  young  patients,  erasion  or 
arthrectomy  being  preferred  in  such  cases,  as  injury  of  the  epiphysis  is  apt 
to  interfere  with  the  subsequent  growth  of  the  bone. 

Excision  finds  its  greatest  utility  in  the  treatment  of  tuberculous  affec- 
tions of  the  joints  of  the  extremities ;  in  these  cases  by  its  employment  it  is 
often  possible  to  remove  the  infected  tissues  and  at  the  same  time  to  pre- 
serve a  useful  limb,  and  in  certain  cases  to  have  more  or  less  complete 
restoration  of  function  in  the  articulation.  The  employment  of  aseptic 
methods  has  also  very  much  increased  the  field  of  excision  and  resection, 
for  by  the  use  of  these  means  it  is  common  to  have  prompt  union  in  the 
wounds,  whereas  before  their  introduction  these  operations  were  often 
contraindicated  on  account  of  the  i^rofuse  and  j)rolonged  suppuration 
which  followed. 

The  result  desired  in  excision  or  resection,  in  addition  to  the  removal  of 
diseased  tissues,  varies  somewhat  with  the  part  involved.  In  excision  of 
the  hiiD,  ankle,  shoulder,  elbow,  and  wrist  we  aim  to  secure  fibrous  and  not 
bony  union,  so  that  a  movable  joint  results,  while  at  the  knee-joint  bony 
ankylosis  gives  the  best  functional  result.  When  the  former  result  is 
desired,  care  should  be  taken  not  to  divide  muscles  or  tendons  transversely, 
and  as  far  as  possible  not  to  interfere  with  their  attachments ;  where  bony 
ankylosis  is  desired,  the  division  of  muscles  and  tendons  is  not  a  serious 
consideration.  Injury  of  imj)ortant  arteries,  veins,  and  nerves  should  be 
642 


EXCISIONS  OR  RESECTIONS. 


643 


avoided.  The  periosteum  should  be  preserved  as  far  as  possible,  to  gain  the 
benefit  of  its  osteogenetic  function  in  the  subsequent  repair  of  the  wound, 
and  also  by  its  i^reservation  the  attachment  of  muscles  may  be  retained. 
A  form  of  subperiosteal  excision  or  resection  is  employed  with  this  object  in 
view,  which  may  be  used  in  operations  when  undertaken  for  disease  in 
which  the  periosteum  is  much  thickened  and  can  be  readily  separated  from 
the  bone,  but  when  jpractised  in  cases  of  injury  the  preservation  of  the  peri- 
osteum is  often  impossible. 

Eesection  of  a  portion  of  a  bone  may  be  required  for  the  removal  of  a 
benign  growth,  and  in  such  a  case  as  much  of  the  bone  as  possible  should  be 
left,  so  as  not  to  interfere  seriously  with  its  function.  A  partial  resection 
for  the  removal  of  a  malignant  growth  of  the  bone  is  not  followed  by  good 
results,  and  amputation,  where  it  is  possible,  should  be  preferred.  In  cases 
where  so  large  a  portion  of  the  shaft  of  a  bone  has  been  resected  that  great 
shortening  and  subsequent  loss  of  function  would  result,  bone-grafting  may 
be  employed,  filling  the  defect  with  decalcified  bone  chiijs,  or  suturing  a 
portion  of  a  bone  of  a  freshly  killed  animal  between  the  resected  ends  of  the 
bone.  When  a  portion  of  one  of  two  parallel  bones  is  removed,  to  prevent 
deformity  and  loss  of  function  bone-grafting  or  the  removal  of  a  similar  sec- 
tion from  the  parallel  bone  may  be  practised. 

In  excision  of  joints  where  ankylosis  is  desired,  primary  fixation  of  the 
excised  surfaces  of  the  bone  may  be  obtained  by  the  use  of  sutures  of 
chromicized  catgut  or  silver  wire,  or  by  the  use  of  steel  nails,  screws,  or 
ivory  j)ius  ;  in  resection  of  a  portion  of  the  shaft  of  a  long  bone,  primary 
fixation  of  the  ends  of  the  bone  should  alwaj'S  be  practised  by  the  employ- 
ment of  some  of  these  means.  In  the  after-treatment  of  excisions  and  resec- 
tions, additional  fixation  of  the  parts  should  be  secured  by 
the  use  of  splints  or  of  a  plaster-of- Paris  dressing.  In  cases 
in  which  bony  ankylosis  is  desu'ed,  these  should  be  retained 
for  some  weeks,  but  where  a  movable  joint  is  sought  for,  as 
soon  as  the  wound  is  firmly  healed  the  splint  should  be 
removed  and  movement  encouraged.  Prolonged  fixation  in 
these  cases  naturally  tends  to  limit  the  motion  at  the  seat 
of  operation. 

Osteoplastic  resection  consists  in  turning  up  a  flap  of 
bone  with  the  soft  parts  and  the  periosteum  attached.  When 
the  operative  procedure  has  been  accomplished,  the  flap  is 
rej)laced  and  sutured  in  position.  This  form  of  resection  is 
often  practised  in  operations  upon  the  cranial  nerves,  to 
expose  the  brain  for  the  removal  of  tumors,  or  for  explora- 
tion, and  in  the  jaw  for  the  exposure  of  growths  situated  in 
the  nasopharynx. 

Instruments  required  for  Excision.— In  per- 
forming excisions  or  resections  of  bones  or  joints  the  follow- 
ing instruments  will  be  found  necessary  :  a  stout  scalpel  with  a  heavy  blade, 
a  probe-pointed  knife,  an  excision  saw  with  a  reversible  blade,  a  narrow- 
bladed  saw,  strong  lion-jawed  forceps  (Fig.  558),  retractors,  elevators,  heavy 
bone-cutting  pliers,  knife-bladed  forceps,  and  a  periosteotome. 


Fig.  558. 


Liou-jawed  forceps. 


644 


EXCISION   OF  THE   SHOULDER-JOINT. 


EXCISION   OF   SPECIAL   JOINTS   AND   BONES. 

Excision  of  the  Shoulder-Joint. — This  operation  generally  con- 
sists in  excision  of  the  head  of  the  humerus,  but  occasionally  both  this 
portion  of  the  bone  and  the  articular  surface  of  the  scapula  are  removed. 
It  is  required  in  cases  of  compound  comminuted  fractures  of  the  head  of 
the  humerus  and  of  severe  gunshot  injuries  of  this  joint,  for  the  relief  of 
deformity  following  vmreduced  dislocations  or  badly  united  fractures  of  the 
neck  of  the  humerus,  and  occasionally  in  cases  of  arthritis.  In  many  cases 
of  compound  fracture  or  gunshot  injury  of  the  head  of  the  humerus  a  typical 
excision  is  not  required  ;  if  great  care  is  taken  to  keep  the  wound  aseptic, 
the  simple  removal  of  detached  fragments  of  bone,  with  careful  drainage  of 
the  wound,  will  be  followed  by  good  results. 

The  arm  should  be  adducted  and  rotated  inward,  and  a  straight  incision, 
three  inches  in  length,  should  be  made,  extending  from  the  beak  of  the 
coracoid  i^rocess  down  the  arm  in  the  line  of  the  bicipital  groove  (Fig. 
559) ;  if  more  room  is  required,  this  incision  should  be  supplemented  by  a 

Fig.  559.  Fig.  560. 


Incision  for  excision  of  tlie  shoulder-joint. 


Excision  of  the  shoulder-joint. 


short  transverse  one  from  the  upper  edge  of  the  first  incision  to  the  acromion 
process.  As  the  incision  is  deepened  the  fibres  of  the  deltoid  muscle  are 
divided  in  this  line,  and  the  capsule  of  the  joint  is  exposed  and  divided 
along  the  outer  edge  of  the  tendon  of  the  long  head  of  the  biceps  muscle. 
This  tendon  should  be  held  to  one  side  and  the  capsule  of  the  joint  freely 
opened  ;  the  periosteum  over  the  upper  portion  of  the  neck  of  the  humerus 
should  then  be  divided  and  separated  as  far  as  jjossible  from  the  bone.  The 
muscles  inserted  into  the  tuberosities  of  the  humerus  are  next  divided  with 
a  probe-pointed  knife  and  freed  with  an  elevator.  The  head  of  the  bone 
may  then  be  forced  out  of  the  articular  cavity  by  forcibly  adducting  and 
pressing  the  arm  upward,  and  can  be  removed  by  sawing  through  its  sur- 
gical neck  with  a  narrow-bladed  saw.  (Fig.  560. )  In  some  cases,  however, 
it  is  difficult  to  disarticulate  the  head  of  the  bone,  and  under  such  circum- 
stances the  neck  of  the  bone  may  be  divided,  while  the  head  remains  in  situ, 
by  sawing  across  its  surgical  neck  with  a  narrow  metacarpal  saw.  After 
the  neck  of  the  bone  has  been  divided,  the  head  is  grasped  with  bone- 
forceps  and  is  twisted  loose  from  its  attachments  in  the  articular  cavity. 


EESECTION  OF  THE  HUMERUS.  645 

After  the  removal  of  the  head  of  the  bone,  the  sawed  surface  of  the  humerus 
should  be  rounded  off  with  gouge  forceps,  so  that  no  sharp  edges  shall  be 
present ;  the  articular  surface  of  the  scapula  should  next  be  carefully  exam- 
ined, and  if  this  be  found  diseased,  the  diseased  portion  should  be  removed 
with  a  gouge  or  with  gouge  forceps.  A  drainage-tube  is  then  introduced  to 
the  depth  of  the  wound,  which  should  be  closed  by  sutures.  The  dressing 
consists  in  the  application  of  a  gauze  dressing,  with  a  pad  of  gauze  in  the 
axilla,  and  the  arm  should  be  fastened  to  the  side  in  the  Yelpeau  position. 
A  very  satisfactory  dressing  after  excision  of  the  shoulder-joint  consists  in 
the  use  of  the  Stromeyer  cushion,  applied  between  the  arm  and  the  chest, 
with  its  apex  in  the  axilla.  After  the  wound  is  healed,  the  fixation  dressings 
should  be  removed,  and  the  ]3atient  should  carry  the  arm  in  a  sling,  and  be 
encouraged  to  move  it,  as  in  this  excision  the  formation  of  a  false  joint  is 
most  desirable. 

Resection  of  the  Humerus. — The  whole  or  a  portion  of  the  humerus 
may  require  resection  for  injury  or  disease.  The  incision  in  this  operation 
should  be  made  uj)on  the  outer  side  of  the  bone,  and  carried  down  in  an 
intermusciilar  space  on  a  line  with  the  shaft,  great  care  being  taken  to  avoid 
injury  of  the  musculo-spiral  nerve,  which  passes  around  the  posterior  sur- 
face of  the  humerus  and  lies  close  to  the  bone  between  the  humeral  heads  of 
the  triceps  muscle,  that  is,  about  the  centre  of  the  shaft  of  the  humerus. 
When  the  surface  of  the  bone  has  been  exposed,  the  periosteum  should  be 
divided  to  the  length  of  the  incision  and  carefully  dissected  loose  from  the 
bone  with  an  elevator.  The  musculo-spiral  nerve  is  isolated  and  held  aside 
while  the  bone  is  being  exposed.  After  separating  the  periosteum  as  com- 
pletely as  possible,  if  the  whole  shaft  of  the  bone  is  found  diseased,  it  may 
be  removed  in  one  piece,  or  by  dividing  it  in  the  middle  with  a  saw 
or  forceps  and  removing  each  fragment  as  far  as  the  upper  and  lower 
epiphyses,  or  the  upper  or  the  lower  portion  only  may  require  removal. 
Resection  of  the  humerus  may  be  required  for  ununited  fracture.  The 
dressing  after  resection  of  the  shaft  of  the  humerus  consists  in  the  introduc- 
tion of  a  rubber  or  gauze  drain  and  the  closure  of  the  wound  with  sutures. - 
A  gauze  dressing  should  be  applied,  and  the  arm  placed  ujjon  a  splint,  and 
subsequently  fastened  to  the  side  of  the  body  to  secure  fixation  of  the  parts, 
or  a  plaster- of- Paris  dressing  may  be  applied. 

Excision  of  the  Elbow-Joint. — This  operation  may  be  required  in 
cases  of  compound  or  gunshot  fractures  or  tuberculous  disease  of  this  joint, 
and  is  occasionally  emj)loyed  to  relieve  the  deformity  and  loss  of  function 
following  unreduced  dislocations  or  bony  ankylosis. 

The  forearm  should  be  slightly  flexed  ;  a  longitudinal  incision  is  made 
from  about  two  inches  above  the  olecranon  process  a  little  to  its  inner  side, 
and  carried  three  or  four  inches  downward  in  the  line  of  the  ulna  (Fig.  561) ; 
the  tissues  should  then  be  divided  down  to  the  bone,  and  the  ulnar  nerve 
dissected  from  its  groove  behind  the  inner  condyle  of  the  humerus  and  held 
aside  by  a  retractor.  The  tendon  of  the  triceps  muscle  is  next  divided,  and 
its  attachment  to  the  fascia  and  periosteum,  over  the  olecranon  process,  is 
separated  with  an  elevator  or  a  periosteotome  and  turned  downward,  the 
capsule  of  the  joint  being  opened  and  the  lateral  ligaments  divided  as  the 


646 


EXCISION   OF  THE  ELBOW-JOINT. 


Fig.  661. 


II 


foi-earm  is  flexed  upon  the  arm.  The  upper  part  of  the  ulna  and  the  head 
of  the  radius  are  freed  with  a  probe-pointed  knife,  and  removed  with  a 
narrow-bladed  saw,  care  being  taken  in  making  the  section  of 
the  radius  to  divide  its  neck  so  that  the  attachment  of  the 
biceps  muscle  shall  not  be  interfered  with.  The  condyles  of 
the  humerus  should  next  be  freed  and  removed  with  a  saw. 
In  exjjosing  the  bones  at  the  anterior  portion  of  the  joint,  injury 
of  the  brachial  artery  and  vein  and  the  median  nerve  should 
be  avoided. 

In  excision  of  the  elbow -joint  for  disease,  the  amount  of 
bone  to  be  removed  depends  largely  upon  the  extent  of  the 
disease ;  the  rule,  however,  is  to  remove  the  diseased  bone 
freely,  as  better  functional  results  occur  after  free  removal 
than  in  cases  where  the  bone  has  been  removed  sparingly. 
In  excision  for  ankylosis,  or  for  the  deformity  following  unre- 
duced dislocations,  and  in  compound  fractures  of  the  elbow- 
joint,  the  same  rule  applies  as  regards  free  removal  of  the 
ends  of  the  bones. 
After  a  sufficient  amount  of  bone  has  been  removed  and  hemorrhage  has 
been  arrested,  the  upper  end  of  the  divided  tendon  of  the  triceps  should  be 
fastened  to  the  lower  end  or  to  its  fascial  ex]3ansion  by  a  few  sutures  of  chro- 
micized  catgut.  A  drainage-tube  should  be  introduced,  and  the  edges  of  the 
wound  brought  together  with  sutures.  After  applying  a  gauze  dressing,  a 
well-padded  anterior  angular  splint  should  be  placed  upon  the  arm  and  fore- 
arm, with  a  moulded  pasteboard  gutter  covering  in  the  posterior  surface  of 
the  elbow,  and  the  splints  held  in  place  by  a  roller  bandage.     The  jslaster- 

FiG.  562. 


Incision  for 
excision  of  the 
elbow-joint. 


Extension  of  the  arm  after  excision  of  the  elbow. 

of- Paris  dressing  may  also  be  emjyloyed  in  these  cases  in  place  of  the  splints 
previously  mentioned.  If  the  wound  runs  an  aseiitic  course  it  need  not  be 
dressed  for  a  week  or  ten  days,  at  which  time  the  drainage-tube  should  be 
removed  as  well  as  the  sutures,  and  the  arm  fixed  in  the  same  position  for 
another  week  or  ten  days.  As  soon  as  the  wound  is  firmly  healed,  the 
splints  should  be  removed,  a  light  gauze  dressing  applied  over  the  region  of 
the  wound,  and  the  patient  allowed  to  carry  the  arm  in  a  sling,  and  encour- 
aged to  pronate  and  supinate,  as  well  as  flex  and  extend,  the  forearm.  In 
this  excision,  it  is  desirable  to  have  a  fair  range  of  motion,  and  with  this 
end  in  view,  it  is  a  mistake  to  retain  fixation  dressings  for  a  long  period ; 
the  sooner  they  are  dispensed  with,  and  the  patient  begins  to  use  the  arm 
after  healing,  the  better  will  be  the  functional  result. 


EXCISION  OF  THE   WRIST-JOINT. 


G47 


Fig.  563. 


The  result  of  an  excision  of  the  elbow-joint  for  an  unreduced  posterior 
dislocation  with  fracture  of  the  inner  condyle  of  the  humerus,  in  which  the 
arm  was  firmly  fixed  at  a  right  angle  and 
was  both  useless  and  painful,  is  shown 
in  Figs.  562  and  563.  This  patient  had 
both  fair  extension  and  flexion  of  the 
arm,  and  the  motions  of  pronation  and 
supination  were  perfect. 

Resection  of  the  Radius  or 
Ulna. — Eesection  of  the  radius  or  ulna, 
either  entirely  or  partially,  may  be  re- 
quired for  disease  or  injury,  or  to  correct 
deformity  resulting  from  ai'rest  of  growth 
or  from  a  loss  of  a  portion  of  one  or  other 
of  the  bones.  An  incision  should  be 
made  upon  the  back  of  the  forearm  over 
the  bone  to  be  resected  ;  the  bone  being 
exposed,  the  periosteum  is  separated 
with  an  elevator,  and  the  bone  divided 
with  a  saw  or  chisel ;  each  fragment  is 
then  lifted  and  separated  from  its  mus- 
cular attachments  up  to  the  j)oint  where  it  is  desired  to  remove  it.  (Fig. 
564.)  If  the  articular  surface  of  the  bone  is  to  be  removed,  the  disarticula- 
tion should  be  carefully  made  with  a  j)robe-pointed  knife,  and  in  exposing 
the  anterior  surface  of  the  bone,  injury  of  the  vessels  and  nerves  lying  ui3on 
its  palmar  surface  should  be  avoided. 


Flexion  of  the  arm  after  excision  of  tlie  elbow. 


Resection  of  tlie  lower  end  of  tiie  radiiis. 

Excision  of  the  Wrist- Joint. — Excision  of  this  joint  may  be 
required  for  injury,  but  is  usually  employed  for  tuberculous  arthritis.  The 
proximity  of  important  blood-vessels,  nerves,  and  tendons,  and  the  irregu- 
lar shape  of  the  articulations  render  excision  of  the  articulation  an  oi^er- 
ation  accompanied  by  more  or  less  difftculty.     (Fig.  565.) 

The  wrist-joint  may  be  excised  by  making  a  dorsal  incision  beginning  at 
the  middle  of  the  ulnar  border  of  the  second  metacarpal  bone  and  carried 


648 


RESECTION   OF  A  METACARPAL  BONE. 


Fig.  565. 


Fig.  566. 


Ai  ticulations  of  the  ■«  rist 


Incision  for  excision  of  the 
wrist.    (After  Stimson.) 


upward  about  four  inches  (Fig.  566),  crossing  the  ulnar  edge  of  the  tendou 
of  the  extensor  carpi  radialis  brevior  and  splitting  the  dorsal  ligaments  of 
the  wrist  between  the  tendons  of  the  extensor  secuudi  internodii  and  the 
extensor  of  the  forefinger.  The  incision  should  be  carried  down  to  the 
bone,  and  the  soft  parts  and  tendons  dissected  loose 
with  an  elevator.  By  flexing  the  hand  the  first 
row  of  the  carpal  bones  is  made  to  present  in  the 
wound,  and  the  scaphoid  is 
sei^arated  from  the  trape- 
zium and  removed,  the 
trapezium  and  pisiform 
being  left  if  possible.  In 
removing  the  second  row 
of  the  carj^al  bones  the 
knife  should  be  j)assed  be- 
tween the  trapezium  and 
the  trapezoid,  and  then 
into  the  carpo-metacarj)al 
joint,  cutting  the  ligaments 
of  the  dorsal  side  of  the 
ends  of  the  metacarpal 
bones,  when  the  trapezoid,  os  magnum,  and  unciform  can  be  taken  away. 
The  lateral  ligaments  are  carefully  divided,  and  the  articular  ends  of  the 
radius  and  ulna  divided  with  a  saw ;  the  ends  of  the  metacarpal  bones,  if 
diseased,  should  next  be  removed. 

Mynter  recommends  the  following  method :  an  incision  is  made,  begin- 
ning upon  the  dorsum  of  the  hand,  extending  from  the  radius  downward 
between  the  second  and  third  metacarpal  bones  and  through  the  palm, 
splitting  the  hand  as  high  as  the  siiperflcial  joalmar  arch,  thus  entering  the 
wrist  between  the  trapezoid  and  os  magnum  and  between  the  scaphoid  and 
semilunar  bones.  By  this  method  it  is  possible  to  excise  the  carpus  without 
injury  of  the  palmar  arches  and  jjalmar  bursa. 

After  the  bones  have  been  excised  and  the  hemorrhage  has  been  con- 
trolled, the  wound  should  be  drained  aud  closed,  a  gauze  dressing  ai^plied, 
and  the  forearm  and  arm  secured  upon  a  well-j)added  straight  splint.  As 
soon  as  the  wound  is  healed  the  splint  should  be  abandoned,  and  the  patient 
should  be  encouraged  to  move  the  fingers,  and  also  to  practise  motions  at  the 
wrist  to  secure  a  movable  joint. 

Resection  of  a  Metacarpal  Bone. — A  metacarpal  bone  may  be 
resected  by  making  a  longitudinal  incision  on  the  back  of  the  hand  over  the 
bone  to  be  removed.  The  incision  should  extend  from  one  articular  end  of 
the  bone  to  the  other,  and  as  it  is  deepened  care  should  be  taken  not  to 
divide  the  extensor  tendons ;  these,  when  exposed,  should  be  held  to  one 
side  by  a  retractor,  and  the  periosteum  should  be  separated  as  far  as  possi- 
ble from  the  bone.  When  the  bone  has  been  fully  exposed  it  may  be  removed 
by  dividing  it  at  the  middle  with  bone-cutting  pliers  (Fig.  567)  and  then 
disarticulating  each  fragment  separately,  or  the  articular  ends  may  be  disar- 
ticulated and  the  bone  removed  iu  one  piece.     All  incisions  employed  in 


RESECTION   OF  THE  CLAVICLE. 


649 
real,  care, 


detaching  tlie  anterior  surface  of  the  bone  should  be  made  with 
to  avoid  injury  of  the  structures  of  the  palm  of  the  hand. 

Excision  of  a  Metacarpo-Phalangeal  Joint  or  an  Interpha- 
langeal  Joint. — In  excising  a   metacarpophalangeal  joint,  the   ioint  is 


Fig.  567. 


Fig.  568 


Resection  of  a  metacarpal  bone. 


Excision  of  a  metacarpo-phalangeal  joint. 
(Smith.) 


exposed  by  a  longitudinal  incision  over  the  dorsal  surface  of  the  knuckle. 
The  extensor  tendon  being  exposed  and  held  to  one  side,  the  lateral  liga- 
ments are  divided.  The  articular  ends  of  the  bones,  being  exposed,  are 
next  removed  with  a  metacarpal  saw  or  with  bone-cutting  pliers.  (Fig. 
.568.)  In  excising  an  iuterphalangeal  joint  an  incision  may  be  made  upon 
the  dorsal  surface  of  the  joint  or  upon  its  lateral  surface,  and  after  exposing 
the  joint  the  lateral  ligaments  are  divided. 
The  articular  surfaces  of  the  bones  are  removed 
with  a  saw  or  with  bone- forceps. 

Resection  of  the  Clavicle. — Eesection 
of  this  bone,  either  jjartial  or  complete,  may 
be  required  for  injury  or  disease.  Disease  of 
the  clavicle  arising  from  tuberculosis  or  infec- 
tive osteomyelitis  usually  involves  the  shaft  of 
the  bone.  The  operation  is  occasionally  re- 
quired for  sarcoma  of  the  clavicle.  An  incision 
is  made  over  tlie  clavicle  from  one  articulation 
to  the  other,  which  is  carried  directly  down  to 
the  bone  ;  the  periosteum  is  then  separated,  the 
shaft  of  the  bone  divided  at  its  middle,  and 
each  fragment  raised  with  forceps  and  disar- 
ticulated (Fig.  569),  or  the  bone  may  be  dis- 
articulated at  one  extremity,  and,  being  raised  up,  freed  from  its  adherent 
tissues  and  disarticulated  at  the  other  extremity.  In  disarticulating  the 
sternal  end  of  the  clavicle  a  probe-pointed  knife  should  be  used,  and  care 


Resection  of  the  clavicle. 


650 


EXCISION  OF  THE  SCAPULA. 


exercised  to  avoid  injury  of  the  important  vessels  and  nerves  which  lie  close 
to  it. 

Resection  of  the  Ribs. — This  may  be  required  for  injiu-y  or  dis- 
ease of  the  ribs,  and  a  partial  resection  of  one  or  more  ribs  is  frequently 
employed  to  secure  free  drainage  in  cases  of  emf)yema.  The  special  opera- 
tions employed  for  this  purpose  are  described  under  Diseases  of  the  Chest. 

The  incision  should  corresiiond  in  length  and  direction  with  the  portion 
of  the  rib  to  be  removed,  and  may  be  crossed  at  each  end  by  a  short  trans- 
verse incision ;  the  tissues  overlying  the  rib  are  then  dissected  loose,  the 
periosteum  is  separated  as  far  as  possible,  the  rib  is  divided  with  cutting 
pliers  at  two  points,  and  the  jDiece  is  grasped  with  forceps  and  removed  by 
separating  the  attachments  to  its  under  surface  with  an  elevator  or  a  dry 
dissector.  When  this  operation  is  not  done  to  secure  drainage  from  the 
chest,  great  care  should  be  taken  to  avoid  oj)ening  the  pleural  cavity. 

Resection  of  the  Sternum. — This  may  be  required  for  injury,  for 
caries,  or  for  sarcoma.  The  entire  sternum  has  been  removed,  as  well  as 
the  individual  sections  of  the  bone.  Resection  of  the  sternum  is  accom- 
plished by  making  a  longitudinal  incision  over  the  portion  of  the  bone  to 
be  removed;  after  the  periosteum  has  been  exposed  it  should  be  carefully 
separated,  and  the  diseased  portion  of  the  bone  is  then  carefully  freed  from 
the  attachments  upon  its  posterior  surface  with  an  elevator,  and  is  removed 
with  forceps.  After  its  removal  a  drainage-tube  should  be  introduced,  and 
a  copius  gavize  dressing  applied  and  held  in  position  by  strips  of  plaster 
placed  so  as  to  produce  some  fixation  of  the  anterior  jjortion  of  the  chest. 

Excision  of  the  Scapula. — Excision  of  the  scapula,  either  partial  or 
comj)lete,  may  be  required  for  necrosis,  or  for  benign  or  malignant  growths 
of  the  bone  ;  in  cases  of  malignant  disease  of  the  scapula  a  complete  excision, 
as  a  rule,  is  the  safer  procedure,  as  partial  excisions  are  very  liable  to  be 
followed  by  a  rapid  recurrence  of  the  disease.  Complete  excision  of  the 
scapula  is  both  a  difBcult  and  a  dangerous  opera- 
tion, the  danger  consisting  largely  in  the  amount 
of  hemorrhage  which  occurs  during  its  perform- 
ance. When,  however,  the  operation  is  done  for 
necrosis,  it  is  a  comparatively  simple  one,  and  is 
not  attended  with  great  risk. 

In  excising  the  scapula  an  incision  should  be 
made  along  the  whole  length  of  its  spine ;  from 
the  posterior  extremity  of  this  line  two  other  inci- 
sions are  made,  one  running  about  an  inch  or  two 
above,  and  the  other  passing  down  the  posterior 
border  of  the  bone  to  its  inferior  angle  (Fig.  570) ; 
the  flaj)S  thus  made  are  loosened  by  separating 
incisio^ns  for  exeision^f  toe  soap-  ^^^  mygcles  attached  to  the  outcr  surfacc  of  the 
bone.  The  attachments  of  the  deltoid  and 
trapezius  to  the  acromion  and  spine  of  the  scapula  are  separated,  and 
the  lower  angle  is  freed  by  detaching  the  teres  major  and  serratus  magnus 
muscles.  The  bone  is  then  raised,  and  the  subscapularis  muscle  is  detached 
from  below  upward.     The  neck  of  the  scapula  should  next  be  divided 


Fig.  570. 


EXCISION  OP  THE  HIP-JOINT. 


651 


with  a  saw  or  cutting  forceps ;  the  acromion  is  separated  from  the  clavicle 
and  scapula  and  turned  u[)ward,  the  joint  being  oi^ened  from  below.  The 
coracoid  process  should  be  separated  from  its  muscular  and  ligamentous 
attachments,  or  may  be  divided  with  a  saw  and  left  in  place.  In  cleaiing 
the  siipraspinous  fossa  care  should  be  taken  not  to  injure  the  suprascapular 
nerve  in  the  suprascapular  notch  ;  to  prevent  injuring  this  nerve,  it  should 
be  raised  with  a  j)eriosteotome  in  its  fibrous  sheath.  As  the  great  risk  of 
this  operation  consists  in  the  amount  of  blood  that  is  lost  during  its  per- 
formance, care  should  be  taken  that  bleeding  vessels  are  promj)tly  secured 
with  hfemostatic  forceps  as  the  operation  proceeds,  and  when  it  is  completed 
the  vessels  should  be  secured  by  ligatures.  After  excision  of  the  scapula, 
one  or  more  drainage-tubes  should  be  introduced,  the  wound  closed  with 
sutures,  a  copious  gauze  dressing  applied,  and  the  arm  securely  fastened  to 
the  side  with  a  Velpeau  bandage. 

Excision  of  the  Hip-Joint.— Excision  of  the  head  of  the  femur  may 
be  required  for  gunshot  injury  or  for  compound  comminuted  fractures  of  the 
head  and  neck  of  the  bone  or  irreducible  dislocation  ;  the  operation  is  most 
frequently  employed  in  cases  of  tuberculous  arthritis  of  the  hip-joint. 

An  incision  is  made  from  a  point  about  three  inches  below  the  crest  of 

the  ilium  and  about  the  same  distance  behind  the  anterior  superior  spine  of 

the  ilium,  extending  downward  to  the  great  trochanter,  where  it  is  carried 

downward  in  the  line  of  the  femur  for  three  or  four  inches  (Pig  571) ;  the 

soft  parts  are  then  dissected  from  the  great  tro- 

FiG.  571.  chanter  and  the  upper  part  of  the  shaft  of  the 

Fig   572 


Incision  for  excision  of  tlie  hip- 
joint. 


Exposure  of  the  head  of  the  femur  in  excision  of  the  hip-joint. 


femur,  and  the  capsule  of  the  joint  is  opened.  An  assistant  should  next 
rotate  the  thigh  inward  and  outward,  and  with  a  blunt-pointed  knife  the 
muscles  attached  to  the  trochanters  are  shaved  off  close  to  the  bone,  or 
the  trochanters  are  chiselled  off  with  the  muscles  ;  the  head  and  neck  of  the 
femur  are  then  freed  by  the  use  of  a  knife  and  the  elevator ;  the  thigh 
is  adducted  and  pushed  upward,  and  the  head  and  neck  of  the  bone  are 


652 


AJvTEEIOE  EXCISION   OF  THE  HIP-JOINT. 


Fig.  573. 


^^iU 


Result  of  excision  of 
the  hip,  showing  amount 
of  liexion  of  the  thigh. 


made  to  jsroject  from  the  wound.  (Fig.  572.)  A  transverse  section  of 
tlie  bone  is  tlien  made  with  a  saw  or  Gigli's  wire  saw,  just  below  the  great 
trochanter.  In  some  cases  it  is  diificult  to  remove  the 
head  of  the  bone,  which  may  be  more  or  less  firmly 
ankylosed  to  the  acetabulum ;  here  the  neck  of  the 
bone  should  be  divided  with  a  narrow  metacarpal  saw 
from  without  inward,  or  with  a  chisel,  the  head  and 
neck  of  the  bone  being  afterwards  removed  with  a 
gouge  or  bone-cutting  pliers.  After  the  bone  has  been 
removed,  the  acetabulum  should  be  carefully  examined, 
and  if  diseased  bone  be  found  it  should  be  removed 
with  a  curette  or  gouge,  or  with  gouge  forceps.  If  the 
acetabulum  has  been  perforated  and  an  abscess  exists 
within  the  pelvis,  the  bony  floor  of  the  acetabulum 
should  be  cut  away  with  a  gouge,  a  curette  being  em- 
ployed to  clear  out  as  far  as  possible  the  abscess-cavity, 
and  a  drainage-tube  should  be  inserted  into  it.  The 
edges  of  the  incision  should  next  be  brought  together 
by  sutures,  and  a  gauze  dressing  applied.  The  resnlt 
of  an  excision  of  the  hip-joint  by  this  method  is  shown 
in  Fig.  573. 

Anterior  Excision  of  the  Hip-Joint. — This 
method  of  excising  the  hip  possesses  the  advantage  that 
it  divides  no  muscular  fibres  nor  vessels  of  importance,  and  interferes  very 
little  with  the  capsular  structures.  It  is  especially  indicated  in  the  early  stage 
of  hip-disease  and  in  those  cases  in  which  anabscess  forms  anteriorly.  We  have 
employed  it  in  a  number  of  cases,  and  consider  it  a  most  satisfactory  operation. 
An  incision  is  made  upon  the  front  of  the  thigh  over  the  joint,  beginning 
half  an  inch  below  the  anterior  sujierior  spine  of  the  ilium,  and  carried 
three  or  four  inches  downward  and  a  little  inward  ;  as  the  incision  is  deep- 
ened the  tensor  vaginae  femoris  and  the  gluteal  muscles  are  exposed,  and 
should  be  di-awn  to  the  outer  side  ;  the  sartorius  and  rectus  muscles  should 
be  drawn  to  the  inner  side,  when  the  neck  of  the  femiir  is  exposed  and 
divided  with  a  metacarpal  or  an  Adams's  saw.  The  head  of  the  bone  is 
then  grasped  with  strong  sequestrum  forceps,  and  by  the  use  of  these  and 
an  elevator  it  is  removed  ;  the  acetabulum  should  then  be  examined,  and  if 
diseased  bone  is  present  it  should  be  removed  with  a  curette,  as  well  as  any 
diseased  soft  structui-es.  The  after-treatment  of  the  wound  consists  in  con- 
trolling bleeding,  and,  after  thoroughly  irrigating  the  wound,  in  filling  its 
cavity  with  iodoform  emulsion  and  closing  the  incision  accurately  with 
sutures.  If  drainage  is  desirable,  a  drainage-tube  may  be  introduced  into 
the  bottom  of  the  wound  and  allowed  to  project  at  some  point  upon  the 
surface  of  the  wound ;  we  have,  however,  in  those  cases  in  which  we 
employed  drainage,  found  it  more  satisfactory,  after  excising  the  head  of 
the  bone,  to  make  an  opening  through  the  tissues  of  the  gluteal  region  and 
pass  a  drainage-tube  from  the  acetabulum  through  this  wound,  completely 
closing  the  anterior  wound  by  sutures.  The  result  of  an  anterior  excision  of 
the  hip  is  shown  in  Figs.  574  and  575. 


EXCISION  OF  THE  KNEE-JOINT. 


653 


After-Treatment. — This  consists  in  the  application  of  a  plaster-of- Paris 
bandage  extending  from  the  foot  of  the  pelvis,  and  including  the  leg,  thigh, 
and  pelvis,  which  gives  complete  fixation  to  the  excised  joint,  or  of  an 
extension  af)paratus  to  the  leg,  to  which  a  weight  is  attached,  lateral 

Fig.  575. 


Result  of  anterior  excision  of  the  hip-joint. 


The  same  case  showing  the  extent  of  flexion 
of  the  thigh. 


support  at  the  same  time  being  given  to  the  leg  and  thigh  by  the  application 
of  sand-bags,  the  limb  being  kept  in  an  abducted  position  during  the 
healing.  As  soon  as  the  wound  is  healed  a  moulded  pasteboard  or  a 
Thomas's  splint  should  be  applied,  and  the  patient  allowed  to  go  about  with 
crutches.  The  use  of  this  siilint  is  often  required  for  some  time  to  prevent 
flexion  of  the  thigh  upon  the  pelvis.  After  excisions  of  the  hip-joint  some 
surgeons  ijrefer  to  keep  the  fixation  apparatus  applied  for  a  considerable 
time,  with  the  idea  of  obtaining  bony  ankylosis  at  the  seat  of  operation, 
fearing  that  if  motion  is  encouraged  early  greater  shortening  and  deformity 
will  result.  We,  however,  are  of  the  opinion  that  it  is  of  decided  advantage 
to  have  a  fair  range  of  movement  in  this  joint  after  excision,  and,  with  this 
end  in  view,  encourage  the  patient  to  practise  motion  at  the  joint  as  soon  as 
the  wound  is  healed.  If  the  splint  is  removed  during  the  day,  it  should  be 
worn  at  night  if  there  is  a  tendency  to  flexion  of  the  thigh  upon  the  pelvis. 

Excision  of  the  Knee-Joint. — Excision  of  the  knee-joint  may  be 
required  for  injury,  for  ankylosis  in  faulty  position,  or  for  disease,  and  the 
operation  is  most  frequently  resorted  to  in  cases  of  tuberculous  arthritis. 

The  knee-joint  may  be  excised  by  making  an  incision  which  begins 
on  the  inner  side  of  the  thigh,  over  the  inner  condyle  of  the  femur,  and 


654 


EXCISION   OF  THE   KNEE-JOINT. 


is  carried  over  the  front  of  the  knee,  just  below  the  patella,  to  a  correspond- 
ing point  upon  the  external  condyle  of  the  femur  (Fig.  576)  ;  the  flap  thus 
formed,  consisting  of  skin  and  connective  tissue,  is  dissected  up  to  a  point 
corresponding  with  the  upper  edge  of  the  patella.  The  ligamentum  patellte 
is  then  cut  through  trans- 
versely, the  leg  is  slightly  ^^'=*-  5^^- 
flexed,    and    the    joint    is 

Fig.  576. 


Incision  for  excision  of  the  knee-joint.  Excision  of  tlie  knee-jomt. 

opened ;  the  lateral  ligaments  are  next  divided,  and  by  flexing  the  leg  upon 
the  thigh  the  joint-surfaces  are  freely  exposed.  The  semilunar  cartilages 
are  next  removed,  the  condyles  of  the  femur  are  freed  posteriorly  with  a 
blunt-pointed  bistoury,  a  narrow-bladed  saw  is  placed  under  the  condyles, 
and  a  transverse  section  of  the  femur  is  removed.  (Pig.  577.)  The  head 
of  the  tibia  is  next  cleared  in  the  same  manner,  and  a  transverse  section  of 
this  bone  is  removed  with  a  saw.  The  patella  may  be  removed  before 
excising  the  ends  of  the  bones,  or,  if  ankylosed  to  the  condyles,  it  may  be 
removed  with  the  section  of  bone  which  includes  a  portion  of  the  condyles. 
After  a  sufficient  amount  of  bone  has  been  removed,  if  localized  areas  of 
carious  bone  present  themselves  upon  the  sawed  surface  of  either  bone,  they 
should  be  removed  with  a  gouge  or  gouge  forceps.  In  excising  the  knee- 
joint  for  ankylosis  with  flexion,  a  very  large  portion  of  the  condyles  and 
of  the  head  of  the  tibia  may  require  removal  before  the  limb  can  be  brought 
into  a  straight  position,  and  if  the  deformity  has  existed  for  some  time  con- 
siderable contracture  of  the  muscles  may  have  resulted,  requiring  a  division 
of  the  hamstring  tendons  before  the  deformity  can  be  satisfactorily  corrected. 
In  such  cases  care  should  be  exercised  in  making  forcible  straightening  of 
the  limb,  to  avoid  rupturing  the  popliteal  vein  or  popliteal  artery.  In 
excising  the  knee-joint  in  children  only  so  much  bone  should  be  removed 
as  may  be  done  without  encroaching  u]3on  the  epiphyseal  cartilages,  as 
injury  of  the  latter  will  interfere  with  the  subsequent  growth  of  the  limb. 
After  sufficient  bone  has  been  removed  to  allow  the  limb  to  be  brought  into 
proper  position,  hemorrhage  should  be  controlled  by  the  application  of 
ligatures,  and  fixation  of  the  excised  ends  may  be  secured  by  introducing 
heavy  silver  wire  sutures,  steel  nails,  ivory  pegs,  or  chromicized  catgut 
sutures.  Drainage  need  not  be  introduced  into  the  wound,  and  the  incision 
should  be  closed  by  sutures.     After  applying  a  gauze  dressing  the  limb  is 


EXCISION   OF  THE   PATELLA. 


655 


enveloped  in  a  flannel  bandage  and  a  plaster-of- Paris  dressing  applied  from 
tlie  foot  to  the  groin.  If  for  any  reason  it  is  considered  desirable  not  to  use 
this  form  of  fixation  dressing,  after  the  wound  has  been  dressed  the  limb 
should  be  placed  upon  a  bracketed  wire  splint,  which  is  fastened  to  the  leg 
and  thigh  by  straps  and  bandages,  and  the  dressing  is 
secured  over  the  wound  by  a  separate  bandage.  This 
allows  the  wound  to  be  dressed,  if  necessary,  without 
any  disturbance  of  the  bones.  The  result  of  an  excision 
of  the  knee  is  shown  in  Pig.  578. 

Excision  of  the  Patella. — Excision  of  this  bone 
may  be  required  in  cases  of  compound  comminiited 
fractures,    or  for   caries   or   necrosis.      In   the   former 


Fig.  580. 


l-»w  / 


^^      '%1^ 


Resection  of  the  lower  part  of  the  fibula. 


Result  of  an  excision  of 

knee-joint.  a  kle  jumt 

class  of  cases  no  formal  method  of  excision  is  practised,  loose  fragments 
being  simply  removed ;  when  the  operation  is  undertaken  for  disease,  a 
longitudinal  or  crucial  incision  is  made  over  the  patella,  the  periosteum  is 
carefully  separated  from  the  bone,  and  the  bone  is  grasped  with  strong  for- 
ceijs  and  dissected  free  from  its  attachments  upon  the  under  surface.  The 
knee-joint  is  generally  oi^ened  in  excising  the  patella,  unless  the  removal  of 
the  bone  is  undertaken  for  necrosis  or  caries,  when  it  is  possible  to  accom- 
plish its  complete  removal  without  opening  the  joint.  After  excision  of  the 
patella  the  wound  should  be  drained  and  closed  by  sutures,  a  gauze  dressing 
applied,  and  the  limb  fixed  in  a  straight  position  by  the  application  of  a 
posterior  splint  or  a  plaster-of- Paris  dressing. 

Resection  of  the  Tibia  or  the  Fibula. — In  resecting  the  tibia  or 
the  fibula,  after  the  shaft  of- the  bone  has  been  exj^osed  by  a  longitudinal 
incision,  the  periosteum  should  be  separated  as  completely  as  possible,  when 
the  shaft  may  be  removed  in  one  piece  or  may  be  divided  at  its  middle,  each 
fragment  being  grasped  with  forceps,  dissected  up,  and  removed  at  its  epi- 
physeal junction.     (Pig.  579.) 


656  EXCISION   OF  THE  OS   CALCIS. 

Excision  of  the  Ankle-Joint. — This  operatiou  may  be  required  for 
injuries  of  the  ankle-joint,  such  as  compound  dislocations  or  fractures,  or 
for  tuberculous  disease  of  the  joint. 

An  incision  is  made  over  the  iibula  at  a  jjoint  two  inches  above  the 
joint  and  carried  down  to  the  tip  of  the  external  malleolus.  The  incision  is 
then  carried  slightly  upward  towards  the  dorsum  of  the  foot  (Fig.  580), 
care  being  taken  that  it  does  not  extend  so  far  forward  as  to  endanger 
the  extensor  tendons  or  the  dorsal  artery.  The  bone  is  exposed  in  this 
incision,  and  the  periosteum  is  separated  and  turned  aside ;  the  peroneal 
tendons  are  next  exposed  and  held  to  one  side  with  retractors  ;  the  external 
malleolus  is  divided  with  bone-cutting  pliers  and  removed,  and  the  astrag- 
alus is  exposed.  The  upj)er  articulating  surface  of  the  astragalus  is  removed 
with  bone-forceps  or  with  a  saw,  or  the  whole  bone  may  be  removed.  The 
foot  is  then  very  much  inverted,  and  the  end  of  the  tibia  is  cleared  with  a 
probe-pointed  knife,  being  careful  not  to  injure  the  posterior  tibial  artery, 
nerve,  or  vein,  and  when  the  articiilating  surface  has  been  freed  it  is 
removed  with  a  saw  or  bone-forceps.  The  articular  end  of  the  tibia  may  be 
exposed  by  making  an  additional  incision  upon  the  inner  side  of  the  ankle, 
over  the  internal  malleolus  if  it  is  desired.  After  the  joint  has  been  excised 
a  drainage-tube  should  be  introduced,  the  incision  closed  with  sutures,  and 
a  gauze  dressing  applied.  The  foot  is  placed  at  a  right  angle  to  the  leg  and 
a  plaster-of- Paris  bandage  applied  to  the  foot  and  leg,  or  fixation  may  be 
given  to  the  parts  by  the  application  of  moulded  binder's  board  splints. 
The  latter  method  of  fixation  is  preferable  if  frequent  di'essings  of  the 
wound  are  necessary.  After  excision  of  the  ankle  in  some  cases  more  or  less 
movement  of  the  joint  remains,  while  in  others  bony  ankylosis  results.  In 
either  event  the  result  is  satisfactory  as  regards  the  usefulness  of  the  part. 

Excision  of  the  Astragalus. — Excision  of  this  bone  may  be  required 
for  compound  fractures  or  dislocations  or  for  tuberculous  disease  of  the 
tarsus,  and  is  often  emploj^ed  to  correct  the  deformity  in  aggravated  forms 
of  club-foot.  In  excising  this  bone  an  incision  is  made  on  the  outside  of  the 
ankle-joint,  very  similar  to  that  employed  for  excision  of  the  ankle-joint ; 
the  external  lateral  ligaments  are  divided,  and  the  astragalus  is  exposed  by 
forcibly  inverting  the  foot ;  the  bone  is  then  seized  with  strong  forceps, 
its  ligamentous  attachments  are  divided  with  a  probe-poiuted  knife,  and 
removed.  The  di-essing  consists  in  introducing  a  drainage-tube  if  it  is  con- 
sidered necessary,  closing  the  wound  with  sutures,  and  applying  a  gauze 
dressing,  after  which  the  foot  should  be  secured  in  a  position  at  a  right 
angle  to  the  leg,  by  means  of  a  plaster-of-Paris  bandage,  coA^-ering  the  foot 
and  leg,  or  by  moulded  splints  of  binder's  board  secured  by  a  bandage. 
The  functional  result  after  excision  of  the  astragalus  is  usually  satisfactory. 

Excision  of  the  Os  Calcis. — This  may  be  required  in  cases  of  com- 
pound fracture  or  necrosis  of  the  os  calcis.  An  incision  is  made  beginning 
at  the  upper  part  of  the  bone  at  the  inner  border  of  the  tendo  Achillis, 
which  passes  around  the  back  and  outer  surface  of  the  foot,  dividing  this 
tendon,  to  the  base  of  the  fifth  metatarsal  bone ;  a  short  incisiou  is  then 
made  at  the  anterior  end  of  the  first  incisiou,  and  carried  down  to  the  sole 
of  the  foot ;  the  bone  is  exposed  and  held  by  forceps,  and  the  flap  thus 


EXCISION  OF  THE  COCCYX.  657 

formed,  wbicli  iuclucles  the  peronei  tendons,  is  separated  from  the  bone ; 
the  cuboid  ligaments  are  divided,  as  well  as  the  interosseous  ligament 
between  the  os  calcis  and  the  astragalus,  and  the  bone  is  removed  with 
forceps.  The  ends  of  the  divided  tendo  Achillis  should  then  be  brought 
together  with  sutures,  the  wound  closed  and  drained,  aud,  after  a  gauze 
dressing  has  been  aj^plied,  the  foot  and  leg  should  be  included  in  a  plaster- 
of-Paris  dressing.  The  bone  may  also  be  removed  by  a  median  incision, 
splitting  the  lower  portion  of  the  tendo  Achillis  and  carried  downward 
over  the  heel,  leaving  the  tendinous  ex]3ansion  attached  to  the  periosteum, 
which  is  separated  from  the  bone  as  it  is  removed.  This  operation  wounds 
no  important  structures.  The  deformity  resulting  after  excision  of  the  os 
calcis  is  very  marked,  but  if  the  ojieration  has  been  a  subperiosteal  one  the 
function  of  the  muscles  exerted  through  the  tendo  Achillis  may  be  more  or 
less  retained.  We  have  resorted  to  excision  of  the  os  calcis  in  a  case  of 
compound  comminuted  fracture  of  the  os  calcis  and  in  a  case  of  necrosis 
following  frost-bite,  and  in  both  cases  the  functional  result  was  very  satis- 
factory. 

Excision  of  the  Tarsal  Bones. — Removal  of  one  or  more  of  the 
tarsal  bones  may  be  required  for  injury  or  disease ;  in  the  former  case  the 
wound  is  enlarged  and  the  bones  removed.  When  required  for  disease  of 
the  bones  it  may  be  accomplished  by  an  external  lateral  incision  or  by  two 
dorsolateral  incisions  on  each  side  of  the  extensor  tendons,  which  gives 
good  access  to  all  the  bones  and  joints  of  the  tarsus.  After  the  bones  have 
been  exposed  their  removal  is  accomplished  by  the  use  of  a  jjrobe-pointed 
knife,  elevator,  and  forceps.  In  advanced  tuberculous  disease  of  the  tarsal 
bones  the  bones  and  ligaments  are  so  softened  that  their  removal  may  be 
largely  accomplished  with  a  curette.  The  astragalus  is  the  tarsal  bone 
most  frequently  requiring  removal. 

Resection  of  the  Metatarsal  Bones. — Eesection  of  these  bones 
may  be  required  for  injury  or  disease.  The  operation  is  jperformed  by 
making  an  incision  on  the  dorsum  of  the 
foot  over  the  bone  to  be  removed  ;  the  bone 
being  exposed,  and  the  extensor  tendons 
being  held  aside  by  retractors,  it  is  dis- 
articulated at  either  end,  or  is  cut  in  its 
middle  and  each  fragment  dissected  up 
and  removed  at  its  articulation.  The  meta- 
tarsal bone  of  the  great  toe  is  exposed  by 

making   a   curved   incision   over   that  bone     incision  for  resection  of  the  metatarsal  bone 
...  .,        J.  .  1       J-      .        ,-r-i-       -o-i   ^  of  the  great  toe.    (Smith.) 

on  the  inner  side  of  the  foot.     ( Fig.  oSl. ) 

Excision  of  the  Coccyx. — This  operation  may  be  required  for  dis- 
ease or  for  a  painful  neuralgic  condition  of  the  coccyx,  known  as  coccygo- 
dynia.  In  removing  the  coccyx  the  finger  should  fir.st  be  passed  into  the 
rectum,  and  the  position  of  the  bone  determined ;  a  longitudinal  incision 
through  the  skin  and  fibrous  tissue  covering  the  coccyx  is  next  made, 
)>eginniug  about  a  quarter  of  an  inch  above  its  upper  limit,  and  is  carried 
down  to  the  bone,  extending  a  little  below  its  lower  extremity.  The  incision 
is  deepened  until  the  surface  of  the  bone  is  exposed,  and  retractors  are 

42 


658 


EXCISION   or  THE  UPPER  JAW. 


applied,  so  as  to  tliorougMy  dilate  the  wound  ;  if  it  is  found  that  more  space 
is  needed,  the  incision  may  be  supplemented  by  a  transverse  one.  The 
sacro-coccygeal  articulation  is  nest  carefully  opened,  and  an  elevator  is 
introduced  into  the  articulation  and  the  bone  raised  and  grasped  with 
forceps  ;  it  should  then  be  separated  fi'om  its  lateral  attachments,  and  from 
those  upon  its  anterior  surface,  with  a  knife  and  an  elevator.  As  the  wound 
resulting  from  excision  of  this  bone  is  a  deep  one,  it  is  well  to  introduce  a 
drainage-tube  before  bringing  the  edges  of  the  wound  together  with  sutures. 
After  applying  a  gauze  dressing,  which  is  held  in  place  by  broad  strips  of 
adhesive  plaster,  the  patient  should  be  kept  at  rest  upon  the  side  or  the 
back,  and  the  bowels  should  be  kept  quiet  for  a  few  days. 

Excision  of  the  Upper  Jaw. — This  operation  may  be  required  on 
account  of  necrosis  of  this  bone  or  for  malignant  or  non-malignant  growths, 
or  may  be  employed  to  facilitate  the  removal  of  nasopharyngeal  tumors. 
The  operation  is  one  attended  with  considerable  hemorrhage,  which  may 
itself  cause  a  fatal  issue ;  but  if  this  is  not  excessive,  union  of  the  parts 
after  the  bone  has  been  excised  is  usually  rapid,  and  the  resulting  deformity 
is  much  less  than  would  be  expected  from  so  serious  a  mutilation.  When 
the  operation  is  undertaken  for  exposure  of  retropharyngeal  growths,  if 
possible,  an  osteoplastic  resection  of  the  jaw  should  be  preferred  to  an 
excision.  An  incision  is  begun  half  an  inch  below  the  inner  canthus  of 
the  eye,  and  is  carried  downward  along  the  line  of  junction  of  the  nose 
and  face,  and  then  downward  to  the  free  border  of  the  lip ;  it  is  also 
advisable  to  carry  the  incision  along  the  lower  edge  of  the  orbit  outward 
over  the  malar  bone.  (Fig.  582.)  This  flap  having  been  dissected  away 
from  the  surface  of  the  bone,  a  meta- 
carpal saw  should  be  applied  to  the  . 


Incision  £or  excision  of  tlie  upper  jaw. 


Excision  of  the  upper  jaw. 


floor  of  the  nostril  until  a  deep  groove  has  been  made ;  the  soft  palate 
should  next  be  divided  within  the  mouth  with  a  strong  knife,  and  one  or 
two  incisor  t«eth  being  removed,  and  one  blade  of  a  pair  of  strong  bone- 
cutting  pliers  introduced  into  the  floor  of  the  nose,  in  the  line  of  the  saw 
incision,  and  the  other  into  the  mouth,  in  the  line  of  the  division  of  the 
structures  of  the  palate,  the  bone  should  be  divided.  The  hard  palate  and 
other  connections  of  the  bone  may  be  divided  with  a  chisel.  The  malar 
bone  should  next  be  divided  with  a  saw  or  forceps  (Fig.  583),  and  finally  the 


EXCISIOX   OF  THE  LOWER  JAW. 


659 


blades  of  a  strong  pair  of  bone-cutting  forceps  should  be  introduced,  one 
into  the  nostril  and  the  other  at  the  edge  of  the  orbit,  the  structiires  of  the 
orbit  being  held  upward  with  a  retractor,  and  the  inner  angle  of  the  orbit 
cut  across ;  the  bone  is  then  gi-asped  with  strong  lion-jawed  forceps  and 
twisted  out,  any  bands  of  tissue  which  remain  being  divided  with  a  knife  or 
scissors.  The  most  serious  hemorrhage  is  apt  to  result  from  division  of  the 
internal  maxillary  artery  ;  this  may  be  grasped  with  hfemostatic  forceps  and 
secuFcd  by  a  ligature,  or,  if  it  is  impossible  to  seize  the  bleeding  vessel,  the 
hemorrhage  may  be  controlled  by  the  actual  cautery.  After  the  bleeding 
has  been  arrested,  the  edges  of  the  incision  should  be  brought  together  by 
sutures,  and  a  pad  of  iodoform  or  sterilized  gauze  placed  in  the  cavity  of  the 
cheek. 

Osteoplastic  Resection  of  the  Upper  Jaw. — Langeubeck's  method 
consists  in  making  first  an  incision  from  the  inner  angle  of  the  orbit  to  the 
malar  bone,  and  a  second  incision  from  the  nostril  to  the  malar  bone,  join- 
ing the  first.  The  soft  parts  are  left  adherent  to  the  bone,  which  is  divided 
with  a  saw  upon  the  line  of  both  incisions  to  the  retromaxillary  fossa ; 
when  this  is  accomplished  the  bony  flap  thus  made  is  bent  over  the 
central  line  of  the  nose  and  drawn  towards  the  opposite  cheek ;  this 
exposes  the  nasopharyngeal  cavity  in  the  retromaxillary  space.  After 
the  tumor  has  been  removed  and  bleeding  has  been  controlled  by  ligatures 
or  the  cautery,  the  parts  are  returned  to  their  normal  position  and  secured 
by  a  few  sutures  introduced  into  the  bone,  and  by  sutures  introduced  through 
the  edges  of  the  wound  in  the  soft  parts. 

Excision  of  the  Lower  Jaw.— Complete  or  partial  excision  of  the 

lower  jaw  may  be  required  for  injury  or  for  disease  of  this  bone.    The  whole 

or  one- half  of  the  lower  jaw,  or  the  anterior 

j)ortion,  including  the  symphysis,  or  a  portion 

of  the  alveolus  only,  may  require  removal. 


Incision  for  excision  of  the  \o\\  er  ]a'\\ . 


Excision  o{  the  lower  jaw. 


Excision  of  the  Ramus  and  Half  of  the  Body  of  the  Lower 
Jaw. — An  incision  should  be  made  from  a  point  just  below  the  free  border 
of  the  lip,  over  the  symphysis,  and  carried  down  to  the  lower  border'of  the 
jaw,  from  which  point  it  extends  along  the  ramus  to  within  a  short  distance  of 
the  lobe  of  the  ear.    (Fig.  .58J:.)    This  flap  is  then  dissected  up,  separating  the 


660  AETHRECTOMY. 

masseter  muscle  from  the  bone  as  far  as  possible  without  openiug  the  cavity  of 
the  mouth.  An  incisor  tooth  is  next  extracted,  and  the  bone  is  divided  with 
a  saw  near  the  symphysis.  The  jaw  is  then  seized  with  forceps  and  drawn 
downward  and  outward,  and  denuded  upon  its  inner  surface.  The  insertion 
of  the  temporal  muscle  into  the  coronoid  process  is  divided,  the  condyle  of 
the  jaw  is  disarticulated  from  the  glenoid  cavity,  and  the  remaining  soft  parts 
are  carefully  detached  with  a  knife  or  an  elevator.  (Fig.  585.)  The  facial 
artery  and  the  inferior  dental  nerve  and  artery  are  necessarily  divided  in 
removing  this  portion  of  the  jaw.  When  the  operation  is  performed  for 
necrosis  of  the  bone,  the  periosteum  should  as  far  as  possible  be  preserved, 
but  in  cases  of  malignant  disease  it  should  be  removed  with  the  bone.  If 
the  middle  portion  of  the  lower  jaw  is  taten  away,  removing  the  sym^jhysis, 
the  attachments  of  the  muscles  inserted  into  the  genial  tubercle  are  divided, 
and  the  tongue  falls  backward.  To  j)revent  this  accident,  before  the  attach- 
ments are  severed  a  strong  silk  ligature  is  i)assed  through  the  tip  of  the 
tongue,  which  is  held  forward  and  secured  in  this  iDosition  until  adhesions 
have  formed.  After  removal  of  the  whole  or  a  portion  of  the  lower  jaw, 
the  edges  of  the  wound  should  be  brought  together  with  sutures,  a  pad  of 
iodoform  or  sterilized  gauze  loosely  packed  into  the  cavity  left  by  removal 
of  the  bone,  a  gauze  dressing  applied  over  the  line  of  incision,  and  held  in 
position  by  an  oblique  bandage  of  the  jaw. 

Partial  Excision  of  the  Lower  Jaw  or  of  the  Alveolus. — Eemoval 
of  a  portion  of  the  alveolar  xjrocess,  or  of  a  ]3ortion  of  the  body  of  the  jaw, 
necessitated  by  necrosis  of  the  bone,  can  often  be  accomplished  without  the 
aid  of  a  cutaneous  incision.  The  jaws  should  be  separated  with  a  mouth- 
gag,  an  incision  made  through  the  tissues  covering  the  bone,  an  elevator 
introduced,  and  the  bone  gradually  loosened  from  the  periosteum  and 
removed  with  forceps,  or  some  bone  may  have  to  be  cut  away  by  rongeur  or 
bone-cutting  forceps. 

Excision  of  the  Condyle  of  the  Jaw. — Thismaybeaccomj)lishedby 
making  an  incision  close  in  front  of  the  temporal  artery  and  carrying  it  for- 
ward along  the  zygoma  for  an  incli  and  a  half;  the  tissue  being  divided  and 
the  bone  exxiosed,  a  second  incision,  involving  only  the  skin,  is  carried  from 
the  centre  of  the  first  incision  directly  downward  for  about  an  inch,  the  soft 
parts  being  carefully  seiDarated  with  a  knife  and  an  elevator  from  the  margin 
of  the  zygoma  and  the  outer  surfaces  of  the  joint,  and  drawn  downward 
with  a  retractor  to  prevent  injury  of  the  i^arotid  gland,  nerves,  and  vessels. 
The  neck  of  the  condyle  is  then  cleared  by  working  around  it  in  front  and 
behind  with  a  director,  keeping  close  to  the  bone  to  avoid  injury  of  the 
internal  maxillary  artery.  A  wire  saw  should  then  -be  passed  around  the 
neck  of  the  bone,  with  which  it  is  divided,  and  the  condyle  is  seized  with 
forceps  and  remo^'ed  with  an  elevator  or  a  gouge. 

Arthrectomy,  or  Erasion, — This  operation  has  been  employed  as  a 
substitute  for  excision  or  resection  in  the  treatment  of  diseases  of  the  joints, 
and  has  been  frequently  resorted  to  in  the  treatment  of  tuberculous  arthritis. 
It  consists  in  exposing  the  joint  by  an  incision  similar  to  that  which  would 
be  employed  for  excision  of  the  joint,  and  after  the  joint  surfaces  are  exposed 
the  diseased  synovial  membranes,  cartilages,  and  carious  deposits  in  the 


OPERATIONS  UPON  BONE.  661 

articular  surfaces  of  the  bone  are  removed  witli  forceps  and  scissors,  or  witli 
a  gouge  or  curette  ;  no  extensive  removal  of  bone  is  practised.  After  all  the 
diseased  structures  have  been  removed,  the  wound  is  irrigated,  a  drainage- 
tube  introduced,  and  the  wound  closed,  deep  sutures  being  used  to  bring 
together  the  capsular  ligament,  and  a  line  of  superficial  sutures  employed 
to  close  the  skin  incision.  This  operation  is  especially  applicable  to  the 
treatment  of  disease  of  the  joints  in  young  pei-sons,  as  it  involves  no  risk  of 
injury  of  the  epiphyseal  cartilages.  The  results  of  arthrectomy  have  been 
fairly  successful  in  tubercular  disease,  some  cases  recovering  with  movable 
joints  ;  in  others  more  or  less  contraction  and  fixation  result  after  the  opera- 
tion. If  recurrence  of  the  disease  takes  place,  an  excision  of  the  joint  may 
be  required  later. 

Erasion  has  been  more  frecpiently  practised  in  diseases  of  the  knee-joint 
than  in  any  other  articulation,  owing  to  the  fact  that  in  this  joint  the  dis- 
eased joint  surfaces  can  readily  be  exposed  by  a  simple  incision  ;  but  it  may 
be  employed  in  other  articulations.  Erasion  of  the  elbow-,  shoulder-,  or 
ankle-joint  is  a  more  difficult  operation,  because  of  the  greater  complexity 
of  structure  of  these  joints. 

Arthrectomy  of  the  Knee-Joint. — The  joint  should  be  exposed  by 
a  transverse  or  slightly  curved  incision  across  the  front  of  the  joint  over  the 
tendo  patellfe,  similar  to  that  employed  in  excision.  The  tissues  should 
be  divided  and  the  joint  opened,  the  tendo  iDatellte  being  divided  ti'ans- 
versely,  and  u]3on  flexing  the  leg  the  articular  surfaces  will  be  freely 
exjposed.  The  diseased  synovial  membranes  and  articular  cartilages  should 
then  be  carefully  removed  with  scissors  or  with  a  curette,  the  patella  being 
turned  np  and  its  under  surface  carefully  inspected.  If  the  semilunar  car- 
tilages are  extensively  diseased  they  should  be  removed,  as  well  as  any 
tuberculous  deposits  in  the  bone.  After  all  the  diseased  structures  have 
been  removed  the  joint  should  be  thoroughly  irrigated  and  dusted  with 
powdered  iodoform,  drainage-tubes  introduced,  and  the  capsular  ligament 
and  the  ends  of  the  severed  tendo  j)atelke  securelj^  brought  together  with 
catgut  or  silk  sutures.  The  superficial  portion  of  the  wound  should  uext 
be  approximated  with  sutures,  and  a  gauze  dressing  applied.  After  the 
wound  has  been  dressed,  the  foot,  leg,  and  thigh  should  be  fixed  in  a  plaster- 
of-Paris  bandage.  Even  after  the  wound  has  solidly  healed,  to  prevent  the 
tendency  to  contraction  of  the  knee,  a  plaster- of-Paris  bandage,  or  a  fixation 
splint  of  leather,  or  a  metallic  brace,  should  be  worn  for  some  months. 

OPERATIONS  UPON  BONE. 

Osteotomy. — This  operation  consists  in  making  a  section  of  bone  with 
a  saw,  an  osteotome,  or  a  chisel,  and  has  of  late  years  been  widely  employed 
to  correct  deformities  of  bone.  The  operation  may  be  done  subcirtane- 
ously, — that  is,  a  small  puncture  is  made  with  a  knife  just  sufficient  to  admit 
the  saw  or  the  osteotome,  and  the  bone  is  then  divided, — or  may  be  ijractised 
as  an  open  one,  a  flap  of  the  soft  parts  being  turned  up  to  expose  the  bone, 
which  is  subsequently  divided. 

Osteotomy  may  be  either  linear,  when  a  simple  linear  section  of  the  bone 
is  made,  usually  subcutaneously,  or  cuneiform,  when  a  wedge  of  bone  is 


662 


OSTEOTOMY. 


removed  by  a  chisel,  the  open  operation  being  employed  in  this  case.     In 

linear  osteotomy,  when  the  section  of  the  bone  is  made  with  the  osteotome 

or  the  saw  and  the  correction  accomplished,  a 

■'^^°'  ^^^'  gap  is  left  on  one  side  of  the  bone,  which  is 

subsequently  filled  with  new  bone.     (Fig.  586.) 

The  instruments  required  for  osteotomy  are 

osteotomes  of  various  sizes  (Fig.  587),  a  narrow 

saw  with  a  short  cutting  surface  and  a  long 

narrow  shank,  Adams's  saw  (Fig.  588),  a  stout 

tenotome,   and  a  mallet.      The    osteotome    or 

chisel  is  the  instrument  most  frequently  used. 

Linear  Osteotomy.— The  skin  of  the  part 
to  be  operated  upon  should  be  carefully  steril- 
ized, and  a  short  flat  sand-bag  covered  with  a 
sterilized  towel  laid  under  the  limb.  A  small 
incision  is  next  made  down  to  the  bone  at  the 
point  where  it  is  to  be  divided,  and  the  osteo- 
tome or  saw  is  introduced.  If  the  osteotome  is 
used,  it  is  driven  carefully  through  the  bone  with 
strokes  of  the  mallet,  being  held  as  shown  in 
Fig.  589.  If  the  saw  is  employed,  the  bone  is  carefully  divided  by  short 
strokes.     It  is  not  always  necessary  to  divide  the  bone  completely  ;  a  small 

Fig.  587. 


Linear  osteotomy :  ab,  line  of  sec- 
tion of  the  bone ;  abc,  gap  left  after 
correction  of  tlie  deformity. 


portion  of  the  posterior  surface  may  be  left  undivided,  the  osteotome  being 
withdrawn,  and  the  remaining  xjortion  of  bone  fractured  by  manual  force. 
This  procedure  is  a  safer  one  than  complete  division  when  large  vessels  lie 
in  close  contact  with  the  posterior  surface  of  the  bone. 


Adams's  saw. 

Cuneiform  Osteotomy. — In  this  operation  a  wedge-shaj)ed  piece  of 
bone  is  removed  with  a  chisel  or  with  a  saw.  The  mechanism  of  the  cor- 
•reotion  of  the  deformity  by  this  operation  is  shown  in  Fig.  590. 

The  limb  is  placed  uxjon  a  sand-bag,  and  the  bone  is  exposed  by  turning 
up  a  flap,  or  by  a  transverse  incision,  and  retracting  the  soft  parts.  A 
wedge-shaped  section  of  bone,  of  sufficient  size  to  permit  of  the  correction 
of  the  deformity,  is  then  removed.      This  oj)eration  is  most  frequently 


OSTEOTOMY. 


6G3 


employed  in  cases  of  anterior  tibial  curvatures,  and  for  the  correction  of 
deformities  of  the  knee  and  jaw,  and  occasionally  in  cases  of  club-foot. 

After-Treatment. — The  small  wounds  in  linear  osteotomy  are  covered 
with  a  compress  of  gauze  or  with  a  scab  of  gauze  and  iodoform  collodion, 

Fig.  590. 


Method  of  holding  osteotome. 


Cuneiform  osteotomy  :  def,  wedge  of  bone 
removed ;  ab,  line  of  approximation  of  the 
tione  surfaces  after  the  removal  of  the  wedge. 


and  in  cuneiform  osteotomy  the  edges  of  the  flap  or  of  the  incision  should 
be  held  in  ijosition  by  sutures  and  covered  with  a  sterilized  gauze  dressing. 
A  pad  of  cotton  is  placed  over  the  dressing,  the  bony  prominences  are  also 
padded,  a  flannel  bandage  is  applied  to  the  whole  limb,  and  while  the  limb 
is  held  in  the  corrected  position  a  plaster-of- Paris  bandage  is  aj)plied  to  the 
part.  This  dressing  is  usually  allowed  to  remain  for  a  month,  when  it  is 
removed  and  a  lighter  one  api^lied  for  a  few  weeks  longer,  union  of  the 
bones  generally  being  quite  firm  at  the  end  of  eight  weeks  ;  but  it  is  wise  to 
give  support  to  the  parts  by  light  splints  for  some  time  longer. 

The  principal  danger  in  this  operation  arises  from  infection  of  the  wound, 
or  from  injury  of  important  blood-vessels  or  nerves.  The  former  danger 
can  be  avoided  by  care  as  regards  asepsis  at  the  time  of  operation,  and 
injury  of  the  blood-vessels  and  nerves  is  an  unusual  accident  if  the  bone  is 
divided  carefullj'  and  slowly. 

Plastic  Operations  vipon  Bone. — These  may  consist  of  osteoplastic 
resections,  replacement  of  separated  portions  of  bone,  or  bone-grafting. 

Osteoplastic  Resection. — This  operation,  which  consists  in  separating 
or  turning  aside  a  portion  of  a  bone  with  its  periosteum,  soft  parts,  and 
skin  attached,  is  sometimes  employed  for  the  exposure  and  removal  of 
necrosed  bone  or  tumors  of  bone,  and  is  also  iDractised  upon  the  skull  and 
the  upx^er  jaw  to  expose  subjacent  growths.  In  these  operations  great  care 
should  be  exercised  as  regards  asepsis,  and  when  the  bone  with  its  soft  parts 
attached  is  replaced,  it  should  be  sutured  to  the  adjacent  bone  by  the  intro- 
duction of  a  few  sutures  into  the  bone  as  well  as  the  soft  parts. 

Replacement  of  Bone  Fragments. — Separated  fragments  of  bone 
may  be  replaced,  and  if  they  ai'e  rendered  aseptic  may  retain  their  vitality 
and  again  form  vital  attachments  to  the  surrounding  bone.     In  fractures  of 


664  OSTEOTOMY. 

the  long  bones  of  the  extremities,  separated  fragments  may  he  replaced, 
where  their  loss  would  cause  so  much  shortening  that  the  limb  would  be 
useless ;  and  the  same  procedure  is  practised  in  fractures  of  the  skull,  or 
after  trephining  of  the  skull,  when  the  button  removed  by  the  trephine  may 
be  replaced.  The  bone  fragments  should  be  placed  in  a  warm  sterilized  salt 
solution  until  the  surgeon  is  ready  to  replace  them.  The  fi'agments  may  be 
simply  laid  upon  the  dura  in  the  case  of  injuries  of  the  skull,  or  may  in  the 
case  of  long  bones  be  drilled  and  sutured  to  the  surrounding  bone  before 
they  are  covered  by  the  soft  i^arts. 

Bone-Grafting. — This  consists  in  splitting  a  portion  of  an  adjacent 
bone,  allowing  it  to  retain  its  periosteal  attachment,  and  turning  it  in  and 
suturing  it  to  the  neighboring  bone  to  fill  a  defect ;  or  in  the  use  of  a  portion 
of  fresh  bone  from  an  amputated  limb,  or  from  one  of  the  lower  animals, 
siud  suturing  it  in  place  to  the  adjacent  bones  to  fill  the  gap.  In  bone-graft- 
ing by  this  method  the  edges  of  the  gap  in  the  bone  are  freshened,  and  a 
portion  of  bone  long  enough  to  fill  the  gap  is  cut  and  sutured  in  position. 

Sennas  modification  of  bone-grafting  consists  in  the  use  of  decalcified 
bone  plates  or  chips.  The. bone  plate  being  cut  to  the  size  of  the  gap  and 
fitted  into  it,  it  may  be  rendered  additionally  secure  by  the  introduction  of 
a  few  catgut  or  silk  sutures.  In  the  case  of  large  defects,  where  bone  plates 
are  used,  thej'  should  be  perforated  at  a  number  of  points,  to  provide  for 
drainage.  In  bone-grafting  with  chips,  the  bone  cavity  should  be  carefully 
sterilized  and  freshened,  and  should  be  loosely  packed  with  bone  chips. 
After  the  bone  plates  or  chips  have  been  introduced,  the  periosteum  and 
soft  parts  should  be  closed  over  them  by  sutures  of  catgut  or  silk,  or,  if 
this  is  impossible  by  reason  of  a  great  loss  of  the  soft  parts,  a  tampon  of 
iodoform  gauze  may  be  emj)loyed  to  keep  the  grafts  in  place.  Bone  plates 
or  chips  act  only  as  a  scaffolding  for  the  production  of  new  bone,  and 
apparently  never  regain  their  vitality,  disappearing  slowly  by  absorption  as 
new  bone  forms.  In  some  cases  they  remain  unabsorbed  for  a  long  time. 
Here,  as  in  other  forms  of  bone-grafting,  perfect  asepsis  of  the  cavity,  of  the 
plates  or  chi^is,  and  of  the  surrounding  soft  parts  is  essential  to  success. 


CHAPTER    XXVII. 

ORTHOPEDIC   SURGERY. 
By  Henry  E.  Wharton,  M.D. 

This  brancli  of  surgery  deals  with  the  prevention  or  correction  of 
deformities,  either  by  ~the  use  of  mechanical  appliances  or  by  operative 
procedures.  Excellent  results  may  follow  either  of  these  methods  in  well- 
selected  cases.  The  deformities  which  require  correction  may  be  either 
congenital  or  acquired.  Congenital  deformities  consist  in  a  large  pro- 
portion of  the  cases  of  deformities  of  the  hands  and  feet,  including  most  of 
the  cases  of  club-foot,  those  of  the  hip  and  shoulder  from  arrest  of  develop- 
ment of  the  acetabulum  or  of  the  glenoid  cavity,  some  cases  of  wry-neck, 
and  arrest  of  development  of  the  limbs.  Such  congenital  deformities  as 
harelip,  cleft  palate,  exstrophy  of  the  bladder,  imperforate  rectum,  etc., 
are  sometimes  considered  as  coming  within  the  domain  of  orthoiitedic  sur- 
gery, but  in  the  i^reseut  work  they  are  not  included  under  this  head. 
Acquired  deformities  may  result  from  injuries,  but  are  in  most  cases  due  to 
tuberculosis  of  the  bones  or  joints,  to  rickets,  or  to  jparalyses  of  muscles,, 
which  may  be  cerebral,  spinal,  or  j)eripheral  in  origin.  The  fact  that  deform- 
ities result  from  these  diseases  should  always  cause  the  surgeon  to  employ 
such  means  iu  their  treatment,  both  mechanical  and  operative,  that  deform- 
itj''  shall  be,  as  far  as  possible,  avoided.  Orthopaedic  surgery,  therefore, 
should  not  be  limited  to  the  correction  of  deformities,  but  should  be 
extended  to  their  prevention. 

Torticollis,  or  Wry-Neck.— This  is  a  deformity  in  which  the  head 
is  held  in  a  distorted  position  through  the  abnormal  action  of  certain  of  the 
neck  muscles.  It  occurs  in  both  sexes  and  is  occasionally  congenital,  but  it 
generally  comes  on  gradually  during  early  childhood.  The  so-called  con- 
genital form  may  be  of  prenatal  origin,  being  due  to  a  faulty  position  in 
utero,  but  is  usually  due  to  an  injury  of  the  sterno-cleido-mastoid  muscle 
during  labor.  The  acquired  form  arises  from  several  causes  :  it  may  be  due 
to  2}aralys is  of  the  opposing  group  of  muscles,  to  an  injury  to  the  muscles  or 
inflammation  of  the  surrounding  structures,  or  to  a  growth  in  the  sterno- 
cleido-mastoid,  as  a  gumma,  or  a  sarcoma,  or  it  may  be  compensatory,  follow- 
ing a  primary  lateral  curvature  in  the  dorsal  spine.  The  torticollis  oculaire  of 
Quignet  is  due  to  an  effort  to  overcome  an  inequality  in  the  strength  of  the 
eyes.  A  majority  of  the  cases,  however,  are  spastic,  in  some  of  which  a 
direct  cause  can  be  discovered,  as  a  central  nervous  lesion,  or  some  source 
of  perij)heral  irritation,  as  abscess  of  the  neck  or  enlarged  cervical  glands  ^ 
while  in  very  many  cases,  one  of  the  eruptive  fevers,  severe  mental  shock, 
or  hysteria,  may  be  the  exciting  cause.  There  is  an  acute  form,  coming  on 
suddenly,  with  local  rheumatic  symptoms,  j)ain  and  stiffness,  and  some  con- 
stitutional disturbance  which  occasionally  becomes  chronic.     An  intermit- 

665 


666 


TORTICOLLIS. 


Fig.  591. 


Torticollis,  or  wry  neck. 


tent  variety  of  nervous  origiu  is  observed,  especially  in  adult  females,  and 
is  either  tonic  or  clonic  in  type,  and  sometimes  choreiform.  The  .sterno- 
cleido-mastoid  is  the  muscle  most  often  aiiected, 
although  seldom  alone,  the  trapezius  being  fre- 
quently involved  with  the  latter  muscle,  both 
being  supplied  by  the  spinal  accessory  nerve. 
The  splenius,  scaleni,  platysma,  and  complexus 
are  sometimes  found  to  be  contracted.  The 
sterno-mastoidof  one  side  when  contracted  turns 
the  head  to  the  opposite  side  and  elevates  the 
chin.  (Fig.  591.)  Unilateral  contraction  of  the 
trapezius  and  decider  muscles  of  the  neck  draws 
the  head  backward  and  down  towards  the  shoul- 
der of  the  affected  side.  The  muscles  in  the 
later  stages  undergo  fibrous  change,  becoming- 
hard  and  rigid.  Attempts  at  reposition  some- 
times cause  pain,  which  is  not,  however,  a  fre- 
quent symptom  in  the  ordinary  cases.  A  com- 
pensating lateral  curvature  takes  place  in  the 
dorsal  sijine,  and  a  cui-ious  asymmetry  of  the 
face  develops  in  long-standing  cases.  It  consists 
in  atrophy  of  the  features  on  the  affected  side,  with  deviation  in  the  line  of 
the  nose,  a  difference  in  level  of  the  eyes,  and  asymmetry  of  the  cranium. 

Treatment. — This  is  therapeutic,  mechanical,  and  operative.  In  the 
acute  variety  the  administration  of  salicylate  of  sodium,  morphine,  and 
atropine,  the  latter  hyijodermically,  and  local  applications  of  heat,  may  be 
of  service.  In  congenital  cases  when  detected  early  massage  and  stretching 
of  the  muscles  are  indicated.  In  paralytic  cases  means  should  be  taken  to 
restore  power  to  the  paralyzed  muscles  by  electricity  and  the  hyijodermic 
injection  of  strj^chnine.  In  the  intermittent  type  careful  attention  must  be 
paid  to  the  underlying  conditions,  treatment  being  directed  to  improving 
the  general  health  and  the  condition  of  the  nervous  system.  In  cases  asso- 
ciated with  reflex  irritation,  as  enlarged  cervical  glands,  and  with  ocular 
troubles,  treatment  should  be  directed  to  these  conditions.  Mechanical 
appliances  are  of  value  after  operative  treatment  and  in  i^aralytic  cases. 
The  sim]Dlest  device  is  that  suggested  by  Little,  consisting  of  a  strip  of 
adhesive  plaster  around  the  head  and  another  around  the  thorax,  traction 
being  made  by  a  bandage  fastened  to  the  first  at  the  side  of  the  head,  run- 
ning across  the  chest,  and  fastened  to  the  second  at  the  opposite  side.  More 
complicated  appliances  are  those  of  Sayre  and  Buckminster-Brown.  Opera- 
tive treatment  is  generally  necessary  in  chronic  cases.  Subcutaneous  tenot- 
omy and  open  incision  are  the  operations  employed  where  there  is  persistent 
contraction  of  the  sterno-mastoid.  Excision  of  the  muscle  recommended  by 
Mikulicz  has  given  good  results.  One  or  both  heads  of  the  muscle  may  be 
di^'ided  by  either  the  subcutaneous  method  or  open  incision.  Open  incision 
should  be  i^referred,  as  there  is  less  risk  of  injuring  the  vessels,  and  the  con- 
tracted tissues  can  be  thoroughly  divided,  which  cannot  always  be  done 
subcutaneously  with  safety. 


SPONDYLITIS  DEFORMANS. 


667 


Fig.  592. 


Apparatus  after  opera- 
n  for  ^vry-neck.  (Dr. 
G.  Davis.) 


Subcutaneous  tenotomy  is  performed  by  maldng  a  puncture  down  to 
the  tendon  on  tlic  inner  side  and  introducing  a  blunt-pointed  tenotome 
beneath  the  tendon  and  cutting  outward.  Open  incision  is  best  performed 
by  making  the  incision  parallel  with  and  one  inch  above  the  clavicle.  It 
permits  of  thorough  division  of  all  resisting  structures. 
In  both  operations  care  must  be  taken  to  avoid  wound- 
ing the  anterior  and  internal  jugular  veins  and  the  carotid 
artery,  as  several  deaths  from  this  operation  have  been 
due  to  hemorrhage.  After  tenotomy  the  head  should 
be  placed  immediately  in  a  position  of  over-correction 
and  held  there  by  a  plaster-of- Paris  dressing  or  other 
means  for  a  couple  of  weeks,  when  a  permanent  appa- 
ratus can  be  applied,  to  be  worn  until  cure  is  complete. 
(Fig.  592.)  In  cases  due  mainly  to  contraction  of  the 
posterior  muscles,  division  of  these  is  often  difficult  or 
even  impossible,  and  forcible  correction  under  ether  is 
recommended  by  Bradford  and  Lovett.  Spinal  caries, 
which  simulates  this  form  of  wry-neck,  must  first  be 
carefully  excluded.  In  the  intermittent,  spasmodic 
cases  tenotomy  or  open  incision  is  of  little  use,  and  the 
best  results  are  obtained  by  division  and  resection  of 
the  spinal  accessory  nerve.  The  posterior  branches 
of  the  upper  cervical  nerves  have  also  been  resected 
in  this  form  of  wry-neck  with  success  in  some  cases. 

Spondylitis  Deformans,  or  Osteoarthritis 
of  the  Spine. — This  affection  consists  in  a  chronic  osteoarthritis  which 
involves  the  vertebral  articulations ;  it  presents  the  same  lesions  that  are 
found  in  a  similar  affection  of  other  joints,  and  is  distinct  from  tuberculosis 
of  the  spine.  It  is  an  affection  of  middle  life  and  old  age,  and  is  rarely 
seen  in  patients  under  twenty-five  years  of  age  ;  it  is  more  common  in  males 
than  in  females.  It  is  generally  observed  in  patients  who  present  a  rheu- 
matic history,  and  often  follows  prolonged  exposure  to  cold  and  wet.  Occu- 
pation appears  to  have  some  relation  to  its  development ;  those  who  in  their 
work  are  comiDcUed  to  stoop  constantly,  or  to  lift  heavy  weights,  or  to  carry 
heavy  burdens  ui^on  the  back,  are  apt  to  develop  this  affection. 

The  pathological  changes  are  the  absorption  of  the  intervertebral  disks 
and  the  formation  of  osteoiDhytes  or  bony  outgrowths  from  the  bodies  of  the 
vertebrae,  generally  occuj)ying  the  lateral  aspects,  which  by  their  union  cause 
complete  ankylosis  of  the  spine.  The  intervertebral  disks  may  be  replaced 
by  bone.     The  costo-vertebral  articulations  may  also  be  involved. 

Symptoms. — The  disease  begins  with  rheumatic  aching  or  pain,  which 
is  followed  by  rigidity  and  gradual  bending  forward  of  the  spine  and  the 
development  of  marked  kyphosis.  (Fig.  593.)  When  the  cervical  region 
of  the  spine  is  involved,  the  chin  is  pushed  forward,  the  gait  is  changed, 
and  lateral  motions  of  the  spine  are  also  greatly  restricted.  As  the  disease 
advances,  the  kyphosis  increases  and.  the  ribs  become  fixed,  so  that  thoracic 
is  replaced  by  abdominal  respiration.  Local  paralyses  may  result  from 
pressure  upon  the  nerves  at  the  intervertebral  foramina.     Many  persons 


668 


CUEVATURES  OF  THE  SPINE. 


Fig.  593. 


Fig.  594. 


Spondylitis  deformans.     (Ger- 
man Hospital  Museum.) 


snfferiDg  from  this  affection  are  able  to  carry  on  their  ordinary  occupa- 
tions, and  it  is  only  when  the  disease  has  been  developed  to  an  extreme 

degree  that  the  patient  is  unable 

to  work  or  attend  to  his  usual 

vocations.     The  disease  does  not 

.seem  to  sliorten  life  materially. 
Treatment. — This   affection 

is  little  influenced  by  treatment. 

In  the  early  stage  the  use  of  the 

actual  cautery  applied  to  the  re- 
gion of  the  disease  seems  to  have 

a  marked  effect  in  diminishing 

the  pain. 

Curvatures  of  the  Spine. 

— The  natural  curves  of  the  spinal 

column  are  autero-ijosterior,  with 

a  slight  lateral  tendency  at  the 

upper  j)art  of  the  dorsal  region. 

In  the  cervical  region  the  curve 

is  concave  behind  and  convex  in 

front ;   in  the  dorsal  region  the 

concavity  is  anterior  and  the  con- 
vexity is  posterior  ;  while  in  the 

lumbar  region  the  concavity  is 
posterior  and  the  convexity  is  anterior.  (Fig.  594.) 
The  pathological  curvatures  of  the  spine  are  scoliosis,  or 
lateral  curvature ;  kyjihosis,  an  antero-posterior  curva- 
ture with  the  convexity  backward;  and  lordosis,  an 
antero-posterior  curvature  with  the  convexity  forward. 

Lateral  Curvature. — Scoliosis. — In  this  affection 
the  spine  describes  two  or  more  lateral  curves,  with 
their  convexities  on  opposite  sides  of  the  longitudinal 
axis  of  the  back  ;  at  the  same  time  the  relations  of  the 
vertebrae  to  the  same  axis  are  changed  by  rotation,  so 
that  the  spinous  j)rocesaes  point  towards  the  concavities  of  the  lateral  curves. 
If  the  primary  curve  is  in  the  lumbar  region,  and  directed  to  the  left  side, 
the  compensating  curve  will  be  in  the  dorsal  region,  and  will  be  in  the  oppo- 
site direction,  or  to  the  right  side,  and  a  third  compensating  curve  will  be 
observed  in  the  cervical  region  (Fig.  595),  with  its  convexity  in  the  same 
direction  as  the  original  lumbar  curve.  These  compensating  curves  arise 
from  the  necessity  of  maintaining  the  erect  position. 

The  intervertebral  cartilages  in  the  region  of  the  curves  are  compressed 
and  become  wedge-shaijed,  with  their  bases  towards  the  convexity  of  the 
curve.  The  vertebral  bodies  are  similarly  altered  in  shape,  also  the  laminae 
and  articular  processes,  and  in  severe  cases  there  is  practically  ankylosis  of 
a  portion  of  the  spinal  column.  The  ribs  in  dorsal  curves  are  crowded 
together  upon  the  concave  side,  and  upon  the  convex  side  are  widely  sepa- 
rated (Fig.  596),  the  scapula  is  carried  forward  with  them,  making  a  hump. 


Normal  curves  of  the 
spine. 


LATERAL  CURVATURE  OF  THE  SPINE. 


669 


Fig.  596. 


and  the  tlioras  is  rniicli  distorted.    Lateral  curvature  begius  most  frequently 
in  the  dorsal  region,  and  commonly  involves  the  right  side. 

Causes. — A  great  variety  of  causes  may  lead  to  lateral  curvature  of  the 
spine.     Among  the  predisposing  causes  may  be  mentioned  congenital  asym- 
metry, general  weakness,  rapid  growth,  and  rickets,  which  affects  the  struc- 
ture of  the  bones,  diminishing 
the  resisting  power  necessary  to  ^'*'-  '^^^■ 

withstand  the  effects  of  pressure 
and  of  muscular  action.  The 
principal  exciting  causes  are 
habitual  one-sided  positions  of 
the  body,  resulting  from  an  im- 
proper method  of  carrying  chil- 
dren, and  later  in  subjects 
between  twelve  and  twenty 
years  from  sitting  at  desks  in 
school  for  hours  with  the  body 
inclined  to  one  side,  or  from 
carrying  heavy  weights  upon 
one  side  of  the  body.  Obliquity 
of  the  pelvis  from  one  limb 
being  shorter  than  the  other 
may  cause  lateral  curvature. 
Unilateral  muscular  atrophy 
resulting  from  changes  in  the 
central  nervous  system  or  from  undue  exercise  of  the  muscles  of  the  opposite 
side,  or  unilateral  muscular  hypertrophy  from  overuse  of  the  muscles  of  one 
side,  or  spasm  of  the  muscles  from  disease  of  the  central  nervous  system, 
draws  the  spinal  column  to  the  side  of  strongest  muscular  contraction. 
Empyema  may  cause  lateral  curvature  by  the  contraction  of  the  walls  of  the 
thorax,  and  sacro-iliac  disease,  as  well  as  morbid  growths  of  the  trunk  and 
pelvis,  may  also  give  rise  to  lateral  distortion  of  the  spinal  column.  It 
should  not  be  forgotten  that  in  rare  cases  tuberculosis  of  the  lateral  portions 
of  the  bodies  of  the  vertebrae  causes  lateral  curvature  of  the  spine. 

Symptoms. — In  the  early  stages  of  this  affection  the  symptoms  may 
not  be  marked  :  the  patient  may  notice,  if  a  boy,  that  the  susijenders  have  a 
tendency  to  slip  off  one  shoulder,  and,  if  a  girl,  the  dressmaker  may  notice 
that  it  is  difficult  to  fit  the  dress  upon  one  side.  The  patient  in  stooping 
often  complains  of  pain  in  the  dorsal  or  the  lumbar  region,  or  of  weakness 
of  the  back.  If  the  patient  is  stripped  and  made  to  stand  before  the 
surgeon,  if  the  curvature  is  in  the  dorsal  region  the  lower  angle  of  one  or 
other  of  the  scapulae  or  of  the  iliac  crests  is  unduly  prominent.  If  the  tips 
of  the  spinous  processes  are  marked  with  chalk  or  a  pencil  the  line  of  curva- 
ture can  be  distinctly  demonstrated  (Fig.  597) ;  the  shoulder  upon  the 
alfected  side  is  unduly  elevated,  and  the  breast  on  one  side  may  be  more 
prominent  than  its  fellow.  The  limbs  may  also  present  asymmetry,  shown 
by  obliqirity  of  the  pelvis  when  the  patient  stands.  In  lumbar  curvature,  if 
the  patient  bends  forward,  with  the  arms  hanging  loosely,  the  erector  spinae 


Primary  and  second- 
ary lateral  curvatures. 
(Agnew.) 


Position  of  the  ribs  and  verte- 
brfe  in  lateral  curvature.  (Ag- 
new.) 


670 


TREATMENT  OF  LATERAL   CURVATURE   OF  THE  SPINE. 


muscles  become  more  prominent  ou  the  convexity  of  the  curve.  In  dorsal 
curvature  the  angles  of  the  ribs  on  the  side,  of  convexity  are  on  a  higher 
level  than  on  the  side  of  concavity.  (Fig.  598.)  Where  there  is  great 
deformity  of  the  chest  the  action  of  the  heart  and  lungs  may  be  seriously 
impaired. 

Fig.  597.  Fig.  598. 


Lateral  curvature  o£  the  spine.    (Sayre. 


Lateral  curvature  of  the  spine  associated  with 
rhachitic  deformities. 


Lateral  curvature  is  likely  to  be  confounded  only  with  hysterical  curva- 
ture of  the  spine,  which  entirely  disappears  if  the  patient  is  made  to  stooj) 
forward  until  the  fingers  touch  the  floor,  and  with  tuberculosis  of  the  lateral 
aspects  of  the  bodies  of  the  vertebrae,  which  may  cause  lateral  curvature  of 
the  spine  ;  but  the  latter  condition  is  associated  with  rigidity  of  the  spine 
and  other  symj)toms  of  Pott's  disease,  so  that  it  is  not  usually  difficult  to 
recognize  the  true  nature  of  the  affection. 

Treatment. — In  the  treatment  of  lateral  curvature  of  the  spine  sys- 
tematic exercise  of  the  muscles  of  the  trunk  holds  the  first  place  as  a  cura- 
tive measure.  Improper  positions  such  as  tend  to  aggravate  the  deformity 
should  be  avoided.  In  addition  to  regulated  gymnastic  exercise,  intervals  of 
rest  in  the  recumbent  posture  and  good  hygiene  are  imj)ortant  factors  in 
attaining  a  good  result.  Self- suspension  by  the  arms  from  a  bar,  or  suspen- 
sion by  means  of  a  Sayre  head-piece,  combined  with  pressure  upon  the 
convex  side  of  the  curve,  are  often  employed  with  benefit.  As  a  rule,  the 
use  of  steel  braces  or  the  plaster  of  Paris  or  leather  jacket  is  not  required, 
and  often  if  employed  does  more  harm  than  good,  except  when  used  as  will 
be  described  later.  Massage  of  the  weakened  spinal  muscles  is  a  valuable 
agent,  and  should  be  combined  with  systematic  exercises. 


POSTERIOR   CURVATURE   OF  THE   SPINE.  671 

The  use  of  spinal  braces  in  tliis  affection  is  often  much  abused,  but  we 
have  seen  many  cases  where  they  proved  valuable  agents  in  the  treatment, 
used  in  connection  with  massage  and  gymnastics  and  recumbency  ;  in  such 
cases  they  should  be  worn  only  at  short  intervals ;  for  instance,  in  lateral 
spinal  curvature  the  i)atient  sliould  have  systematic  gymnastics  with  mas- 
sage, and  rest  upon  the  back  on  a  firm  couch,  with  the  head  low,  at  certain 
times  during  the  day.  If  the  deformity  is  marked,  the  patient  should  be 
suspended,  and  a  j)! aster- of- Paris  jacket  applied  while  in  this  position,  and 
as  soon  as  it  is  firm  it  is  split  down  the  front,  so  that  it  can  be  removed ; 
eyelets  are  fastened  to  this,  so  that  it  can  be  reapplied,  or  we  have  made 
from  this  cast  a  leather  jacket.  This  jacket  is  worn  for  a  few  hours  each 
day  while  the  patient  is  taking  out-door  exercise,  being  removed  during  the 
gymnastics  and  while  the  patient  is  recumbent.  A  steel  brace  may  be  worn 
in  the  same  way.  Used  in  this  manner,  spinal  Tjraces  may  be  of  great  ser- 
vice in  the  treatment  of  lateral  curvature  of  the  spine,  but,  as  before  stated, 
they  are  not  required  in  most  cases.  In  young  children  forcible  correction 
with  the  ai^plication  of  a  j)l aster- of- Paris  jacket  is  often  useful.  In  cases  of 
lateral  curvature  due  to  inequality  in  the  length  of  the  limbs,  a  high  shoe 
on  the  short  leg  will  often  correct  the  deformity.  In  addition  to  local  treat- 
ment previously  mentioned,  good  diet,  regular  meals,  tonics,  exercise  in  the 
fresh  air,  and  a  change  of  climate,  when  it  is  possible,  are  all  means  which 
may  verj'  materially  aid  in  bringing  about  a  cure  of  the  affection. 

Posterior  Curvature  of  the  Spine. — Kyphosis. — This  affection  is 
usually  seen  in  young  children,  and  is  the  result  of  rickets,  or  develops  in 
weak  and  anaemic  children  who  are  compelled  to  sit  without  proper  suj)port 
to  the  back.  It  is  often  seen  in  older  children  in  the  same  class  of  patients 
that  present  lateral  curvature  of  the  spine.  Kyphosis  maj^  also  result  from 
occupation  :  tailors,  shoemakers,  and  other  workmen  who  are  employed  con- 
tinuously with  the  back  bent  are  apt  to  develop  this  form  of  spinal  curvature. 

The  condition  results  from  relaxation  of  the  vertebral  ligaments  and 
spinal  muscles,  which  is  accompanied  by  separation  of  the  laminae  and 
spinous  processes,  and  in  aggravated  cases  there  may  be  absorption  of  the 
intervertebral  disks  and  of  a  portion  of  the  bodies  of  the  vertebrae. 

This  disease  is  likely  to  be  confounded  with  the  kyphosis  of  tuberculous 
disease  of  the  vertebrje,  but  may  be  distinguished  from  this  affection  by  the 
facts  that  in  the  early  stages  of  the  disease  there  is  no  rigidity,  and  that  the 
curve  is  a  general  one  and  does  not  present  an  angular  projection  at  one 
point  (see  page  547),  as  is  the  case  in  Pott's  disease;  it  is  most  common 
in  infants  and  young  children,  in  whom  it  is  due  to  rickets,  and  they 
present  other  evidences  of  the  disease.  When  seen  in  adults  it  usually 
results  from  occupation,  and  may  be  confounded  with  osteoarthritis  of  the 
vertebrae  or  spondylitis  deformans. 

-  Treatment. — Kyphosis  due  to  rickets  should  be  treated  by  rest  in  the 
recumbent  posture,  by  massage  of  the  weak  spinal  muscles,  and  by  the  use 
of  the  constitutional  treatment  appropriate  for  that  disease.  In  older 
patients,  when  rickets  is  not  the  cause  of  the  afiection,  massage,  systematic 
exercise,  and  the  abandonment  of  the  vicious  posture  will  often  result  in  the 
relief  of  the  deformity.     A  spinal  brace  is  rarely  required. 


672 


KNOCK-KNEE. 


EiG.  599 


Anterior  Spinal  Curvature. — Lordosis. — This  affection  may  occixr 
as  tlie  result  of  rickets,  or  from  relaxation  of  the  anterior  spinal  ligaments, 

or    from    tuberculous    diseases 
Fig.  600.  affecting  the   posterior  portion 

of  the  vertebrse,  and  is  often  ob- 
served as  a  compensating  curve 
in  tuberculosis  of  the  spine,  or 
in  hip-disease.  (Fig.  .599.)  In 
congenital  dislocation  of  the  hij), 
marked  lordosis  is  a  prominent 
feature  of  the  deformity.  It  is 
often  observed  in  acrobats  who 
acquire  preternatural  mobility 
of  the  lumbar  spine.  It  may 
also  result  from  paralytic  condi- 
tions, as  infantile  palsies  or 
pseudo-hypertrophic  paralysis. 

Treatment. — When  lordosis 
is  a  compensating  deformity  to 
bring  the  upper  part  of  the  spine 
back  to  the  centre  of  gravity,  no 
special  treatment  is  indicated, 
but  the  iDrimary  affection  which 
causes  the  lordosis  should  re- 
ceive attention.  When  it  results 
from  rickets,  recumbency  and 
tonics  with  proper  diet  are  indi- 
cated ;  when  it  results  from  par- 
alytic conditions,  the  employ- 
ment of  massage  and  galvanism  may  be  followed  by  good  results ;  when  a 
consequence  of  tuberculous  disease  of  the  spine,  it  sliould  be  treated  by  a 
brace  or  the  plaster-of-Paris  jacket.  The  use  of  supporting  apparatus,  such 
as  a  leather  or  a  plaster-of-Paris  jacket,  while  the  child  is  taking  exercise, 
but  not  continuously,  is  often  of  marked  benefit. 

Knock-Knee,  or  Genu  Valgum. — This  consists  in  an  angular  pro- 
jection of  the  knee  inward.  It  is  a  common  deformity,  and  may  be  either 
single  or  double.  (Fig.  600.)  It  arises  especially  in  children  beginning  to 
walk,  as  a  result  of  rhachitic  disease  of  the  bones,  and  develops  more  rarely 
during  adolescence,  the  genu  valgum  adolescentium,  which,  according  to  Miku- 
licz, is  due  to  latent  rickets,  although  this  is  denied  by  many.  The  deformity 
depends  partly  on  the  muscles  and  ligaments  and  partly  on  the  bones  enter- 
ing into  the  formation  of  the  joint.  In  the  rhachitic  form  the  bones  are 
especially  affected,  while  in  some  cases  relaxation  of  the  ligaments  is  the 
main  feature.  There  is  very  generally  lengthening  of  the  internal  condyle 
of  the  femur,  and  sometimes  the  entire  epiphysis  is  twisted  outward,  but 
the  former  condition  is  the  most  common  factor  in  turning  the  tibia  outward. 
The  tibia  itself  is  sometimes  deformed  at  its  upx^er  extremity,  and  there  may 
be  bowing  of  the  shaft  below,  forming  a  compensatory  bow-leg.    The  internal 


Anterior  curvature 
of  the  spine. 


um,  or  knock-knee. 


KNOCK-KNEE. 


673 


lateral  ligameut  is  lengthened,  and  the  external  ligament  shortened,  -with 
similar  changes  in  the  inner  and  outer  groups  of  muscles.  Flat-foot  is  often 
associated  as  a  cause  or  as  a  result  of  the  deformity. 

As  has  been  already  mentioned,  rickets  is  the  most  common  primary 
etiological  factor.  The  deformity  usually  appears  when  the  child  begins  to 
walk.  In  standing  in  the  so-called  "attitude  of  rest"  the  weight  is  borne 
on  the  external  condyles,  and  in  the  rhachitic  child,  the  bones  being  preter- 
naturally  soft,  there  are  produced  an  atrophy  of  the  external  condyle  and 
au  increased  growth  of  the  internal  condyle.  At  the  same  time  the  internal 
lateral  ligament  is  lengthened  by  the  strain  upon  it.  Adolescent  knock-knee 
develops  in  patients  with  relaxed  muscular  systems  whose  occupations  neces- 
sitate much  standing  and  walking.  Other  rarer  causes  are  flat-foot,  infantile 
paralysis,  arthritis,  and  traumatism. 

Symptoms. — Besides  the  unsightly  deformity,  there  may  be  pain  in  the 
knees  and  a  tendency  to  fatigue  upon  slight  exertion.  In  unilateral  knock- 
knee  with  much  deformity  (Fig.  601)  there  may  be  limp- 
ing, obliquity  of  the  pelvis,  and  a  development  of  lateral 
curvature.  In  double  knock-knee  the  gait  is  a  rolling 
one.  In  marked  cases  of  knock-knee  we  have  seen  ulcers 
form  over  the  inner  condyles  from  pressure  and  friction 
in  walking.  When  the  legs  are  flexed  upon  the  thighs 
the  deformity  largely  disappears.  This  is  due  to  the 
fact  that  the  condyles  are  altered  in  length  but  not  in 
thickness,  and  in  this  position  the  tibia  articulates  with 
their  unaltered  posterior  surfaces. 

Treatment. — In  mild  cases  in  very  young  children 
the  deformity  may  be  outgrown,  although  this  favorable 
termination  is  more  common  in  bow-legs  than  in  knock- 
knee.  No  matter  what  course  of  treatment  is  decided 
upon,  attention  must  be  paid  to  the  underlying  causative 
condition,  which  is  usually  rickets.  This  includes  proper 
diet,  fi'esh  air  and  sunlight,  and  the  administration  of 
certain  di'ugs,  as  phosphorus  and  the  phosphates,  cod- 
liver  oil,  and  syruj)  of  iodide  of  iron.  The  local  treat- 
ment may  be  mechanical  or  oj^erative.  Rubbing  of  the 
limbs,  and  systematic  manipulation,  bending  the  knee 
outward  towards  the  correct  position,  should  be  practised 
daily.  In  early  life,  before  the  stage  of  eburnation  of 
the  bones  has  been  reached, — that  is,  up  to  about  the  end  of  the  third  year, 
— braces  will  suffice  for  correction.  They  should  extend  well  up  the  thigh, 
or  even  to  a  band  around  the  waist,  and  be  so  adjusted  as  to  make  pressure 
over  the  inner  side  of  the  knee,  which  joint  should  be  kept  fixed.  (Fig. 
602.)  If  the  bones  have  become  hardened,  au  operation  will  be  required. 
Osteoclasis  and  osteotomy  are  the  operations  usually  emj^loyed. 

Osteoclasis,  or  forcible  fracture  by  instrumental  devices,  is  popular  in 
France,  but  in  America  is  not  often  employed  in  kuockknee,  on  account 
of  the  danger  of  injury  to  the  articulation. 

Osteotomy  may  be  performed  upon  the  femur  or  the  tibia  and  fibula, 

43 


Unilateral  knock-knee. 


674 


KNOCK-KNEE. 


commonly  on  the  femur,  which  is  the  bone  usually  at  fault.  Ogston, 
Eeeves,  and  Chieue  chiselled  through  the  internal  condyle  to  permit  its 
displacement.  Macewen's  operation,  the  one  most  commonly  employed,  is 
an  osteotomy  of  the  femur,  half  an  inch  above  the  adductor  tubercle. 
(Fig.  603.)  The  limb  should  be  thoroughly  ster- 
ilized, and  may  be  rendered  bloodless  by  the  ap- 
plication of  an  Esmarch's  bandage.     We  prefer, 


Fig   602 


(jenu  \alguiii  brace 


Bone  section  in  Macewen's  op- 
eration :  AC,  line  of  section. 


Result  of  osteotomy  for  knock-knee  i 
case  shown  in  Fig.  600. 


however,  to  omit  the  use  of  this,  as  the  small  amount  of  blood  which  is 
lost  during  the  operation  is  a  matter  of  no  moment,  and  the  use  of  hiemo- 
static  apparatus  favors  consecutive  bleeding.  The  limb  is  next  laid  with 
its  outer  surface  upon  a  small  sand-bag  placed  uader  the  knee  and  the  lower 
part  of  the  thigh,  and  the  leg  is  flexed  uj)on  the  thigh.  A  longitudinal 
incision,  about  half  an  inch  in  length,  is  made  down  to  the  bone,  on  the 
inner  side  of  the  thigh,  an  inch  above  the  adductor  tubercle  ;  an  osteotome 
is  introduced  through  this  incision  and  carried  down  to  the  bone,  and  is 
turned  so  that  its  cutting  surface  shall  be  at  a  right  angle  to  the  axis  of 
the  femur  ;  the  bone  is  then  divided  by  driving  the  osteotome  through  it 
by  strokes  of  the  mallet,  great  care  being  taken,  as  the  posterior  surface  of 
the  bone  is  divided,  not  to  injure  the  large  vessels  which  .are  in  close  rela- 
tion to  it.  It  is  usually  better  not  to  divide  the  bone  comj)letely  with  the 
osteotome,  but,  when  it  is  about  three-fourths  cut  through,  to  remove  the 
osteotome  and  complete  the  fracture  by  manual  force.  After  correcting  the 
deformity  the  wound  should  be  closed  by  one  or  two  sutures  of  silk  or  cat- 


BOW-LEGS. 


675 


Fig.  605. 


gut,  and  should  then  be  covered  with  a  compres.s  of  iodoform  gauze,  or  gauze 
and  iodoform  collodion,  and  a  pad  of  gauze  or  cotton.  A  flannel  bandage 
is  next  applied  from  the  toes  to  the  groin,  and,  while  the  limb  is  held  in 
a  slightly  over- corrected  position,  a  plaster-of-Paris  bandage  is  applied  from 
the  toes  to  the  groin,  and  the  limb  held  in  this  position  until  the  bandage 
has  set.  The  patient  should  be  kept  in  bed  for  a  month,  and  at  the  end  of 
this  time  the  plaster  bandage  should  be  removed  and  a  new  one  applied,  to 
be  worn  for  another  month.  At  the  end  of  this  time  the  patient  may  be 
allowed  to  begin  to  use  the  limbs  in  locomotion.  The  mortality  following 
this  operation  is  very  slight,  hemorrhage  and  sepsis  being  very  rare  acci- 
dents. The  result  of  osteotomy  in  the  case  shown  in  Pig.  600  is  shown  in 
Pig.  604. 

Bow-Legs,  or  Genu  Extrorsum. — This  is  the  opposite  condition  to 
knock-knee.  The  legs  are  bowed  outward,  and  the  deformity  may  be  single 
or  double,  generally  the  latter.  The  shafts  of 
the  femur  and  of  the  bones  of  the  leg  usually 
take  the  principal  part  in  producing  the  de- 
formity, the  tibia  especially  being  curved  out- 
ward, and  a  forward  bowing  of  the  same  bone 
may  be  associated.  There  is  sometimes  obliq- 
uity also  in  the  articular  surface  of  the  femur, 
with  elongation  of  the  external  condyle.  (Pig- 
605.)  Like  knock-knee,  it  occurs  as  a  result  of 
the  bone-changes  in  rhachitis  when  the  child 
begins  to  walk,  but,  unlike  the  latter  affection, 
it  rarely  develops  during  adolescence.  Its 
production,  according  to  Bradford  and  Lovett, 
is  probably  due  to  the  position  in  which  the 
rhachitic  child  stands, — that  is,  with  the  lum- 
bar spine  arched  and  the  thighs  flexed.  This 
produces  a  separation  of  the  knees  and  a  rotai- 
tion  of  the  femora,  bringing  the  line  of  gravity 
inside  the  knee-joint  and  causing  the  bending 
of  the  softened  bones  outward.  Like  knock- 
knee,  it  may  appear  before  the  child  begins  to 
walk,  and  is  then  due  to  tonic  muscular  ac- 
tion. 

Symptoms. — There    is    the  characteristic 
deformity,  which  is  associated  with  a  waddling 

gait,  resembling  that  observed  in  double  congenital  dislocation  of  the  hips, 
although  not  so  well  marked.     The  feet  are  inverted  in  walking. 

Treatment. — Expectant  treatment  is  more  promising  in  bow-legs  than 
in  knock-knee,  as  there  is  a  greater  tendency  to  obliteration  of  the  deformity 
as  growth  proceeds.  This  fortunate  result  is  more  likely  to  take  place  when 
the  curve  is  a  gradual  one,  involving  both  femur  and  tibia.  When  the  tibia 
is  mainly  involved,  and  presents,  as  is  often  the  case,  at  its  lower  end  an 
outward  projection,  the  expectant  treatment  will  be  less  apt  to  be  followed 
by  disappearance  of  the  deformity.      Here  also  the  stage  at  which  the  child 


Genu  extrorsum,  or  l30w-leffs. 


676 


BOW-LEGS. 


Fig.  606. 


irace  for  bow-leg 


is  first  seen  has  a  bearing  on  the  prognosis ;  as  soon  as  the  bones  become 
hard,  there  is  less  chance  of  spontaneous  improvemeat.  The  hygienic 
measures  described  for  cases  of  knock-knee  must  be  carefully 
carried  out.  Manipulation  involves  bending  in  the  inward 
direction  towards  a  straight  line.  Mechanical  treatment  is 
promising  up  to  the  end  of  the  third  year.  Various  appli- 
ances are  used,  aiming  at  luaking  pressure  on  the  outer  side 
of  the  knee,  or  wherever  the  greatest  convexity  is  situated, 
with  pads  for  counterpressure  at  the  inner  side  of  the  thigh 
and  ankle.  (Fig.  606.)  Inversion  of  the  toes  must  be  pre- 
vented. 

Operative  treatment  includes  both  osteoclasis  and  oste- 
otomy. Osteoclasis  gives  good  results  where  the  deformity 
is  due  to  curvatures  of  the  shafts  of  the  femur  and  tibia. 
Eizzoli's  or  Grattan's  instrument  may  be  used,  and  after 
correction  a  plaster-of- Paris  dressing  is  applied. 

Linear  osteotomy  is,  however,  a  preferable  operation, 
as  by  its  em]3loyment  the  correction  can  be  accomplished 
with  greater  precision  and  with  less  risk  of  injury  to  the 
neighboring  articulations.  The  legs  should  be  thoroughly 
sterilized,  and,  if  the  operator  desires,  they  may  be  rendered 
bloodless  by  an  Esmarch  bandage ;  but  here,  as  in  the  case 
of  osteotomy  for  knock-knee,  we  prefer  to  omit  this  detail.  The  limb  being- 
supported  upon  a  small  sand-bag,  a  small  incision  is  first  made  over  the  fibula 
at  the  point  of  greatest  curvature,  and  the  point  of  the  knife  is  carried  down 
to  the  bone  ;  a  narrow  osteotome  is  slipped  down  ujpon  this  as  a  guide  until 
it  touches  the  bone,  when  the  knife  is  withdrawn  and  the  osteotome  is  turned 
at  a  right  angle  to  the  bone  ;  the  bone  is  then  partially  divided  by  a  few 
strokes  of  the  mallet,  the  osteotome  is  withdrawn,  and  the  wound  is  covered 
with  a  compress  of  antiseptic  gauze.  An  incision  is  next  made  over  the 
anterior  portion  of  the  tibia  at  the  iioint  of  greatest  curvature,  and  an  oste- 
otome is  introduced  and  turned  so  that  its  cutting  edge  shall  be  at  a  right 
angle  to  the  long  axis  of  the  bone,  when  the  tibia  is  gradually  divided  by 
driving  the  osteotome  through  the  bone  by  strokes  of  the  mallet.  The  oste- 
otome may  be  removed  before  the  posterior  shell  of  the  bone  is  divided,  and 
the  separation  of  the  bone  completed  by  manual  force.  In  cases  where  the 
deformity  is  largely  confined  to  the  tibia  and.  fibula,  division  of  these  boues 
as  described  above  will  be  sufficient  to  correct  the  deformity ;  but  if  the 
femur  is  involved  in  the  deformity,  osteotomy  of  this  bone  may  also  be 
required,  and  should  be  performed  in  the  same  manner. 

Cuneiform  osteotomy  may  be  employed  in  cases  in  which  the  de- 
formity is  very  marked  and  the  bones  are  very  hard.     (See  page  662. ) 

The  dressing  consists  in  closing  the  small  incisions  by  a  few  catgut  or 
silk  sutures  and  applying  over  them  a  scab  of  gauze  and  iodoform  collodion 
or  a  small  compress  of  iodoform  gauze  and  cotton.  A  flannel  bandage  is 
next  applied  to  the  limb  from  the  toes  to  the  groin,  and  while  the  limb 
is  held  in  a  position  of  slight  over-correction  a  plaster-of- Paris  bandage 
is  applied  from  the  toes  to  the  groin,  and  the  limb  is  held  in  this  position 


ANTERIOR  TIBIAL  CURVATURES. 


677 


until  the  bandage  has  set.  This  bandage  is  retained  for  a  month,  when  it 
is  removed,  and  a  new  and  lighter  one  is  applied,  to  be  worn  for  three  or 
four  weeks  longer;  after  eight  weeks  the  iiatient 
may  use  the  limbs  in  locomotion  without  any  risk 
of  recurrence  of  the  deformity.     (Fig.  607.) 

Fig.  60S. 


Fig.  607. 


Result  of  osteotomy  for  bow-legs 
in  case  shown  in  Fig.  605. 


Skiagraph  of  anterior  tibial  curvatures. 


If  care  has  been  taken  as  regards  asepsis,  and  no  large  vessels  have  been 
injured  in  the  operation,  the  patients  do  well.  Occasionally  on  the  second 
or  third  day  after  the  operation  it  will  be  noticed  that  the  toes  are  discolored 
and  swollen,  in  which  case  the  bandages  should  be  removed  and  the  wound 
inspected,  and  if  no  wound-complication  is  present  a  new  bandage  should 
be  applied.  If  suppuration  has  occurred  in  the  wound,  drainage  should  be 
introduced  and  a  new  bandage  applied,  with  a  fenestra  over  the  wound  to 
I)ermit  of  its  dressing.  We  have  seen  serious  complications  occur  after 
osteotomy  for  bow-legs  in  two  cases  only, — secondary  hemorrhage  from  the 
anterior  tibial  artery,  and  osteomj'elitis  of  the  tibia, — both  of  which  termi- 
nated favorably. 

Anterior  Tibial  Curvatures. — In  these  cases,  which  occur  in  sub- 
jects of  rickets,  the  most  marked  anterior  curvature  is  in  the  lower  third  of 
the  bone  (Fig.  608),  and  this  deformity  is  very  frequently  associated  with 
knock-knee  and  flat-foot.  The  deformity  seems  to  be  largely  due  to  mus- 
cular force  exerted  uj)on  the  softened  bones  by  the  posterior  muscles  of  the 
leg.  The  appearance  presented  by  a  well-marked  case  of  anterior  tibial 
curvature  is  shown  in  Fig.  609. 

Treatment. — The  treatment  in  this  condition  consists  in  a  cuneiform 
osteotomy  of  the  tibia  and  linear  osteotomy  of  the  fibula  at  the  point  of 


678 


GENU  RECURVATUM. 


greatest  curvature,  with  subcutaneous  division  of  tlie  tendo  Achillis  or 
splitting  and  lengthening  of  the  tendon,  and  fixation  of  the  limb  in  the 
corrected  position  by  a  plaster-of- Paris  bandage.  In  mild  cases  linear  oste- 
otomy may  correct  the  deformity  satisfactorily,  but  in  cases  of  marked 


Fig.  609. 


Anterior  tibial  curvature. 


01  osteotomy  for  anterior  tibial 
curvature. 


Fig.  611. 


deformity  it  will  be  found  necessary  to  perform  a  cuneiform  osteotomy  of 
the  tibia  and  a  simple  section  of  the  fibula  and  to  divide  the  tendo  Achillis 
before  the  deformity  can  be  corrected.  In  performing  cuneiform  osteotomy 
in  these  cases  the  bones  are  exjjosed  by  turning  up  a  flap  or  by  a  ti-ansverse 
incision,  when  a  wedge  of  bone  of  sufficient  size  is  re- 
moved by  a  chisel  from  the  tibia,  and  the  fibula  is 
divided  ;  the  tendo  Achillis  is  next  divided,  and,  after 
closing  the  wounds  and  applying  a  gauze  dressing,  the 
leg  is  held  in  the  corrected  position  and  a  plaster-of- 
Paris  bandage  is  applied ;  fenestrte  may  be  cut  over 
the  wounds  if  subsequent  dressing  is  required.  The 
result  of  a  cuneiform  osteotomy  for  anterior  tibial  cur- 
vature is  shown  in  Fig.  610. 

Genu  Reciirvatum. — This  is  a  deformity  in 
which  the  knee  is  hyperextended  ujjon  the  thigh,  pre- 
senting a  prominence  behind  the  joint.  (Fig.  611.) 
The  condition  may  be  slightly  developed,  or  may  be  so 
marked  as  to  constitute  a  serious  deformity  and  ij  re  vent 
flexion  of  the  leg  upon  the  thigh.  It  seems  to  be  due 
to  stretching  and  relaxation  of  the  posterior  ligaments 
of  the  knee,  with  marked  contraction  of  the  anterior 
portions  of  the  capsular  and  lateral  ligaments  of  the 
joint. 
Treatment. — As  soon  as  the  deformity  is  noticed  in  an  infant,  systematic 
manipulation  should  be  practised  by  bending  the  knee  in  the  proper  direc- 


Genu  reeurvatum 
Treves. ) 


ANKYLOSIS. 


679 


tiou,  and  this  method  of  treatment  if  continued  for  some  time  may  be  fol- 
lowed by  marked  improvement  in  the  position  and  motion  of  the  joint.  In 
cases  coming  under  the  care  of  the  surgeon  when  the  deformity  has  been 
untreated,  repeated  manipulations  under  anaesthesia  and  fixation  with  a 
plaster-of- Paris  dressing  may  be  practised  with  improvement  in  the  condi- 
tion. Subcutaneous  division  of  the  anterior  portion  of  the  capsule  of  the 
joint  and  of  the  lateral  ligaments  has  been  emijloyed,  and  in  cases  which 
resist  these  methods  of  treatment,  excision  of  the  joint  with  the  view  of 
correcting  the  deformity  and  securing  bony  ankylosis  in  good  firnctional 
position  would  be  a  justifiable  procedure. 

Ankylosis. — Bony  Ankylosis  of  the  Knee.— This  deformity  usu- 
ally results  from  tubercular  osteitis  of  the  knee  or  from  wounds  involving 
the  knee-joint,  followed  by  suppurative  arthritis, 
and  may  occur  in  any  of  these  affections  if  the  Fig.  612. 

articular  cartilages  have  been  destroyed.  Bony 
ankylosis  of  the  knee  with  little  deformity  calls 
for  no  operative  treatment,  as  a  patient  presenting 
this  condition  usually  has  good  use  of  the  limb  by 
wearing  a  high  shoe  to  compensate  for  the  shorten- 
ing. Wlien,  however,  the  knee  is  ankylosed  and 
marked  angular  deformity  is  present,  as  shown  in 
Fig.  612,  operative  treatment  is  required  to  give 
the  patient  a  useful  limb. 

Treatment. — This  deformity  may  be  corrected 
by  turning  up  a  flaj)  from  the  anterior  surface  of 
the  knee  and  removing  a  wedge-shaped  section  of 
bone  with  a  saw  or  a  chisel,  including  the  patella 
and  a  portion  of  the  head  of  the  tibia  and  condyles 
of  the  femur,  the  base  of  the  wedge  corresponding 
to  the  anterior  surface  of  the  knee.  In  removing 
the  apex  of  the  wedge  great  care  should  be  taken 
to  avoid  injury  of  the  popliteal  vessels.  Injury 
of  the  vessels  and  nerves  may  be  avoided  by  pass- 
ing a  retractor  behind  the  bones  before  using  the  Ankylosis  of  the  knee, 
chisel  or  saw.    After  a  sufficient  amount  of  bone  has 

been  removed  to  permit  of  the  limb  being  brought  into  a  straight  i^osition, 
fixation  of  the  surfaces  of  the  bone  may  be  secured  by  wire  sutures  or  nails. 
The  flap  is  replaced,  the  wound  is  closed  by  sutures  and  covered  with  a 
gauze  dressing,  and  the  limb  from  the  toes  to  the  groin  is  fixed  by  a  plaster- 
of-Paris  dressing,  which  should  be  retained  for  a  mouth  and  then  replaced 
by  a  fresh  one.  Fixation  should  be  maintained  for  some  months  after 
union  seems  firm,  otherwise  there  will  be  a  tendency  to  recurrence  of  the 
deformity.  In  less  aggravated  cases  of  this  deformity  the  correction  may 
be  accomplished  by  osteotomy,  a  section  being  made  through  the  condyles 
of  the  femur  and  another  through  the  head  of  the  tibia,  which  allows  the 
limb  to  be  brought  into  the  straight  position.  The  limb  shoiild  then  be 
fixed  by  a  plaster-of-Paris  bandage,  and  fixation  maintained  for  several 
months. 


680 


TREATMENT  OF  ANKYLOSIS. 


Ankylosis  of  the  Hip  with  Flexion  after  Hip-Disease. — In  many 
cases  of  tuberculosis  of  the  hip-joint  which  terminate  in  recovery,  owing 
to  destruction  of  the  joint  or  change  in  the  shax)e  of  the  head  and  neck 
of  the  bone,  flexion  of  the  thigh  iipon  the  pelvis  occurs,  and  a  permanent 
bony  or  firm  fibrous  ankylosis  of  the  joint  results,  with 
the  limb  in  such  a  position  that  the  j)atient  is  only  able 
to  bring  the  toes  of  the  extended  foot  in  contact  with  the 
ground.      (Fig.    613.)     This   deformity  usually  follows 
tubercular  disease  of  the  hip  which  has  not  been  care- 
fully treated.     It  is  observed  in  cases  which  have  been 
comxilicated  by  abscess,  as  well  as  in  those  in  which  this 
complication  has  not  occurred. 

Treatment. — When  the  deformity  results  from  fibrous 
ankylosis,  subcutaneous  division  of  the  contracted  muscles 
and  fascia,  with  subsequent  extension,  is  often  followed 
by  its  correction.  In  cases,  however,  in  which  very  firm 
fibrous  or  bony  ankylosis  exists,  an  osteotomy,  according 
to  the  method  of  Adams  or  Gant,  will  be  required  to 
correct  the  deformity.  Adams's  operation,  which  con- 
sists in  a  subcutaneous  section  of  the  neck  of  the  bone, 
is  made  with  a  short  narrow  saw.  In  correcting  this 
deformity  when  it  is  the  result  of  hip-disease,  we  prefer 
Gant's  operation  to  that  of  Adams,  as  the  head  and 
neck  of  the  bone  are  often  very  much  changed  in  shape, 
and  the  section  is  necessarily  made  through  diseased  tissue 
in  the  latter  situation.  Moreover,  if  only  fibrous  ankylosis _exists,  recurrence 
of  the  deformity  may  take  place  after  section  of  the  neck  of  the  bone  from  the 
action  of  the  muscles  inserted  into  the  lesser  trochanter.  In  Gant's  opera- 
tion, or  subtrochanteric  osteotomy,  the  section  is  made  through  the  femur  just 
below  the  lesser  trochanter  in  healthy  bone,  and  if  the  upper  fragment  is 
flexed  by  the  muscles  inserted  into  the  lesser  trochanter  the  lower  fragment 
unites  at  an  angle,  and  subsequent  flexion  of  the  thigh  will  be  impossible. 
In  performing  subtrochanteric  osteotomy  a  saw  or  an  osteotome  may  be  used. 
The  limb  being  sterilized,  an  incision  is  made  with  a  long,  sharp-pointed 
tenotome  on  the  outer  side  of  the  thigh  just  below  the  position  of  the  lesser 
trochanter,  and  is  carried  down  to  the  bone  ;  an  Adams's  saw  is  next  intro- 
duced upon  the  tenotome  as  a  guide,  and  when  the  bone  has  been  reached 
the  tenotome  is  withdrawn  and  the  blade  of  the  saw  is  gradually  worked 
over  the  upper  surface  of  the  bone  :  as  there  is  often  adduction  of  the  thigh 
as  well  as  flexion,  care  should  be  taken  to  make  the  section  at  right  angles 
to  the  long  axis  of  the  bone.  The  bone  is  then  divided  with  short  strokes 
of  the  saw  from  above  downward,  and  when  it  is  nearly  divided  the  saw  may 
be  withdrawn,  the  division  being  completed  by  fracturing  the  remaining 
portion  of  the  bone  by  bending  the  thigh  downward.  The  wound  should 
be  closed  with  a  compress  of  iodoform  gauze  or  gauze  and  iodoform  collodion, 
and  the  limb  brought  into  a  straight  position  and  slightly  abducted.  The 
after-treatment  consists  in  the  apijlication  of  a  plaster-of- Paris  bandage  to 
the  leg,  thigh,  and  pelvis  to  fix  the  parts,  or  the  case  may  be  treated  by  an 


Ankylosis  of  the  hip  fol- 
lowing coxalgia. 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


681 


Fig.  615. 


extension  apparatus,  weight  and  pulley,  lateral  support  at  the  same  time 

being  given  to  the  limb  by  sand  bags.     Fixation  or  extension  should  be 

maintained  for  at  least  six  or  eight  weeks,  after  which  the  patient  should 

use  crutches  for  a  few  weeks  before  he  is  allowed  to  bear  his  weight  upon 

the  limb  in  walking.     The  results  follow- 

iug  this  operation  are  very  satisfactory, 

and  the  operation  is  one  attended  with  little 

danger.     The  correction  of  the  deformity 

in  Pig.  613,  by  osteotomy,  is  shown  in  Fig. 

614. 

Coxa  Vara. — This  is  an  aifection  in 
which  there  is  bending  or  incurvation  of 
the  neck  of  the  femur.  It  affects  children 
and  adolescents,  and  is  most  commonly 
observed  between  the  thirteenth  and  twen- 
tieth years.  It  is  much  more  frequently 
unilateral  than  bilateral,  and  is  more  com- 
mon in  the  male  than  in  the  female.  It 
seems  to  be  predisposed  to  by  early  rickets. 
According  to  Whitman,  it  is  due  to  a  dis- 
proijortiou  between  the  strength  of  the  part 
and  the  strain  it  has  to  bear.  Another 
cause  is  fracture  of  the  neck  of  the  femur 
in  childhood  with  a  gradual  increase  in 
the  deformity  after  repair.  The  neck  of 
the  bone  is  usually  bent  downward  and 
backward,  the  trochanter  is  elevated  and 
prominent,  the  limb  shortened  and  abducted,  and  the  muscles  atrophied. 
(Fig.  615.)  Abduction,  flexion,  and  internal  rotation  are  limited,  and  there 
is  weakness,  pain,  and  disability.  This  affection  may  be  confounded  with 
hip-joint  disease  or  congenital  dislocation  of  the  hip.  Treatment. — This, 
while  the  bending  is  progressive,  consists  in  hygienic  measures  with  rest 
and  fixation  of  the  joint ;  but  if  the  deformity  is  marked,  osteotomy  of  the 
femur  below  the  trochanters  may  be  required  later  to  correct  the  deformity. 
Operative  treatment  has  apparently  arrested  the  progress  of  the  deformity 
in  some  cases. 

Congenital  Dislocation  of  the  Hip.— This  is  a  rather  infrequent 
condition,  although  the  most  common  of  the  congenital  dislocations.  It  is 
more  frequent  in  females  than  in  males,  and  may  be  single  or  double.  A 
number  of  theories  have  been  advanced  as  to  its  causation,  the  most  probable 
being  that  which  ascribes  it  to  an  arrest  of  development  of  the  rim  of  the 
acetabulum.  According  to  Lorenz,  certain  subluxations  due  to  mechanical 
causes  in  connection  with  the  cartilaginous  and  ijerhaps  rhachitic  structures 
may  become  complete  luxations  through  exertion  and  muscular  action.  It 
is  sometimes  hereditary.  Before  walking,  the  acetabulum  is  shallow  and 
undeveloped,  and  the  head  of  the  femur  may  occupy  any  of  the  positions 
noted  in  traumatic  dislocations,  but  most  commonly  it  lies  on  the  dorsum  ilii. 
After  walking  the  head  becomes  deformed  and  flattened,  and  forms  a  new 


Result  of  subtro- 
chanteric osteotomj' 
in  case  shown  in  Fig. 
613. 


Deformity  in  coxa 
vara.  (After  Whit 
man.) 


682 


TBEATMEIs'T  OF  CONGENITAL  DISLOCATION   OF  THE   HIP. 


cavity  for  itself  over  the  ilium,  the  original  acetabulum  filliug  up  with  car- 
tilage, fat,  fibrous  tissue,  or  exostoses.  The  capsule  becomes  thickened  and 
elongated,  often  drawn  out  into  the  shape  of  an  hour-glass,  and  the  round 
ligament  sometimes  disappears.  The  gait  is  characteristic  in  double  cases, 
being  a  duck-like  waddle.  The  buttock  is  flattened,  the  trochanter  promi- 
nent and  high.  In  early  years  the  range  of  motion  is  increased,  later 
abduction  is  abnormally  diminished.  There  is  lumbar  lordosis,  with  great 
prominence  of  the  abdomen,  and  tilting  of  the  pelvis  ;  the  lower  extremities 
are  short.  (Fig.  616.)  In  unilateral  cases  there  are  much  limping,  shorten- 
ing of  one  leg,  lateral  curvature  of  the  spine. 
Fig.  616.  and  flexion  and  tilting  of  the  pelvis. 

The  condition  must  be  diagnosed  from  infan- 
tile paralysis,  bow-legs,  hip-disease,  coxa  vara, 
and  traumatic  dislocations.  The  history,  ap- 
]5earance,  position  of  the  trochanters,  laxity  of 
joint  structures,  and  absence  of  pain  are  the 
imx)ortant  diagnostic  points.  A  skiagraj)h  will 
show  the  position  of  the  head  of  the  femur.  The 
prognosis,  without  treatment,  is  bad,  natural 
cure  never  occurring,  and  much  disability  often 
resulting. 

Treatment. — Mechanical  measures  aimed  at 
accomplishing  and  maintaining  reduction  have 
often  been  tried.  They  include  continuous  ex- 
tension for  a  long  time,,  and  the  plaster-of-Paris 
dressing,  but  are  rarely  curative.  Pelvic  belts 
and  corsets  sometimes  afford  relief  by  fixing  the 
pelvis  and  suijporting  the  trochanters.  Various 
operative  procedures,  as  subcutaneous  tenotomy, 
excision,  and  chiselling  out  the  acetabulum,  have 
been  practised.  Hoffa  and  Lorenz  have  done  the 
most  valuable  work  in  this  direction.  The  open 
operation  is  preceded  by  the  application  of  exten- 
sion to  the  limb  to  draw  down  the  head  of  the 
bone  ;  sometimes  a  tenotomy  of  the  adductors  is 
required.  In  adults  this  may  require  confinement 
to  bed  for  some  time.  An  incision  is  made  between  the  tensor  vaginre  femoris 
and  the  gluteus  medius  down  to  the  capsule,  which  is  opened  by  a  T-shaped 
or  transverse  incision  parallel  to  the  neck  of  the  bone.  The  head  and  neck  of 
the  femur  are  shaped,  if  necessary,  and  the  acetabulum  is  chiselled  out,  the 
reduction  being  then  accomplished.  In  young  children  it  may  not  be  neces- 
sary to  enlarge  the  acetabulum.  The  capsule  and  ligaments  should  be 
spared  as  far  as  possible.  The  wound  is  dressed,  and  the  leg  firmly  fixed 
in  a  position  of  extension,  abduction,  and  slight  inward  rotation,  with  a 
plaster-of-Paris  dressing.  After  a  few  months  the  patient  is  allowed  to  walk, 
the  leg  still  being  fixed.  Later,  manipulations,  exercise,  and  massage  are 
indicated.  Up  to  the  age  of  six  years  an  attempt  may  be  made  to  replace 
the  head  in  the  acetabulum  by  manipulation.     To  accomplish  this  Lorenz 


Double  congenital  dislocation  of  the 
hip. 


DEFORMITIES   OF  THE  FINGERS. 


683 


recoaimends  reduction  by  extension,  either  gradual  or  immediate,  followed 
by  attempts  under  anaesthesia  to  replace  the  head  of  the  bone  in  its  natural 
socket.  These  consist  in  movements  in  the  direction  of  flexion,  abduction, 
and  inward  rotation,  and  combined  attemjjts  to  lift  and  press  the  trochanter 
and  head  of  the  bone  over  the  rim  of  the  acetabulum.  After  reduction  fixa- 
tion is  maintained  in  the  position  of  abduction,  flexion,  and  inward  rotation 
for  eight  or  ten  months ;  after  which  locomotion  is  encouraged,  abduction 
being  gradually  lessened.  Osteotomy  of  the  shaft  of  the  femur  below  the 
trochanters  may  be  necessary  to  overcome  inward  rotation. 

Congenital  dislocations  other  than  of  the  hip  are  very  rare,  and  are 
often  associated  with  other  marked  defects  of  development,  as  acrania, 
spina  bifida,  etc.  Among  other  rare  congenital  malformations  are  absence 
of  the  upper  and  lower  extremities,  and  partial  or  complete  absence  of  the 
humerus,  femur,  tibia,  and  fibula. 

Club-hand  is  also  a  rare  affection,  and  may  be  congenital  or  acquired. 
The  congenital  variety  consists  usually  in  a  flexion  (rarely  an  extension)  of 
the  hand  on  the  forearm,  often  in  combination  with  an  inclination  towards 
the  radial  or  the  ulnar  side.  There  may  be  partial  or  complete  absence  of 
the  radius,  and  there  are  sometimes  associated  malformations  of  the  fingers. 
Acqiiired  club-hand  may  follow  injuries  to  nerves  or  other  forms  of  paral- 
ysis, the  contraction  of  cicatrices,  and  injuries  of  the  bones.  When  the 
epiiDhysis  of  the  radius  or  of  the  ulna  is  destroyed  by  disease  or  injury,  the 
growth  of  the  other  bone  forces  the  hand  into  an  unnatural  position. 

Treatment. — In  mild  cases  manipulations  and  tenotomies  are  of  benefit. 
In  those  following  epiphyseal  inflammation  the  excision  of  a  suf&cient  por- 
tion of  the  uninjured  bone  to  permit  of  straighten- 
ing is  indicated.  Amputation  may  be  called  for 
if  the  limb  is  absolutely  useless. 

Deformities  of  the  Fingers.— These  com- 
prise supernumerary  digits,  or  a  deficiency  in  their 
number,  malformations,  and  congenital  or  cica- 
tricial webbing  of  the  fingers. 

Supernumerary  digits  are  usually  situated 
on  the  ulnar  side  of  the  hand,  but  are  also  ob- 
served upon  the  radial  side.  (Fig.  617.)  They 
may  be  perfectly  formed,  even  to  the  presence  of 
a  distinct  metacarpal  bone,  or  may  spring  from 
another  finger,  sometimes  being  attached  only 
by  a  very  slender  pedicle.  Amputation  is  indi- 
cated if  they  are  unsightly  or  useless,  and  should 
be  performed  in  early  life. 

Webbed  Fingers. — Sj'^ndactylism  consists  in  a  union  of  two  or  more, 
sometimes  all,  of  the  digits  in  a  part  or  in  their  entire  length,  and  is  often 
associated  with  a  lack  of  development.  The  union  may  be  by  skin,  muscle, 
and  fibrous  tissue,  or  the  bones  may  be  fused.  (Pigs.  618  and  619.)  In 
complete  webbing  the  hand  is  often  shortened,  and  the  movements  of  the 
fingers  are  restricted.  Treatment. — Several  oi^eratious  have  been  devised 
for  the  relief  of  this  deformity,  their  object  being  to  bring  flaps  of  sound 


Fig.  617 


Supernumerary  thumb.   (Agnew. ) 


684 


DEFORMITIES   OF  THE  FINGEES. 


skin  to  the  opposing  sides  of  the  fingers,  and  to  secure  rapid  healing  at  the 
bottom  of  the  cleft,  as  granulation  starting  here  is  liable  to  lead  to  recur- 

FiG.  618.  Fig.  619. 


Webbed  fingera. 


AVebbed  fingers. 


rence  of  the  condition  by  the  formation  of  a  cicatricial  web.  Didot's  method, 
as  shown  in  the  diagram  (Fig.  620),  consists  in  turning  back  a  palmar  and 
a  dorsal  flap  from  opposite  fingers,  and  after  dividing  the  rest  of  the  web, 
bringing  them  round  and  stitching  them  in  place.  Zeller's  and  Agnew's 
operations  are  done  by  turning  back  a  triangular  flap  of  skin  from  the  dor- 
sum of  the  web,  its  base  downward  corresponding  to  the  bases  of  the  fingers, 
and,  after  dividing  the  rest  of  the  web,  turning  it  forward  into  the  inter- 
digital  cleft,  thus  securing  a  bridge  of  skin  between  the  fingers. 


Fig.  620. 


Fig.  621. 


Didot's  operation  for  webbed  fingers.  Dupuytren's  finger  conti  action 

Trigger-Finger. — This  is  a  rare  condition  in  which  free  fiexion  and 
extension  of  the  finger  is  prevented  and  the  finger  is  brought  to  a  sudden 
stop  while  in  motion.  If  the  finger  be  grasped  with  the  other  hand  and  an 
effort  be  made  to  complete  the  motion,  the  obstruction  is  overcome  with  an 


CONTEACTUEES  OF  JOINTS.  685 

appreciable  jerk  and  flexion  or  extension  is  completed.  The  condition  may 
be  due  to  a  circumscribed  enlargement  of  the  flexor  tendon,  to  contraction 
of  the  groove  in  the  transverse  ligament  in  the  palm,  to  tenosynovitis,  or 
to  the  presence  of  a  fibroma  or  an  enchondroma.  Treatment. — This  consists 
in  the  use  of  passive  motion  or  a  splint  and  compress  ;  or  if  the  presence  of 
a  tumor  can  be  demonstrated,  an  incision  should  be  made  and  the  growth 
removed. 

Dupuytren's  finger  contraction  isafiexion  of  the  finger  due  to  contrac- 
tion of  the  palmar  fascia,  which,  being  inserted  into  the  proximal  phalanx, 
when  shortened  draws  the  digit  down  into  the  palm.  (Fig.  621.)  The  ring 
and  little  fingers  are  commonly  the  subjects  of  this  deformity.  The  causes 
are  gout  and  rheumatism,  the  constant  pressure  of  instruments  on  the  palm, 
and  reflex  nervous  irritation  excited  by  traumatism.  Neuralgic  pains  in  the 
arm  are  sometimes  present.  Oases  have  beeu  recorded  of  syphilitic  origin 
(Eicord  and  Eichet)  which  were  cured  by  the  administration  of  iodide  of 
potassium.  Dupuytren's  contraction  must  be  diagnosed  from  contractures 
due  to  shortening  of  the  flexor  tendons,  from  cicatrices,  and  those  due  to 
joint  disease.  Treatment. — This  consists  in  a  division  of  the  contracted 
bands  by  subcutaneous  tenotomy,  as  advised  by  Adams.  The  tenotome  is 
introduced  beneath  the  skin,  and  the  fascia  is  divided  by  cutting  downward  ; 
it  is  generally  necessary  to  introduce  the  knife  at  several  points,  owing  to 
the  adhesions  between  the  fascia  and  the  skin.  The  after-treatment  consists 
in  the  use  of  a  splint  for  three  weeks,  and  the  subsequent  use  of  the  splint 
at  night  for  a  year.  When  the  open  method  is  practised,  a  V-shai^ed  flap  of 
skin  with  its  apex  towards  the  palm  is  turned  up,  and  a  uumbei'  of  transverse 
incisions  of  the  contracted  bands  are  made,  or  the  contracted  bands  may  be 
removed  by  dissection. 

Contractures  of  Joints. — These  may  result  from  diseases  of  the  joints 
of  the  upper  and  lower  extremities,  or  may  follow  paralysis,  either  of  cere- 
bral origin,  as  the  cerebral  spastic  palsies,  or  of  spinal  origin,  as  acute 
anterior  poliomyelitis.  The  measures  taken  to  overcome  deformities  result- 
ing from  joint  disease  are  considered  under  Excisions.  For  the  spastic  con- 
tractures, manipulation  and  massage,  electricity,  and  muscular  exercise 
should  be  directed,  and,  finally,  tenotomy  may  be  useful.  Mechanical 
treatment  is  not  entirely  satisfactory,  as  the  contractures  return  after  the 
removal  of  the  apparatus.  After  an  attack  of  acute  infantile  paralysis  an 
apparatus  is  very  useful  in  the  prevention  of  contractures,  and  should  be 
employed  as  a  sujiport  for  the  body  and  to  hold  the  limb  in  proper  position 
in  walking.  If  there  is  a  tendency  to  flexion  or  over-extension  of  the  knee, 
a  brace  with  a  lock -joint  at  the  knee  should  be  worn  ;  and,  similarty,  if  there 
is  extensor  paralysis  of  the  foot,  it  should  be  kept  at  a  right  angle,  to  pre- 
vent the  occurrence  of  talipes  equinus,  or,  what  is  more  usual,  equino-varus 
or  equino- valgus.  If  these  measures  are  neglected,  severe  contractures,  sub- 
luxations, and  even  dislocations  (especially  of  the  hip)  are  likely  to  occur. 
In  addition,  electricity  and  massage  should  be  employed.  If  deformities 
are  present  when  the  case  comes  under  observation,  mechanical  aj)pliances 
are  still  useful  for  correction,  and,  in  addition,  tenotomy,  myotomy,  shorten- 
ing or  lengthening  of  tendons,  or  forcible  straightening  may  be  practised. 


686 


HAMMER-TOE. 


The  superficial  and  deep  flexor  muscles  of  the  hip,  the  adductors  and  rota- 
tors, may  require  division  ;  open  incision  being  preferable  when  the  deeper 
muscles  are  to  be  attacked.  The  hamstring  tendons  in  flexion  of  the  knee 
are  usually  accessible  for  subcutaneous  tenotomy,  the  knife  being  introduced 
so  as  to  cut  from  the  middle  of  the  popliteal  space  outward,  esi^ecial  care 
being  necessary  in  dividing  the  tendon  of  the  biceps  femoris  to  avoid  wound- 
ing the  external  popliteal  nerve,  which  runs  close  to  its  inner  border.  Sim- 
ilarly, at  the  ankle,  the  tibialis  anticus,  tibialis  posticus,  peroneals,  etc., 
may  be  attacked  subcutaneously.  Tendons  are  best  lengthened  by  the  method 
of  Walsham  and  Willet,  whereby  the  tendon  is  slit  obliquely  and  the  ends 
slid  past  each  other  until  the  desired  lengthening  is  obtained. 

Arthrodesis. — This  consists  in  removing  the  cartilaginous  surfaces  of  a 
joint  as  a  means  of  bringing  about  bony  ankylosis  of  the  joint,  thus  securing 
a  stiff  joint  in  place  of  a  flail-like  one.  It  is  esi^ecially  indicated  in  iiaralytic 
deformities,  and  has  been  employed  in  the  ankle-,  tarsal,  and  knee-joint  with 
satisfactory  results.  The  operation  consists  in  opening  the  joint  and  remov- 
ing the  cartilage  from  the  opposed  surfaces  of  the  bone  with  a  sharji  spoon 
or  chisel,  and  afterwards  fixing  the  bone  surfaces  in  contact  with  sutures  or 
nails  and  maintaining  fixation  by  a  plaster- of-Paris  dressing. 

Hammer-Toe. — This  is  a  not  uncommon  aifection,  in  which  the  proxi- 
mal phalangeal  joint  of  the  toe  is  permanently  flexed  and  the  distal  joint  is 
hyperextended,  the  deformity  being  caused  by  shortening  of  the  lower  fibres 
of  the  lateral  ligaments.  The  second  toe  is  the  one  most  commonly  affected 
(Fig.  622),  although  other  toes  may  be  involved  ;  the  affection  may  also  be 
symiuetrical.  The  deformity  is  commonly  seen  in  children  and  young  adults, 
and  probably  arises  from  unusual  length  of  the  affected  toe,  whose  extremity 
is  pressed  backward  by  the  boot,  and  gives  rise  to  permanent 
flexion  and  hy]3erextension  as  above  described.  The  deform- 
ity is  very  marked,  and  causes  great  pain  and  discomfort,  as 
corns  are  apt  to  form  on  the  extremity  of  the  toe  and  upon 
the  summit  of  the  projection. 

Treatment. — Subcutaneous  section  of  the  lateral  liga- 
ments may  be  followed  by  relief,  but  the  deformity  often 
recurs  ;  so  that  the  radical  treatment  which  consists  in  ampu- 
tation of  the  toe  at  the  metatarso-phalaugeal  joint  or  in  exci- 
sion of  the  proximal  phalangeal  joint  is  usually  employed. 
Amputation  is  often  practised  with  good  results,  but  in  the 
case  of  the  second  toe  may  be  followed  by  the  development 
of  hallux  valgus  from  want  of  lateral  support  to  the  great 
toe,  so  that  in  this  toe  excision  should  be  preferred.  In 
excising  the  joint  enough  bone  should  be  removed  to  allow 
the  toe  to  be  brought  into  a  straight  position.  The  wound 
should  be  dressed  with  a  gauze  dressing,  and  a  narrow  strip 
of  binder's  board  incorporated  in  the  dressing  to  keep  the 
toe  in  a  straight  position,  and  worn  until  union  of  the  bones  has  occurred, 
which  usually  takes  place  iu  two  or  three  weeks. 

Hallux  Flexus  or  Rigidus. — This  consists  in  a  painful  affection  of 
the  great  toe. in  which  there  is  restriction  of  motion  especially  in  the  range 


Fig.  622. 


Hammer-toe. 


INGROWING  TOE-NAIL. 


687 


Fig.  623. 


of  dorsal  flexion.  It  is  most  commonly  seen  in  adolescence  and  is  often  asso- 
ciated with  the  condition  of  flat-foot.  Treatment. — This  consists  in  manip- 
ulation and  the  use  of  properly  fitting  shoes,  and  if  this  is  not  followed  by 
improvement,  the  head  of  the  proximal  phalanx,  or  the  head  of  the  meta- 
tarsal bone,  should  be  excised,  which  will  usually  correct  the  deformity. 

Hallux  Valgus. — This  deformity  consists  in  abduction  of  the  great  toe 
at  the  metatarso-phalangeal  joint,  with  marked  enlargement  of  the  head  of 
the  first  metatarsal  bone  by  osteophytic  growths,  caused 
by  a  chronic  osteoarthritis.  (Fig.  623.)  The  distal 
phalanx  may  rest  upon  or  pass  under  the  second  toe, 
and  a  bursa  or  bunion  is  usually  present  between  the 
skin  and  the  bone,  which  becomes  inflamed  from  press- 
ure of  the  shoe  and  causes  great  pain  and  disability. 
Treatment. — When  the  deformity  is  slight,  the  wear- 
ing of  proj^erly  shaped  shoes  may  prevent  the  subse- 
quent development  of  ^  the  condition  to  one  of  marked 
deformity  or  discomfort.  The  use  of  a  properly  fitting- 
splint  may  also  be  followed  by  good  results.  In  severe 
cases  the  best  results  are  obtained  by  excision  of  the 
head  of  the  metatarsal  bone  and  of  any  bony  outgrowths 
which  ax-e  present,  and  the  toe  should  afterwards  be 
fixed  in  a  position  of  adduction.  We  have  seen  very 
satisfactory  correction  of  this  deformity  by  osteotomy  of 
the  metatarsal  bone  above  its  head  ;  after  relieving  the 
deformity  the  correction  should  be  maintained  for  some 
weeks  by  a  plaster- of-Paris  bandage.  Foidey'  s  operation  consists  in  making  an 
incision  in  the  web  and  on  the  dorsum  between  the  toes,  followed  by  division 
of  the  external  lateral  ligament,  and  dislocation  of  the  toe  inward,  opening 
the  joint ;  the  internal  condyle  of  the  metatarsal  bone  is  next  removed,  the 
toe  replaced,  and  the  wound  closed  with  sutures,  the  resulting  scar  being  out 
of  the  way  of  pressure.  This  operation  is  not  to  be  employed  when  suppu- 
ration has  cojnmenced  in  the  bursa  or  joint. 

Pigeon  Toe. — This  consists  in  the  habitual  turning  in  of  one  or  both 
feet  in  walking.  It  may  arise  from  bow-legs  or  coxa  vara,  but  in  most  cases 
is  symptomatic  of  weakness  of  either  the  arch  of  the  foot  or  of  the  knees. 
Treatment. — When  due  to  knock-knee  or  bow-legs,  the  relief  of  the  latter 
condition  will  correct  the  deformity  ;  in  milder  cases,  unassociated  with  the 
above  deformities,  raising  of  the  sole  of  the  shoe  on  the  outer  border,  com- 
bined with  training  in  walking,  will  often  prove  satisfactory,  or  an  apparatus 
may  be  applied  which  holds  the  feet  in  the  proper  attitude. 

Ingrowing  Toe-Nail. — The  most  common  and  distressing  affection 
of  the  nails  is  the  so-called  ingro%ving  toe-nail,  which  usually  begins  by  an 
irritation  set  up  in  the  fold  of  skin  at  oue  or  both  sides  of  the  nail,  caused 
by  some  miuute  wound  or  the  pressure  of  a  tight  shoe.  The  skin  thickens 
and  presses  against  the  corner  of  the  nail  and  ulcerates,  and  the  patient  is 
very  apt  to  cut  away  the  nail  still  more,  forming  a  sharp  corner  in  the  nail 
farther  back,  which  causes  additional  irritation.  The  affection  is  really  one 
of  overgrowing  skin,  not  of  ingrowing  nail.     The  ulcer  which  develops  at  the 


Hallux  valgus. 


INGROWING  TOE-NAIL. 


Fig.  624. 


Ingrowing  toe-nail  perforating  the  skin. 


side  of  the  uail  deepens  constantly,  and  the  corner  of  the  nail  may  perforate 
the  fold  of  swollen  skin.  (Fig.  624.)  Ingrowing  nails  are  occasionally, 
though  rarely,  observed  upon  the  fingers,  sometimes  resulting  from  the  habit 
of  biting  the  nails.  Prophylaxis  demands  that  the  toe-nail  should  always 
be  cut  scxuarely  across  at  right  angles  to  its 
long  axis,  and  the  corners  left  untrimmed 
and  long  enough  to  reach  well  beyond  the 
folds  of  skin  ou  each  side,  so  that  the  latter 
cannot  be  injured  by  them. 

Treatment. — If  seen  early,  the  aj)iDlica- 
tion  of  a  saturated  solution  of  alum  until 
inflammation  is  subdued,  and  the  introduc- 
tion of  a  little  lint  or  cotton  between  the 
corner  of  the  nail  and  the  skin  which  pro- 
jects over  it,  will  in  mild  cases  effect  a  cure. 
A  method  of  treatment  which  we  have  found 
very  satisfactory,  even  in  severe  cases,  con- 
sists in  cocainizing  the  ulcerated  surface  and 
with  a  curved  probe  introducing  a  pledget 
of  cotton  under  the  edge  of  the  nail  and  then 
a  layer  of  cotton  between  the  nail  and  the 
ulcerated  surface.  A  few  drops  of  a  mixture 
of  tincture  of  benzoin  and  collodion  are  next  dropped  uj)on  the  cotton  and 
a  narrow  strip  of  adhesive  plaster  is  wrapped  around  the  toe.  This  dressing- 
is  renewed  at  intervals  of  three  or  four  days,  and  may  be  required  for  several 
weeks. 

Of  the  A^arious  operations.  Anger's  operation  is  excellent  for  ordinary 
cases.  A  narrow  sharxD-pointed  knife  is  made  to  transfix  the  soft  parts  on 
the  affected  side,  just  grazing  the  bone  at  a  point  level  with  the  highest 
extent  of  the  matrix,  and  is  carried  forward  so  as  to  cut  a  flap  from  the  side 
of  the  toe,  the  flap  being  as  -nide  as  possible,  and  with  its  apex  well  forward 
at  the  end  of  the  toe.  This  flap  is  held  aside,  and  the  knife  applied  to  the 
bone  inside  of  the  base  of  the  flap,  directed  forward,  and  the  matrix  shaved 
off  the  side  of  the  bone  with  a  strip  of  nail  and  the  affected  area  of  soft 
parts.  The  flap  is  returned  and  secured  in  place  with  two  or  three  sutures. 
Every  possible  antiseptic  precaution  must  be  employed,  and  primary  union 
will  generally  be  obtained  for  the  greater  part  of  the  wound.  It  is  best  to 
keep  the  foot  at  rest,  but  we  have  obtained  perfect  results  in  jjatients  who 
insisted  upon  going  about  during  healing.  For  cases  with  much  infection  of 
the  soft  parts  Cotting's  operation  is  preferable.  In  this  method  no  flap 
is  cut,  but  the  knife  is  carried  down  to  the  bone  at  the  same  high  point,  so 
as  to  include  the  entire  matrix  at  that  side,  and  carried  forward  in  a  sweep, 
so  as  to  slice  off  at  once  the  entire  side  of  the  toe,  matrix,  corresi^ondiug 
nail,  and  soft  parts.  The  wound  is  left  to  granulate.  The  method  is  a  good 
one,  but  healing  is  sometimes  tedious  on  account  of  the  large  size  of  the 
wound.  We  have  used  skin-grafts  from  the  excised  skin  to  cover  the  raw 
siu-face  with  success.  Finally,  for  cases  which  obstinately  recur,  or  in  which 
the  nail  has  become  greatlv  deformed  or  the  entii-e  matrix  inflamed,  extir- 


TALIPES,  OR  CLUB-FOOT.  fi89 

pation  of  the  nail  and  matrix  is  advisable.  A  rectangular  flaj)  of  skin  is 
turned  up  from  the  base  of  the  nail,  with  the  base  of  the  flap  directed 
upward  towards  the  foot,  and  the  matrix  removed  thoroughly  with  a  knife. 
It  is  exceedingly  difficult  to  eradicate  the  matrix  entirely,  especially  the  two 
points  which  run  high  up  on  each  side  of  the  phalanx.  For  all  these  opera- 
tions cocaine  anaesthesia  properly  used  is  satisfactory.  These  operations  are 
preferable  to  the  old  plan  of  avulsion  of  the  nail,  being  less  likely  to  be 
followed  by  recurience,  and  not  involving  any  more  delay  or  suffering  for 
the  patient. 

TALIPES,  OPv  CLUB-FOOT. 

Talipes,  or  club-foot,  is  a  deformity  in  which  the  I'elations  of  the  different 
parts  of  the  foot  to  one  another,  and  of  the  foot  to  the  leg,  are  altered  from 
the  normal.  It  may  be  either  congenital  or  acquired,  and  embraces  the  fol- 
lowing ijrimary  forms.  Talipes  equinus  is  the  condition  in  which  the  foot 
is  extended,  the  weight  being  boi-ne  on  the  balls  of  the  toes.  Talipes  cal- 
caneus is  the  reverse  condition,  the  toes  being  drawn  up  and  the  heel  in 
contact  with  the  ground.  Talipes  varus  consists  in  an  invei'sion  of  the 
foot ;  the  inner  side  is  drawn  upward,  and  the  patient  walks  on  the  outer 
edge  of  the  foot.  Talipes  valgus  is  the  opposite  of  varus,  the  foot  being 
everted.  Alterations  in  the  arch  include  two  varieties, — talipes  cavus, 
in  which  the  arch  is  increased,  the  anterior  portion  of  the  foot  being  flexed 
on  the  posterior,  accompanied  by  the  presence  of  a  furrow  across  the  sole, 
and  talipes  planus,  in  which  the  arch  is  broken  down.  These  different 
primary  forms  are  very  frequently  combined,  the  name  indicating  the 
deformity,  as  equino-varus,  equi no- valgus,  calcaneo-valgus,  and  calcaneo- 
varus,  the  combinations  producing  compound  deformities  with  flexion  and 
eversion,  flexion  and  inversion,  etc.  Club-foot  is  a  frequent  deformity :  of 
the  two  forms,  acquired  and  congenital,  the  former  is  encountered  the  more 
frequently,  the  proportion  being  about  three  to  two,  according  to  Adams. 
Congenital  club-foot  is  more  common  in  male  than  in  female  infants,  and  is 
oftener  double  than  single. 

Etiology. — It  is  undoubtedly  inherited  in  some  cases,  and  consanguinity 
in  the  parents  is  well  established  as  a  favoring  factor.  It  has  been  regarded 
as  a  result  of  retarded  development,  ascribed  to  a  failure  of  rotation  from 
the  primary  intra-uterine  position,  in  which  the  soles  are  turned  inward,  and 
to  prenatal  lesions  of  the  nervous  system.  The  acquii-ed  forms  are  generally 
paralytic  in  origin,  especially  as  sequelte  of  acute  anterior  poliomyelitis, 
resulting  in  equinus,  equino-varus,  and  equino-valgus,  calcaneus  and  valgus 
being  rarer.  Pure  equinus  is  excessively  rare  as  a  congenital  type.  Hys- 
terical club-foot  has  been  observed  in  young  neurotic  females.  Other  rare 
cases  are  the  results  of  sprains,  fractures,  and  osteitis  of  the  ankle.  It  may 
also  occur  as  a  sequel  of  knock-knee.  The  skin,  tendons,  fascite,  and  bones 
all  take  part  in  the  deformity.  The  soft  tissues  are  lengthened  or  shortened, 
as  the  case  may  be,  the  tendons  are  misijlaced,  and  the  bones  are  altered  in 
shape  and  brought  into  new  relations  with  one  another. 

Treatment. — This  may  be  divided  into  mechanical  and  operative. 
Mechanical  treatment  by  the  use  of  apparatus  necessitates  also  manipulation 
and  massage,  and  sometimes  electricity  can  be  used  with  advantage.    Opera- 

44 


690  TEEATMENT  OF  CLUB-FOOT. 

tive  treatment  comprises  forcible  correction  (brisement  force),  tenotomy, 
Phelps's  operation  (open  incision),  and  the  various  bone  operations.  In 
cases  of  paralytic  origin  transplantation  of  the  tendons  of  healthy  muscles  to 
take  the  place  of  the  paralyzed  ones  may  be  employed  with  advantage. 
Manipulation  should  be  instituted  from  the  first  in  congenital  cases,  and 
practised  daily,  the  foot  being  pressed  into  the  natural  position  and  held 
there  while  massage  is  applied  to  the  contracted  muscles.  This  must  be  com- 
bined with  the  use  of  a  suitable  shoe  for  retention,  and  will  sometimes  alone 
effect  a  cure.  Under  ansesthesia  the  foot  can  be  at  once  over- corrected,  and 
then  can  be  held  in  that  position  by  a  plaster-of- Paris  dressing  renewed  from 
time  to  time.  Aj)paratus  is  designed  to  assist  in  correction,  and  to  retain 
the  foot  in  position  after  it  has  been  brought  into  the  normal  position  by 
other  measures.  Aj)paratus  employed  to  correct  the  deformity  depends  on 
the  application  of  force  by  elastic  traction,  leverage  and  screw  power,  the 
appliances  most  widely  employed  being  the  shoes  of  Scarpa  and  Knapp, 
Taylor's  shoe,  Shaffer's  modification  of  the  same,  and  the  elastic  traction 
appliances  of  Barwell  and  Sayre,  the  latter  being  especially  applicable  to 
paralytic  cases.  As  retentive  apparatus,  the  simple  plaster-of- Paris  dressing 
is  very  useful  by  itself,  or  when  employed  to  hold  in  position  felt,  steel,  or 
other  materials  used  for  support. 

Tenotomy. — In  the  severer  grades  of  club-foot,  and  as  an  adjunct  to 
mechanical  treatment,  tenotomy  is  of  great  usefulness,  from  the  ease  with 
which  it  can  be  performed  and  the  amount  of  time  saved,  the  foot  being 
immediately  straightened,  although  the  importance  of  the  subsequent  treat- 
ment, carefully  and  continuously  carried  on,  must  never  be  overlooked. 
Subcutaneous  tenotomy,  or  open  incision  of  the  tendons,  may  be  employed. 
Tendons  may  also  be  lengthened  by  oblique  incision  or  by  splitting  them  and 
applying  sutures.  (See  page  416.)  Several  forms  of  tenotomes  are 
employed,  a  sharjp-pointed  one  being  often  used  to  pierce  the  skin,  after 
which  a  blunt-pointed  knife  is  introduced  flatwise  beneath  the  tendon,  and 
the  section  made  from  below  upward  by  a  to-and-fro  rocking  motion,  the  foot 
being  held  so  as  to  render  the  tendon  tense  until  it  is  felt  to  give  way,  when 
the  foot  is  released,  the  knife  withdrawn,  and  the  wound  covered  with  a  piece 
of  gauze.  The  foot  is  forcibly  over-corrected  and  put  up  immediately  in  a 
plaster-of- Paris  dressing.  If  a  vessel  be  wounded,  which  is  an  uncommon 
accident  if  ordinary  care  be  exercised,  the  bleeding  can  generally  be  easily 
controlled  by  a  compress.  Authors  differ  as  to  the  time  at  which  tenotomy 
should  be  resorted  to  in  congenital  cases,  some  practising  it  as  early  as  the 
second  or  third  month,  while  others,  who  lay  more  stress  upon  manipulation 
and  mechanical  measures,  do  not  recommend  it  before  the  child  is  ten  months 
or  a  year  old.  We  are  in  favor  of  the  latter  method  of  treatment.  After 
tenotomy  a  retention  walking-shoe  will  be  required,  and  after  repair  is  com- 
pleted a  continuance  of  the  daily  manipulation  and  massage. 

Brisement  force,  or  forcible  correction  under  ether,  is  practised,  aided  by 
instruments  capable  of  exerting  great  force,  as  the  devices  of  Gibney,  Mor- 
ton, Bradford,  and  Phelps.  The  bone  operations  emjiloyed  in  the  correction 
of  club-foot,  which  are  required  only  in  old  and  neglected  cases  after  milder 
methods  have  proved  ineffectual,  are  numerous.     Excision  of  the  astragalus 


TALIPES  EQUINO-VAEUS.  691 

and  tarsedomy,  or  excision  of  a  wedge-shaped  portion  from  the  outer  side  of 
the  tarsus,  are  the  most  important.  Excision  of  the  astragalus  yields  excel- 
lent results.  It  has  the  disadvantage  of  shortening  the  limb,  but  does  not 
impair  the  form  of  the  foot  or  the  stability  of  the  arch  as  much  as  does 
resection  of  the  tarsus. 

Transplantation  of  Tendons. — This  operation,  first  introduced  by 
Nicoladoni,  is  of  value  in  some  cases  of  infantile  and  spastic  paralysis  in 
children,  and  even  in  paralysis  the  result  of  central  or  peripheral  lesions  in 
later  life.  The  operation  consists  in  altering  the  attachments  of  healthy 
muscles  so  as  to  have  them  fulfil  the  functions  of  those  which  are  paralyzed. 
Thus  in  jjaralysis  of  an  extensor  group  of  muscles  one  or  more  of  the  flexor, 
abductor,  or  adductor  muscles  is  transplanted  and  vice  versa.  Thus  the 
flexor  carpi  ulnaris  may  be  made  to  take  the  place  of  the  extensor  com- 
munis, the  tendon  of  a  healthy  peroneus  longus  may  be  sutured  to  the 
tendo  Achillis,  or  the  tibialis  anticus  may  be  made  to  take  the  place  of  the 
extensor  communis  of  the  toes.  The  muscles  soon  accommodate  themselves 
to  their  altered  functions  and  the  application  of  braces  can  often  be  dis- 
pensed with.  Four  methods  of  transplantation  may  be  iiractised.  The 
tendon  of  the  healthy  muscle  may  be  completely  divided  and  its  upper  end 
sutured  to  the  paralyzed  tendon.  The  tendon  of  the  paralyzed  muscle  may 
be  divided  and  its  lower  end  sutured  to  the  healthy  one.  The  tendon  of  the 
sound  muscle  may  be  split,  one  end  remaining  attached  at  its  normal  inser- 
tion, and  the  other  sutured  to  the  paralyzed  tendon.  A  portion  or  the 
whole  of  the  healthy  tendon  may  be  implanted  svibperiosteally  at  the  desired 
point,  instead  of  stitching  it  to  the  paralyzed  tendon.  The  part  is  fixed  by 
a  i3laster-of- Paris  dressing  for  several  weeks,  and  the  transplanted  tendon 
protected  from  strain  for  several  months. 

Talipes  Equino-Varus. — This  is  the  most  common  congenital  form 
of  club-foot,  constituting  about  three-fourths  of  the  congenital  cases.  It 
generally  aflects  both  feet  (Fig.  625),  but  may  be  confined  to  one  foot.  The 
deformity  consists  in  an  elevation  of  the  inner  border  of  the  foot,  the  sole 
being  turned  towards  the  median  line  of  the  body,  the  heel  being  more  or 
less  drawn  wp,  and  the  distal  portion  of  the  foot  being  flexed  upon  the  prox- 
imal at  the  medio-tarsal  articulation.  (Fig.  626.)  In  equino- varus  the 
astragalus  is  tilted  forward,  and  the  head  and  neck  of  this  bone  are  deflected 
inward,  the  scaphoid  articulating  with  the  inner  side  of  the  head,  or  even 
in  some  cases  with  the  inner  malleolus,  and  the  os  calcis  and  cuboid  are 
altered  in  shape.  When  the  child  begins  to  walk  these  changes  are  all 
exaggerated,  and  the  deformity  increases.  The  muscles  of  the  legs  become 
atrophied,  and  callosities  and  bursse  form  over  the  jDoints  of  pressui-e,  which 
often  become  inflamed  and  cause  great  paiu  and  disability.  There  is  great 
impaii-ment  of  the  gait  in  severe  cases,  the  feet  being  lifted  one  over  the 
other  in  walking. 

Treatment. — In  congenital  cases  of  equino-varus  much  can  be  done  to 
correct  the  deformity  by  manipulation  and  systematic  straightening  of  the 
feet.  An  intelligent  mother  or  nurse,  by  persistent  manipulation  under  the 
direction  of  the  surgeon,  is  often  able  to  bring  the  parts  into  such  a  position 
that  the  deformity  will  be  largely  corrected  by  the  time  the  patient  is  able  to 


692 


TREATMENT  OF  EQUINO-VARUS. 


walk,  and  with  the  aid  of  a  brace  or  a  walking-shoe  the  patient  will  get  on 
very  well,  and  operative  treatment  may  not  be  required.     Another  method 


Double  equino-var 


Equino-varus,  rxjsterior  and  anterior  view. 


Fig.  628. 


of  treatment  consists  in  the  use  of  the  plaster-of- Paris  bandage  applied  after 
the  position  of  the  foot  has  been  corrected  by  the  use  of  force,  the  bandage 
being  removed  at  intervals  of  two  or  three  weeks,  when, 
Fig.  627.  the  correction  being  increased,  a  fresh  plaster  bandage 

should  be  applied.  These  procedures  are 
repeated  until  the  child  is  able  to  walk, 
when  a  brace  is  applied  to  maintain  the  cor- 
rection and  to  allow  him  to  exercise  the 
physiological  function  of  the  foot,  which  in 
itself  tends  to  prevent  the  recurrence  of  the 
deformity. 

Tenotomy  may  also  be  employed  to  cor- 
rect the  deformity  ;  but,  as  a  rule,  when  it  is 
possible,  we  prefer  to  employ  the  methods 
of  treatment  previously  described  until  the 
patient  is  able  to  walk,  and  seldom  resort  to 
tenotomy  in  j)atients  under  one  j^ear  of  age. 
The  subcutaneous  division  of  the  anterior  and 
posterior  tibial  tendons,  the  tendo  Achillis, 
and  the  plantar  fascia  will  generally  correct 
the  deformity.  The  tendo  Achillis  should  be 
the  last  tendon  divided,  as  it  furnishes  a 
After  the  foot  has  been  brought  into  good 
position  it  should  be  put  up  in  a  plaster-of- Paris  dressing,  which  should  be 
worn  for  a  few  weeks ;  when  this  is  removed  a  brace  is  applied,  and  the 
patient  is  encouraged  to  walk.     (Pigs.  627  and  628.)     In  relapsing  cases,  or 


Club-foot  brace.  Walking-shoe 

for  use  after 
operation  for 
club-foot. 

fulcrum  for  forcible  extension. 


TALIPES  VALGUS.  693 

in  old  cases  in  which  no  treatment  has  been  used,  the  deformity  may  be  cor- 
rected by  Phelps's  operation,  by  excision  of  the  astragalus,  or  by  a  cuneiform 
osteotomy. 

Open  incision,  or  Phelps's  operation,  consists  in  making  an  incision, 
with  full  aseptic  precautions,  on  the  inner  side  of  the  foot,  beginning 
directly  in  front  of  the  inner  malleolus,  and  carrying  it  down  to  the  inner 
side  of  the  neck  of  the  astragalus.  All  the  shortened  muscles  and  tendons 
are  divided,  as  well  as  the  plantar  fascia  and  the  deltoid  ligament.  After 
straightening  the  foot,  the  wound  is  allowed  to  fill  with  blood-clot  and  is 
covered  with  a  gauze  dressing  ;  a  plaster-of- Paris  dressing  is  then  applied, 
to  be  retained  until  the  wound  has  healed. 

Excision  of  the  astragalus  is  in  our  judgment  the  most  satisfactory 
method  of  correcting  the  deformity  in  inveterate  and  relapsing  cases.  The 
astragalus  is  exi^osed  by  an  incision  upon  the  outer  side  of  the  foot,  and 
after  it  has  been  disarticulated  any  tendons  or  fascia  which  resist  the  cor- 
rection of  the  deformity  are  divided  subcutaneously  ;  the  wound  is  closed,  a 
gauze  dressing  is  applied,  and  the  foot  is  held  in  the  corrected  position  by 
a  plaster-of- Paris  dressing.  We  have  seen  most  satisfactory  correction  of 
the  deformity  and  excellent  functional  results  follow  this  operation. 

Tarsectomy. — This  consists  in  removing  a  wedge-shaped  section  of  the 
tarsal  bones  from  the  external  surface  of  the  foot.  Although  excellent 
results  follow  this  operation,  we  do  not  think  they  compare,-  as  a  rule,  with 
those  following  excision  of  the  astragalus. 

After  the  deformity  has  been  corrected  by  any  of  these  operations,  a 
properly  fitting  brace,  by  which  extension  and  eversion  of  the  foot  can  be 
maintained,  should  be  worn  for  some  time.     (Fig.  628.) 

Talipes  Valgus,  or  Fiat-Foot.— This  deformity  is  usually  acquired, 
and  consists  in  eversion  of  the  foot,  with  flattening  or  disappearance  of  the 
arch.     There  is  abduction  of  the 

anterior  part   of   the   foot,    and  Fks.  629. 

more  or  less  elevation  of  the 
outer  boi'der  of  the  foot  from  yield- 
ing of  the  arch.  (Fig.  629.)  The 
tarsal  bones,  especially  the  as- 
tragalus and  scaphoid,  are  altered 
in  their  relations,  but  are  not 
much  changed  in  shape.  There 
is  relaxation  in  the  extensors, 
especially  in  the  peroneus  longns,  ^-^ 

as  well  as  in  the  plantar  muscles       -<-' 
and   ligaments.      Talipes  valgus  /^c^ 

is  usually  seen  in  feebly  devel-  ^^»^ — -"     '  ^X,F^ 

oped  children,  and  results  from 
the  body  weight  coming  upon  a 

foot  which  is  unable  to  sustain  it.  It  is  also  often  seen  in  adults,  consti- 
tuting talipes  adolescentium,  which  is  most  common  after  puberty  and  is  due 
to  the  flattening  of  a  relaxed  arch  under  the  increased  body  weight.  This 
condition  may  be  due  to  prolonged  strain  from  work  requiring  constant 


694  TALIPES   CALCANEUS. 

standing,  as  is  seen  in  cooks  and  waiters.  This  deformity  may  also  be  due 
to  rickets,  knock-knee,  sprains,  and  badly  united  fractures  of  the  bones  of 
the  leg  in  the  region  of  the  ankle-joint. 

Symptoms. — In  talipes  valgus  the  patient  stands  with  the  knees  flexed 
and  with  the  feet  everted,  and  in  walking  the  gait  is  heavy  and  uncertain, 
and  the  disability  may  be  very  marked.  Pain  is  a  common  symptom,  and 
is  referred  to  the  astragalo-scaphoid  articulation  {tarsalgia),  the  inner  malle- 
olus, and  the  ball  of  the  great  toe.  Pain  may  be  an  early  symptom  before 
the  arch  of  the  foot  has  given  way.  This  form  of  talipes  is  often  over- 
looked, the  severe  pain  which  accompanies  the  condition  often  being 
referred  to  sprains,  rheumatism,  or  osteitis ;  but  a  careful  examination  will 
show  the  deformity  and  the  altered  gait. 

Treatment. — Congenital  valgus  may  be  treated  by  gradual  reposition 
of  the  parts,  massage,  and  bandaging,  and  later  by  the  application  of  appa- 
ratus supporting  the  arch  of  the  foot.  In  the  acquired  form,  where  there  is 
weakness  of  the  extensors,  much  benefit  may  be  gained  by  exercise  of  the 
foot,  the  patient  being  taught  to  avoid  improper  attitudes  calculated  to 
favor  deformity  and  to  practise  raising  himself  a  number  of  times  daily  on 
tiptoes,  and  by  the  application  of  massage  and  electricity  to  the  weakened 
muscles.  In  addition,  the  use  of  a  metal  plantar  spring  worn  in  the  shoe 
which  supports  the  arch  is  of  great  value.  (Fig.  630.)  The  inner  side  of 
the  sole  and  heel  of  the  shoe  may  be  elevated.  In  cases  in  which  there  is 
much  eversion  of  the  foot  the  use  of  a  steel  ankle-brace  is  often  required, 
and  in  very  marked  cases  it  may  be  necessary  to  restore  the  position  of  the 
arch  under  ether  before  the  plantar  spring  or  brace  can  be  used.  Tenotomy 
or  tarsectomy  is  rarely  required  in  this  deformity. 

Fig.  630.  Fig.  631. 


Plantar  spring  for  flat-foot.  Talipes  calcaneus. 


Talipes  Calcaneus. — This  deformity  may  be  congenital  or  acquired, 
and  most  frequently  results  from  infantile  i^aralysis.  In  this  condition  the 
patient  walks  upon  the  heel,  with  the  anterior  portion  of  the  foot  raised, 
and  there  is  usually  some  abduction  of  the  foot.  (Fig.  631.)  Treatment. 
— This  condition  can  often  be  relieved  by  manipulation  and  bandaging,  or 
by  the  use  of  a  shoe  with  an  extension  sole  and  a  brace.  In  severe  cases, 
or  those  which  have  resisted  other  forms  of  treatment,  the  deformity  may 
be  corrected  by  resecting  a  ijortion  of  the  tendo  Achillis,  suturing  the  ends 
together,  or  shortening  the  tendon  by  the  method  of  Walsham  and  Willet, 
and  fixing  the  foot  in  the  corrected  position  by  a  plaster-of- Paris  bandage. 
After  repair  of  the  divided  tendon  has  taken  place  the  patient  should 
wear  for  some  time  a  brace  to  prevent  recurrence  of  the  deformity. 


TALIPES  EQUINUS. 


695 


Fig.  632. 


Ficx.  633. 


Pes  Cavus. — This  deformity  consists  in  marked  exaggeration  of  the  arch 
of  the  foot.  It  jnay  be  either  congenital  or  acquired,  but  the  latter  form  is 
most  common.  It  may  result  from  contraction 
of  the  tibialis  anticus  and  peroneus  longus 
muscles  and  of  the  plantar  fascia,  and  may 
also  result  from  paralysis  of  the  gastrocnemius 
and  soleus  muscles.  In  this  affection  the  dor- 
sum of  the  foot  is  i^rominent,  and  in  walking 
the  patient  bears  his  weight  upon  the  heel  and 
the  balls  of  the  great  and  little  toes.  (Fig.  632. ) 
Treatment. — This  consists  in  the  use  of  a 
shoe  with  a  steel  plate,  and  in  severe  cases  the 
free  division  of  the  ijlantar  fascia  and  subcu- 
taneous section  of  the  contracted  tendons  may 
be  required.  After  the  deformity  has  been 
corrected   by  operative    treatment    the    foot 

should  be  fixed  in  the  corrected  position  by  a  j)laster-of- Paris  bandage,  and 
subsequently  a  walking-shoe  or  a  brace  should  be  worn  to  prevent  relapse. 

Talipes  Equinus. — This  deformity  consists  in  an  elevation  of  the  heel, 
which  may  be  so  slight  as  merely  to  prevent  the  foot  from  being  fully  flexed 
beyond  a  right  angle,  or  so  marked  as  to  compel  the  patient 
to  walk  upon  the  balls  of  the  toes  and  the  metatarsal  bones. 
(Fig.  633.)  Talipes  eqxiinus  is  rare  as  a  congenital  but 
common  as  an  acquired  affection,  and  results  from  infantile 
paralysis,  spastic  paralysis,  and  post-hemiplegic  contrac- 
tures ;  contraction  of  the  superficial  extensor  muscles  and 
relaxation  or  j)aralysis  of  the  flexor  muscles  of  the  leg  are 
the  essential  factors  in  its  production.  The  deformity  in 
severe  cases  is  very  marked ;  the  head  of  the  astragalus 
projects  upon  the  dorsum  of  the  foot  above  the  astragalo- 
scaphoid  joint,  and  the  scaphoid  is  subluxated.  Contrac- 
tion of  the  plantar  ligaments  and  fascia  is  also  well  marked. 
Treatment. — If  the  deformity  is  moderately  developed, 
manipulation  and  the  use  of '  a  shoe  and  brace  with  an 
extension  sole  may  serve  to  correct  it.  In  severe  cases, 
however,  subcutaneous  division  of  the  tendo  Achillis  and 
plantar  fascia  may  be  required  before  the  deformity  can 
be  satisfactorily  corrected.  The  division  of  the  plantar  fascia  should  first 
be  done,  and  subsequently  the  tendo  Achillis  should  be  divided.  After 
section  of  these  structures  the  deformity  should  be  corrected  and  a  j)laster- 
of- Paris  bandage  worn  for  a  few  weeks  ;  after  this  a  shoe  with  an  extension 
sole  is  applied. 

Metatarsalgia. — Metatarsalgia  is  a  neuralgic  affection  of  the  foot, 
which  has  been  described  by  T.  G.  Morton,  the  pain  radiating  from  the  head 
of  the  fourth  metatarsal  bone.  In  this  condition  there  is  marked  tenderness 
upon  j)ressure,  but  there  are  no  signs  of  inflammation.  It  is  supposed  to  be 
due  to  flattening  of  the  transverse  arch  normally  present  in  the  anterior 
portion  of  the  foot,  formed  by  the  metatarsal  bones,  aud  crowding  together 


Talipes  equinus. 


696 


TARSALGIA. 


Fig.  634. 


of  the  heads  of  the  bones  when  lateral  pressure  is  made,  filaments  of  the 
plantar  digital  nerves  being  pressed  upon.  (Fig.  634.)  Ill-fitting  shoes 
seem  to  play  an  important  part  in  its  development.     Treatment. — This 

consists  in  the  application  of  a 
flannel  roller  over  the  ball  of  the 
foot,  or  the  use  of  circular  strap- 
ping to  prevent  the  foot  from 
flattening,  and  the  wearing  of 
broad,  properly  fitting  shoes. 
A  steel  spring  worn  in  the  shoe 
to  support  the  arch  is  often  use- 
ful. In  severe  cases  the  only 
treatment  which  gives  permanent 
relief  is  excision  of  the  meta- 
tarso-phalangeal  articulation  of 
the  fourth  toe,  or  amputation  of 
this  toe,  with  removal  of  the 
head  of  the  fourth  metatarsal 
bone. 
Tarsalgia. — Tarsalgia  is  a  neuralgic  affection  of  the  tarsus  which  occurs 
in  those  who  are  compelled  to  stand  or  walk  constantly,  and  is  probably  due 
to  relaxation  of  the  ligaments  ;  it  is  frequently  associated  with  flat-foot. 
Treatment. — This  consists  in  the  wearing  in  the  shoe  of  a  metal  plantar 
spring  to  support  the  arch  of  the  foot,  or  a  light  brace  attached  to  the  shoe, 
which  prevents  lateral  movements  of  the  tarsus. 


Skiagraph  of  the  feet  in  a  case  of  metatarsalgia  of  the  left 
foot.    (Dr.  J.  M.  Stern.) 


CHAPTEE    XXVIII. 

SURGERY  OF  THE  HEAD. 
By  B.  Farquhar  Curtis,  M.D. 

the  scalp. 

Injliries. — While  the  scalp  is  naturally  protected  by  the  hair,  it  is 
much  exijosed  to  injury  on  account  of  its  situation.  Contusions  of  the  scalp 
are  marked  by  the  amount  of  effused  blood  and  serum  which  collects 
in  the  loose  connective  tissue  under  the  skin,  and  causes  great  swelling, 
sometimes  an  inch  or  more  in  thickness.  On  account  of  the  underlying 
curved  siirface  of  bone,  blows  on  the  scalp  with  blunt  bodies  often  produce 
rather  sharp-cut  wounds  instead  of  contusions,  the  edges  of  which  may, 
however,  be  so  much  contused  as  to  be  liable  to  gangrene.  If  the  force  is 
applied  at  a  tangent  to  the  skull,  the  soft  parts  may  be  detached,  forming 
undermined  pockets  or  large  ragged  flaps.  Incised  wounds  of  the  scalp  are 
not  very  common,  and  do  not  differ  from  those  in  other  situations  except  that 
the  hemorrhage  is  profuse  and  may  even  be  fatal.  The  arrest  of  hemor- 
rhage may  be  difficult,  because  the  forceps  do  not  hold  well  in  the  tough 
scalp,  and  it  may  be  necessary  to  grasp  its  entire  thickness  with  them. 
Ligatures  are  aj)t  to  slip  off,  and  if  compression  is  not  enough  and  the  liga- 
tures do  not  hold,  a  suture  should  be  passed  through  the  scalp  around  the 
divided  vessel.  A  hcematoma  may  form  under  the  skin,  the  fascia,  or  the 
pericranium.  The  deeper  effusions  present  a  hard  oedematous  zone  at  the 
edges,  where  the  blood  has  coagulated,  leaving  a  soft  centre  which  may  per- 
sist for  some  time  and  may  closely  resemble  a  dej)ressed  fracture  of  the  skull. 
If  the  blood  is  effused  under  the  pericranium,  a  ring  of  fibrous  tissue,  or 
even  of  new  bone,  may  form,  and  remain  permanently  at  the  site  of  the 
injury.  This  is  most  often  seen  in  the  newly  born  infant  as  the  result  of  the 
caimt  succedaneum.  If  a  large  vessel  be  injured,  a  pulsating  hfematoma  may 
be  formed,  which  requires  an  incision  with  ligature  of  the  bleeding  vessel 
lest  an  aneurism  form  later. 

Treatment. — Contusions  are  best  treated  by  astringent  or  cold  applica- 
tions, such  as  an  ice-bag.  Massage  may  be  useful  to  promote  absorption  of 
the  oedema  and  the  blood-clot.  A  hematoma  may  suppurate  and  form  an 
abscess  recxuiring  incision.  Very  large  and  persistent  hjematomata  may  be 
treated  by  aspiration  or  by  small  incisions  to  remove  the  blood.  Incised 
loounds,  and  even  wounds  which  are  contused  and  lacerated,  may  be  closed  by 
sutures  with  safety,  provided  full  aseptic  precautions  are  taken.  The  hair 
must  be  cut  away  and  the  scalp  shaved  for  an  area  of  two  or  three  inches 
from  the  wound  in  all  directions,  and  all  hair  and  foreign  bodies  should  be 
picked  out  of  the  wound.  The  wound  and  the  surrounding  skin  should  be 
washed  with  soap  and  water,  then  with  turpentine  or  alcohol,  and  finally 
with  the  bichloride  solution.     If  asex)sis  be  secured,  primary  union  can  be 

697 


698 


AVULSION  OF  THE  SCALP. 


obtained  in  wounds  of  tlie  scalp  as  well  as  in  other  tissues,  but  if  the  edges 
are  much  contused  and  the  scalp  has  been  detached  from  the  head,  so  as  to 
leave  ragged  flaps,  it  is  wiser  not  to  insert  many  sutures,  but  to  employ 
drainage.  Any  exposed  bone  should  be  covered,  if  possible,  in  order  to 
avoid  necrosis.  Wounds  in  this  region  need  very  careful  watching  after 
suture,  in  order  to  prevent  any  retention  of  secretions,  on  account  of  the 
difficulty  of  providing  for  their  natural  escape.  Burns  and  scalds  of  the 
scalp  do  not  differ  from  those  in  other  regions  except  in  the  loss  of  the  hair. 
Avulsion. — In  persons  with  long  hair  the  latter  may  be  caught  in  revolv- 
ing machinery,  and  the  entire  scalj),  or  a  large  portion  of  it,  may  be  torn 
directly  from  the  head,  leaving  the  pericranium  exjjosed.     (Fig.  635.)    The 


Fig.  63.5. 


Fig.  636. 


^>-^ 

'?^^^^% 


The  scalp  torn  { 


(Sick.) 


The  patient  after  recoTerj'.     (Sick.) 


shock  of  this  accident  is  very  great,  and  the  loss  of  blood  may  be  consider- 
able, so  that  death  has  occurred  from  these  causes  alone.  Great  care  is 
necessary  during  recovery  in  order  to  preserve  the  patient's  strength,  on 
account  of  the  constant  loss  of  serum  from  so  large  a  granulating  surface, 
and  deaths  from  exhaustion  are  not  uncommon.  These  large  wounds  granu- 
late, and  are  covered  partly  by  contraction  and  jpartly  by  the  epidermis 
growing  from  the  edges.  (Fig.  636.)  Skin-grafting  is  usually  necessary, 
and  has  cured  many  cases,  the  best  method  being  that  of  Thiersch. 

Inflaniniations. — Dermatitis  of  the  scalp  may  be  caused  by  infection 
or  irritation  by  chemicals.  It  is  treated  by  the  usual  methods,  but  the  hair 
must  be  kept  short  in  order  to  maintain  cleanliness.  Mrysipelas  and  cellulitis 
occurring  on  the  head  are  very  serious  affections,  because  of  the  large 


OSTEOMYELITIS  OF  THE  SKULL.  699 

amount  of  loose  areolar  tissue  between  the  scalp  and  the  pericranium,  the 
meshes  of  which  afford  an  excellent  opf)ortunity  for  the  stagnation  of  serum 
and  for  the  growth  of  bacteria,  and  also  because  of  the  liability  that  phlebitis 
may  extend  to  the  cerebral  sinuses,  or  that  meningitis  may  follow.  On 
account  of  the  thickness  of  the  skin  of  the  scalp,  the  j)us  is  apt  to  pocket 
and  burrow  in  all  directions  instead  of  finding  its  way  to  the  surface.  Early 
and  free  incisions  and  constant  watching  of  the  infected  area  are  necessary 
in  cellulitis,  which  is  often  followed  by  an  osteitis  and  even  necrosis  of  the 
bones  of  the  skull.     (For  the  treatment  of  erysipelas  see  page  51.) 

Cicatrices. — The  cicatrices  of  former  wounds  of  the  scalp  may  cause 
severe  headache,  neuralgia,  or  even  epileptic  attacks,  and  simple  excision 
followed  by  primary  union  has  cured  these  conditions.  Hypertrophy  may 
occur  in  these  scars  as  elsewhere. 

THE   SKULL. 

Hypertrophy  and  Atrophy. — In  rare  instances  there  is  a  uniform 
hypertrophij  of  the  bones  by  an  external  new  growth  of  bone,  which  does  not 
lessen  the  cavity  of  the  skull.     (See 

Fig.  451.)   Sometimes  the  bones  of  the  ^''^^  '^^^• 

face  are  involved,  producing  the  con- 
dition of  leontiasis.  (See  Fig.  452.) 
The  opposite  condition  of  atrophy  is 
very  rare,  but  it  may  be  so  extreme 
that  the  pericranium  and  dura  are  in 
contact  over  considerable  areas.  Atro- 
phy of  the  bones  must  not  be  con- 
founded with  crauiotabes  (Fig.  637), 
which  is  a  not  uncommon  condition, 
evidently  of  rhachitic  origin,  found  in 
•  infants,  in  which  the  bones  are  so  soft 

Lraniotai  es 

that  they  can  be  easily  depressed  by 

the  finger,  and  may  become  flattened  merely  by  the  weight  of  the  head  as  it 

rests  on  the  pillow. 

Inflammation. — Osteomyelitis.— The  bones  of  the  skull  are  liable 
to  the  same  diseases  as  the  flat  bones  elsewhere  in  the  body.  An  osteomye- 
litis in  them  is  usually  accompanied  by  periostitis  and  detachment  of  the 
pericranium.  The  large  veins  of  the  dij)loe  communicate  almost  directly 
with  the  venous  sinuses  of  the  skull,  and  a  phlebitis  of  the  former  may  be 
communicated  at  once  to  the  sinuses.  As  these  veins  are  large,  unable  to 
contract,  and  not  easy  to  block  up,  all  the  conditions  are  most  favorable 
for  the  production  of  pyaemia,  which  is  exceedingly  common  as  a  result 
of  osteomyelitis.  Necrosis  is  generally  confined  to  the  outer  layer  of  the 
skull  and  diploe,  biit  occasionally  sequestra  are  formed  which  involve  the 
entire  thickness  of  the  bone  and  lie  in  contact  with  the  dura  mater.  Osteo- 
myelitis may  be  due  to  the  staphylococcus  or  other  pyogenic  germs,  or  to  the 
typhoid  bacillus,  or  it  may  occur  in  tuberculosis  and  syphilis.  The  ordinary 
purulent  osteomyelitis  is  generally  caused  by  direct  infection  through  a 
wound  of  the  soft  parts  overlying  the  bone,  especially  if  there  is  a  contusion 


700  TUMORS  OF  THE  SCALP  AND  SKULL. 

or  some  other  injury  of  the  bone.  Syphilitic  Osteomyelitis. — The  skull 
is  attacked  late  in  syphilis,  numerous  large  gummata  forming  under  the 
pericranium  or  in  the  bone,  presenting  flattened  swellings  scattered  over  the 
head,  occasionally  surrounded  by  a  ring  of  new  bone  which  forms  a  hyper- 
ostosis. A  common  result  of  syphilitic  periostitis  or  osteitis  of  the  skull  is 
the  production  of  large  hard  masses  of  permanent  bone  upon  its  surface. 
When  necrosis  occurs  the  sequestra  are  worm-eaten  and  often  very  hard  from 
condensing  osteitis.  Tubercular  Osteomyelitis. — Tuberculosis  of  the 
skull  closely  resembles  the  syphilitic  lesions  in  its  clinical  appearances. 
This  variety  of  osteitis  is  usually  accompanied,  however,  by  the  formation 
of  cold  abscesses  under  the  scalp,  and  caries  is  more  common  than  true 
necrosis.  The  diagnosis  between  the  two  processes  is  exceedingly  difficult, 
unless  aided  by  the  presence  of  other  syphilitic  or  tuberculous  lesions. 

Treatment. — The  treatment  of  necrosis  of  the  skull  consists  in  freely 
incising  the  abscesses,  laying  open  the  sinuses,  cutting  down  on  the  diseased 
bone,  and  removing  the  latter  with  the  curette  or' the  chisel.  Occasionally 
the  sequestra  are  very  slow  in  separating,  and  the  process  may  last  for 
months,  even  when  the  necrosed  bone  is  only  as  thick  as  a  piece  of  paper. 
When  the  sequestrum  is  loose  it  is  easily  removed,  but  when  it  is  firmly 
adherent  there  is  danger  that  attempts  to  remove  it  may  cause  a  phlebitis 
of  the  diploe  which  may  spread  to  the  sinuses  of  the  brain  or  result  in 
pyaemia.  But  it  is  also  dangerous  to  allow  the  sequestrum  to  remain, 
because  pus  is  retained  under  the  dead  bone  and  acquires  increased  infec- 
tious power.  An  excellent  method  of  treating  adherent  superficial  sequestra 
of  large  extent  is  to  perforate  them  with  a  drill  at  points  about  a  quarter  of 
an  inch  apart,  the  numerous  openings  allowing  the  granulation-tissue  under- 
neath to  spring  up  so  that  the  sequestrum  will  be  loosened  and  thrown  off. 
If  this  is  insufficient  the  sequestrum  may  be  removed  by  the  chisel,  but  the 
surrounding  bone  should  be  freely  cut  away  also,  for  its  vitality  is  j)robably 
impaired,  and  it  is  likely  to  undergo  further  necrosis.  It  is  also  essential 
that  the  exposed  bone  should  be  covered  with  skin  if  possible,  because 
otherwise  it  is  liable  to  further  necrosis.  Flaps  should  be  slid  over  the 
wound  and  secured  in  place,  allowance  being  made  for  drainage ;  or  skin- 
grafting  may  be  done.  On  account  of  the  danger  of  acute  osteomyelitis  or 
acute  infection  of  a  wound  in  which  the  bone  is  exposed,  every  precaution 
should  be  taken  to  provide  for  drainage,  and  to  keep  the  parts  aseptic. 

Tumors  of  the  Scalp  and  Skull. — Sebaceous  Cysts.— Among 
the  most  common  tumors  of  the  head  are  the  sebaceous  cysts  or  wens.  They 
are  foixnd  of  all  sizes,  on  all  parts  of  the  head,  and  often  in  great  numbers. 
(Fig.  638.)  The  sacs  of  adjacent  cysts  occasionally  communicate  with  each 
other.  They  sometimes  attain  a  large  size,  and  we  have  seen  them  twice  as 
large  as  the  fist,  but  they  are  of  very  slow  growth  and  require  years  in  order 
to  reach  this  extreme  size.  Apart  from  the  fact  that  they  are  a  deformity 
and  an  annoyance  to  the  patient,  they  are  of  little  clinical  significance,  unless 
they  become  inflamed,  when  they  suppurate  and  form  persistent  sinuses,  in 
which  malignant  tumors  may  develop.  The  inflammation,  however,  may 
be  so  acute  as  to  destroy  the  lining  membrane  of  the  sac  entirely  and  thus 
bring  about  a  permanent  cure.     The  sebaceous  cysts  present  tense,  fluctu- 


DERMOID  CYSTS   OF  THE  SCALP. 


701 


Sebaceous  cysts  of  the  scalp.    (Case  ot  Dr. 
F.  H.  Markoe.) 


ating  swellings  covered  witli  unaltered  skin  ;  but  when  inflamed,  the  skin 
becomes  adherent  and  reddened,  the  surrounding  parts  become  oedematous, 
and  the  tumor   is   more   or  less  fixed. 
Theoretically,  the  cyst  should  always  be  " 

adherent  to  the  skin  at  the  situation  of 
the  gland  from  which  it  originated  by  re- 
tention of  secretion,  and  occasionally  this 
point  can  be  found  and  sebaceous  mate- 
rial squeezed  out,  but  more  frequently 
the  skin  is  entirely  non-adherent.  Even 
without  inflammation,  when  the  tumor 
has  been  in  existence  for  a  long  time  the 
skin  is  apt  to  be  adherent,  ijarticularly 
if  the  wen  is  situated  where  it  is  exjjosed 
to  pressure.  In  some  instances  the  con- 
tents and  even  the  walls  of  the  cyst  be- 
come calcified.  Treatment. — The  only 
possible  treatment  of  these  tumors  is  re- 
moval, with  entire  extirjiation  of  the  sac, 
as  described  in  the  chapter  on  Tumors. 

Dermoid  Cysts. — Dermoid  cysts  are 
also  found  on  the  head,  and  must  not  be  confounded  with  the  ordinary  seba- 
ceous cyst.  They  can  usually  be  distinguished  by  their  situation,  being  most 
common  in  the  region  of  the  fontanelles,  and  also  by  the  existence  of  a  depres- 
sion in  the  bone  beneath  them,  due  to  their  pressure  during  the  development 
of  the  bone.  Dermoid  cysts,  however,  do  not  occur  so  frequently  upon  the 
scalp  as  upon  the  face.  A  meningocele  is  distinguished  from  a  dermoid  cyst 
by  its  reducibility,  by  its  occasional  pulsation,  and  especially  by  its  usual  situa- 
tion at  the  root  of  the  nose  or  on  the  occiput.  The  treatment  of  dermoid  cysts 
is  extirpation,  with  complete  removal  of  the  sac,  which  often  contains  hair. 

Angioma.  Tumors  connected  with  the  blood-vessels  are  exceedingly 
frequent  upon  the  head.  All  the  varieties  of  angioma,  capillary,  cavernous, 
and  arterial  are  to  be  found.  Capillary  angiomata  and  cavernous  angiomata 
are  particularly  common  on  the  head,  about  four-fifths  of  these  tumors  being- 
found  in  this  situation,  and  one-third  on  the  scalp.  They  are  especially 
common  in  children,  and  are  almost  always  congenital,  although  generally 
very  minute  at  birth.  They  sometimes  attain  a  large  size,  and  the  vessels 
may  communicate  directly  with  the  sinuses  within  the  skull,  a  fact  which 
should  be  remembered  in  operating  upon  these  tumors  when  they  are  situated 
in  the  median  line,  particularly  in  the  neighborhood  of  the  fontanelles. 

Treatment. — All  the  ordinary  methods  of  treating  angiomata  are  suit- 
able for  use  xipon  the  scalp,  but  excision  is  the  best,  because  in  this  situation 
the  scar  is  a  matter  of  no  moment  and  the  hemorrhage  is  easily  controlled 
by  the  pressure  of  an  assistant's  fingers  around  the  edge  of  the  tumor.  A 
little  dissection  of  the  scalp  generally  allows  the  edges  to  be  brought  into 
good  apposition,  flaps  being  made  if  necessary. 

Lipoma. — Lipoma  is  rare,  but  congenital  lipomata  are  found  under  the 
temporal  fascia  or  between  the  pericranium  and  the  skull,  and  depressions 


702  EPITHELIOMA  OF  THE  SCALP. 

in  the  bone  may  exist  under  them,  as  under  dermoid  cysts.     A  soft  lipoma 
closely  resembles  a  cyst.     These  tumors  can  be  removed  by  excision. 

Fibroma. — The  scalp  is  a  common  situation  for  the  fibroneuromata 
growing  from  the  sheaths  of  the  nerves,  the  so-called  elephantiasis  of  the 
nerves,  and  they  sometimes  form  extensive  tumors  like  large  folds  of  skin 
hanging  down  from  the  head  and  full  of  cord-like  or  vermiform  masses. 
Simple  iibroma  of  the  skin  also  occurs,  and  is  often  pedunculated.  Treat- 
ment.— Small  fibromata  may  be  excised.  The  large  fibroneuromata  are 
often  very  vascular  and  too  extensive  for  removal. 

Sarcoma. — Sarcomata  frequently  originate  from  some  small  granulating 
■wound,  and  we  have  seen  one  growing  from  an  ulcerating  -wen  which 
resembled  a  large  papilloma.  Tumors  formed  of  pure  granulation-tissue 
are  not  infrequent  in  the  scalp,  and  the  diagnosis  of  these  tumors  from 
sarcoma  is  not  easy.  We  have  sometimes  found  it  possible  to  make  the 
distinction  by  observing  the  method  in  which  the  granulation-tissue 
develops  thi-ough  the  hair.  Sarcoma  grows  beneath  the  skin  and  destroys 
the  hair  when  the  skin  ulcerates,  but  exuberant  granulations  project  over 
the  sound  skin  among  the  hairs,  surrounding  the  latter  in  such  a  way  that 
they  stand  straight  up  through  the  mass  of  the  tumor.  Sarcomata  of  the 
scalp  grow  rapidly,  ulcerate  early,  extend  to  the  bone,  and  result  in  death 
either  by  hemorrhage  or  by  early  invasion  of  the  cranial  contents.  Another 
variety  appears  as  a  small  wart,  aud  if  it  is  removed  early  a  permanent  cure 
follows.  Treatment. — These  tumors  should  be  removed  early  by  very 
free  excision. 

Epithelioma. — Epithelioma  of  the  scalp  is  quite  common.  In  some 
cases  it  runs  a  slow  and  chronic  coui\se,  like  epithelioma  of  the  skin  in  other 
situations,  and  we  have  observed  one  tumor 
which  had  grown  for  twenty  years  and  in- 
volved the  entire  vertex  of  the  skull  and 
penetrated  the  bones  for  a  considerable  area. 
(Fig.  639.)  This  patient  had  no  idea  of  the 
extent  of  the  disease,  never  suffered  any 
pain,  and  finally  died  after  a  week's  illness 
from  meningitis  due  to  infection  of  the  ulcer. 
Epithelioma  may,  however,  occur  early  in 
life,  and  we  have  observed  it  in  a  girl  of 
.eight  years,  in  whom  it  began  in  the  scar  of 
a  burn  received  at  the  age  of  two  years, 
which  had  constantly  remained  ulcerated, 
never  entirely  healing  over,  the  malignant 
Epithelioma  of  the^s^c^ip  of  twenty  years'    pj^j^^ggg    probably  Commencing   two   years 

before  we  saw  her.  In  this  case  also  the 
epithelioma  involved  almost  the  entire  scalp,  and  had  destroyed  a  large 
portion  of  the  bone.  Bruns  has  reported  a  similar  case.  Treatment. — 
Epithelioma  must  be  removed  by  free  excision,  the  underlying  bone  being 
deeply  gouged  out  if  the  tumor  is  adherent  to  it.  "When  the  bone  is  involved 
it  is  almost  impossible  to  eradicate  the  tumor  completely.  The  lymphatics 
may  not  be  infected  early,  but  all  enlarged  glands  should  also  be  dissected  out. 


ANEURISMS  OF  THE  SCALP.  •  703 

Osteoma. — The  bones  of  the  skull  are  peculiarly  liable  to  osteomata, 
which  form  ou  their  external  surface  (very  rarely  on  the  internal)  and  are 
usnally  of  the  eburnated  variety.  These  tumors  are  most  common  on  the 
frontal  bone,  and  generally  form  small,  flat,  hard  nodules.  They  are  of  little 
or  no  clinical  significance,  but  may  rec^uire  removal  on  account  of  deformity 
or  discomfort.  Treatment. — They  may  be  removed  easily  by  the  chisel, 
but  the  base  in  the  diploe  should  be  thoroughly  chiselled  out  in  order  to 
avoid  recurrence.  Primary  malignant  disease  of  the  bones  of  the  skull 
is  not  very  common,  the  tumor  generally  being  secondary  to  tumors  in  other 
situations  or  to  tumors  in  the  dura  mater  or  in  the  brain  itself.  Sarcomata 
originating  in  the  diploe  are  sometimes  covered  with  a  thin  shell  of  bone, 
which  can  be  recognized  by  "egg-shell  crackling,"  even  when  they  attain 
a  considerable  size.  In  some  cases  secondary  carcinoma  forms  cyst-like 
fluctuating  masses  filled  with  a  clear  jelly-like  fluid,  which  may  be  mistaken 
for  a  sebaceous  cyst  unless  the  existence  of  the  primary  tumor  is  known. 
Although  operations  for  camcer  of  the  skull  are  generally  useless,  cures 
have  been  effected  by  extensive  resection  of  the  bones,  even  when  it  has 
also  been  necessary  to  renaove  some  of  the  adherent  dura  mater. 

Pneumatocele. — Limited  sacs  in  the  connective  tissue  containing  air 
are  not  infrequently  found  ou  the  head,  and  the  ordinary  subcutaneous 
emphysema,  originating  in  a  penetrating  wound  of  the  air-passages  or  lungs, 
may  extend  to  the  head  or  may  arise  from  perforating  wounds  of  the  frontal 
sinuses  or  other  air-containing  sinuses.  Spontaneous  perforation  of  the 
mastoid  cells  occurs  in  rare  instances,  in  which  case  air  may  be  driven  into 
the  surrounding  tissue  by  forcible  expiratory  efforts.  Treatment. — Emphy- 
sema is  to  be  kept  down  by  a  firm  bandage  and  a  pad  over  the  point  of 
escape  of  the  aii*,  if  it  be  accessible.  The  air-sacs  are  to  be  incised,  packed, 
and  allowed  to  heal  by  granulation. 

Cirsoid  Aneurism. — The  arterial  angioma,  or  so-called  cirsoid  aneu- 
rism, is  almost  limited  to  the  arteries  of  the  head,  being  seldom  foun(i  in 
other  parts  of  the  body,  and  appears  to  bear  some  relation  to  the  capillary 
angiomata,  having  become  less  common  since  the  latter  have  been  more  thor- 
oughly treated.  Anatomically,  the  tumor  consists  of  dilated  arterial  vessels 
running  in  all  directions  through  a  portion  of  the  scalp  and  making  it  pulsate 
strongly.  The  disease  is  generally  limited  to  one  set  of  the  terminal  branches 
of  the  arteries,  the  temporal  being  most  freciuently  affected,  but  sometimes 
the  entire  scalp  is  involved  and  the  dilatation  may  extend  backward  along 
the  carotid  to  the  aorta.  Occasionally  connecting  openings  are  formed 
between  the  veins  and  the  arteries,  thus  making  an  aneurism  by  anasto- 
mosis and  causing  pulsation  in  the  veins.  !No  large  tumor  is  formed,  but  a 
flat  mass,  composed  of  dilated  vessels.  (See  page  351.)  Treatment. — 
The  treatment  of  cirsoid  aneurism  has  i^roved  exceedingly  unsatisfactory. 
Multiple  ligation  of  all  the  arteries  which  supply  the  aneurism,  followed  at 
the  same  sitting  by  ligature  of  the  external  carotid  (on  both  sides  in  very 
extensive  cases),  is  probably  the  best  treatment. 

Aneurisms. — Ordinary  aneurisms  do  not  differ  from  those  in  other  situ- 
ations. They  are  usually  small  and  originate  in  an  incised  wound,  being 
often  seen  in  the  temporal  region,  where  stabs  with  a  penknife  or  some  sharp 


704  FRACTURES   OF  THE  SKULL. 

instrument  have  wounded  a  small  artery  and  hemorrhage  has  been  controlled 
by  iiressure,  without  cutting  down  upon  and  tying  the  artery  at  the  bottom 
of  the  wound.  Arteriovenous  aneurisms  of  similar  origin  are  also  found. 
These  small  aneurisms  are  best  treated  by  extirpation  and  ligation  of  the 
artery  at  both  ends.  Sacs  containing  blood  connected  with  the  veins  of  the 
diploe  or  the  sinuses  within  the  skull  sometimes  develoj)  as  the  result  of 
injuries  to  the  vessels  by  a  contusion  or  fracture  of  the  bone.  These  form 
soft,  easily  compressible  tumors,  which  grow  tense  during  expiratory  efforts 
and  occasionally  pulsate  with  the  brain  when  distended.  They  are  rare 
tumors,  but  should  be  borne  in  mind  in  making  a  diagnosis. 

FEACTUEES  OF  THE  SKULL. 

Fractures  of  the  skull  are  more  naturally  considered  with  injuries  of  the 
head  than  with  fractures  of  other  bones,  for  they  are  chiefly  important  on 
account  of  the  liability  to  complication  with  injury  to  the  brain. 

Mechanics  of  Fractures  of  the  Skull. — The  mechanics  of  fractures 
of  the  skull  would  be  naturally  supposed  to  depend  in  large  part  uj)on  its 
shape  and  construction.  According  to  Felizet,  the  skull  may  be  considered 
as  formed  of  certain  pillars  or  buttresses  of  thick  bone,  with  thinner  parts 
between,  the  pillars  following  the  vertical  or  meridian  lines  from  the  base  to 
the  vertex,  and  he  advanced  the  theory  that  fissures  are  apt  to  run  in  the 
thin  bone  between  these  pillars.  But  exijerience  does  not  uphold  this 
theory.  Before  Felizet,  Aran  had  claimed  that  the  fissures  ran  in  definite 
and  limited  directions ;  thus,  blows  upon  the  anterior  or  posterior  jsarts  of 
the  vertex  would  produce  fissures  running  down  to  the  corresponding  por- 
tions of  the  base,  and  blows  on  the  side  of  the  head  would  involve  the  base 
on  the  same  side.  More  recent  investigators,  however,  find  that  only  about 
one-third  of  the  fractures  appear  to  be  governed  by  this  assumed  law. 

It  is  regarded  as  settled  at  present  that  the  direction  of  the  fissures 
depends  upon  the  force  which  produces  them.  If  the  skull  is  compressed  in 
a  vice  and  we  consider  the  j)oiuts  of  pressure  to  represent  the  poles  of  a 
globe,  and  that  part  of  the  skull  half-way  between  them  as  its  equator,  we 
shall  find  that  the  skull  is  flattened  by  the  pressure,  the  two  poles  being 
brought  nearer  together,  while  all  the  diameters  running  through  the  equator 
are  lengthened,  and  its  circumference  is  also  increased  at  that  point.  Imagi- 
nary lines  drawn  through  the  poles  on  the  surface  of  the  skull  23erj)endicular 
to  the  equator,  like  the  meridians  of  a  globe,  would  therefore  tend  to  sepa- 
rate at  the  equator,  and  when  fissures  appear  as  the  result  of  increasing- 
pressure  they  would  follow  these  meridian  lines.  The  effect  is  the  same 
whether  the  skull  is  compressed  laterally,  vertically,  or  from  before  back- 
ward, without  reference  to  its  shape,  to  its  sutures,  or  to  differences  in  the 
thickness  of  the  bone.  I^ot  only  is  this  true  of  forcible  compression  in  a 
vice,  but  the  same  law  holds  of  a  blow  received  upon  one  side  of  the  head, 
the  inertia  sufiicing  to  make  counterpressui'e,  and  the  fissures  run  in  straight 
radiating  lines  frojn  the  pole  where  the  blow  is  struck  towards  the  opposite 
pole.  These  are  known  as  the  bursting  lines  of  the  skull.  When  the  skull  is 
compressed  the  fissures  appear  first  near  the  "equator,"  but  when  it  is 
struck  on  one  side  only,  the  fissures  begin  at  that  point.     If  the  pressure 


MECHANICS   OF  FEACTURES   OF  THE  SKULL.  705 

applied  by  the  vice  in  the  experiment  described  be  great,  and  the  skull  very 
elastic,  sometimes  equatorial  fissures  will  appear,  either  with  or  without  the 
others.  Equatorial  fracture,  when  seen  clinically,  is  produced  by  heavy 
bodies  moving  with  a  low  velocity.  A  blunt  object  striking  the  skull  pro- 
duces not  only  radiating  fissures,  but  concentric  fissures  surrounding  the 
point  struck,  the  latter  resulting  from  the  bending  inward  of  the  bone  at 
that  point.  The  "ring-fracture"  produced  in  the  occipital  bone  when  it  is 
forced  down  upon  the  spine  (Fig.  641)  is  an  example  of  this  mechanism. 

The  momentum,  with  which  the  blow  is  struck  determines  the  occurrence 
of  the  fracture ;  a  light  body  propelled  at  high  velocity  is  capable  of  doing 
as  much  damage  as  a  heavy  body  moving  slowly.  The  character  of  the 
injury,  however,  varies  with  the  velocity  and  the  weight  of  the  body.  A  small 
body  moving  with  great  velocity  may  perforate  the  skull,  whereas  a  large 
body  with  a  low  velocity  does  less  damage  at  the  point  of  inipact,  but  pro- 
duces more  diffuse  injury  in  other  parts  of  the  skull.  The  shape  and  char- 
acter of  the  part  of  the  striking  body  which  comes  in  contact  with  the  bone 
must  be  taken  into  considei'ation,  for  a  pointed  or  sharj)-edged  body  will 
perforate  the  skull,  while  a  blunt  surface  will  produce  fissures  only. 

The  skull  possesses  great  elasticity,  as  is  proved  by  the  change  in  its  shape 
under  strong  jDressure  in  a  vice,  as  just  described,  by  which  the  longitudinal 
diameter  may  be  shortened  as  much  as  fifteen  millimetres,  the  transverse 
diameters  being  lengthened  at  the  same  time  without  fracture,  the  skull 
returning  to  its  original  shape  when  the  pressure  is 
removed.  A  skull  filled  with  paraffin  and  dropped 
from  a  height  will  show  a  depression  upon  the  sur- 
face of  the  parafQu  even  if  the  blow  is  insufficient 
to  produce  any  fissure  in  the  bone,  proving  that  the 
latter  has  sprung  inward  under  the  blow.  In  chil- 
dren the  skull  is  so  soft  that  depressions  of  consid- 
erable area,  and  even  one  centimetre  or  more  deep, 
may  be  produced  without  any  signs  of  fracture  of 
the  bone,  the  latter  sim^jly  bending  inwaid  like  a 
stiff  elastic  piece  of  parchment,  and  si^ringing  back        Trephine  button  of  bone. 

.     ,         ,  ,  1         j_    n       -^1         i       i  J?      _J  showing  hair  caught  in  fissured 

into  place  when  elevated  without  a  trace  oi  a  fassure.    d-acture  of  the  skuii. 
The  elasticity  of  the  skull  is  further  shown  by  the 

fact  that  fissures  oi^en  widely  and  theu  close  again,  for  hairs  or  fragments  of 
clothing  or  other  foreign  objects  may  be  driven  into  the  fissure  while  open 
and  then  retained  there,  as  is  proved  by  certain  specimens.  (Fig.  640. )  In 
one  case. (Von  Bcrgmann)  a  fragment  of  a  bullet  was  found  in  the  brain,  with 
no  trace  of  a  former  opening  in  the  skull  to  show  how  it  entered. 

Contre-coup. — The  original  theory  of  fractures  by  contre-coup,  by  which 
is  meant  the  occurrence  of  a  fracture  on  the  opposite  side  of  the  skull  from 
that  on  which  the  blow  is  received,  supposed  that  the  motion  and  force  of 
the  blow  radiated  over  the  skull  in  different  directions  and  met  upon  the 
opposite  side,  producing  there  so  much  commotion  as  to  result  in  a  fracture  ; 
but  this  explanation  is  now  generally  rejected.  A  large  number  of  the 
cases  of  supposed  fracture  by  contre-coup  are  fractures  in  which  the  fissures 
have  extended  around  the  skull  from  the  opposite  side.     Many  others  are 

45 


706 


FRACTURES  OF  THE  BASE  OF  THE  SKULL. 


Fig.  641. 


to  be  explained  by  the  simultaneous  receipt  of  a  blow  on  the  other  side  of 
the  head ;  thus,  a  man  is  struck  upon  the  forehead,  and  the  head  is  driven 
backward  so  that  the  occiput  strikes  against  a  wall :  or  he  is  struck  upon 
the  vertex,  and  the  spine  resisting  at  the  base  produces  a  fracture  at  that 
point.  The  supposed  fractures  by  contre-eoup  are  found  more  often  in  the 
base  than  in  other  parts  of  the  skull ;  but  in  the  great  majority  of  fractures 
of  the  base  by  contre-coup  the  fissures  can  be  traced  directly  from  the  vertex. 
Fractures  of  the  base  do  not  differ  much  in  the  mechanics  of  their 
production  from  fractures  of  the  vertex,  but  they  are  generally  the  result  of 
indirect  violence,  except  those  produced  by  the  penetration  of  bullets 
through  the  neck,  or  of  bullets  or  pointed  objects  entering  through  the  orbit, 
the  nose,  or  the  ear.  The  orbit  is  the  usual  seat  of  the  latter  injuries,  and 
one  of  their  peculiarities  is  the  slight  external  mark  of  the  injury,  for  a 
cane,  a  fencing-foil,  or  some  such  object  may  readily  penetrate  the  fold  of 
the  conjunctiva  or  the  upper  lid,  and  the  wound  in  the  latter  may  be  almost 
unnoticeable  when  the  weapon  has  been  withdrawn.  Foreign  bodies,  such 
as  the  ferrule  of  a  cane,  are  also  very  commonly  left  in  these  wounds,  the 
soft  parts  closing  over  them  and  giving  no  clue  to  their  presence. 

The  usual  fractures  of  the  base  are  the  results  of  severe  blows  upon  the 
vertex,  the  fissures  running  down  into  the  base.     Another  form  is  produced 

by  the  spine  when  the  head  is  driven  down 
upon  it,  or  when  a  man  falls  upon  the  head 
and  the  weight  of  the  body  produces  a  frac- 
ture of  the  base.  F^lizet  aptly  compares 
these  two  accidents  to  the  two  methods  by 
which  the  head  of  a  hammer  may  be  driven 
upon  the  handle  either  by  striking  the  head 
and  forcing  it  on  directly  or  by  striking  the 
other  end  of  the  handle  and  driving  the 
handle  into  the  head,  as  the  latter  remains 
stationary  by  inertia.  Fissures  through  the 
base  follow  the  laws  already  laid  down. 
Blows  upon  the  forehead  or  upon  the  occiput 
are  likely  to  iDroduce  longitudinal  fissures ; 
blows  upon  the  side  of  the  head  produce 
transverse  fissures  ;  blows  half-way  between 
these  jjoints  produce  oblique  fissures.  Very 
severe  blows  by  falls  upon  the  feet  or  upon 
the  head  may  force  the  spine  into  the  skull 
and  produce  circular  fissures  surrounding 
the  foramen  magnum.  (Fig.  641.)  Simi- 
larly, blows  upon  the  chin  may  drive  the  condyles  of  the  jaw  through  the 
base  of  the  skull.  The  clinoid  processes  may  be  torn  off  by  the  sudden 
tension  of  the  tentorium  in  extensive  fractures,  but  fissures  seldom,  if  ever, 
run  directly  across  the  crista.  According  to  Phelps,  sixty  per  cent,  of  severe 
injuries  of  the  head  are  accompanied  by  fracture  of  the  base. 

Diastasis  of  Sutures. — The  sutures  are  occasionally  forced  apart  by  a 
violent  crushing  blow ;  Phelps  has  recorded  a  case  in  which  the  temj)oral 


Extensive  fraeture  of  the  base  of  the  skull 
(Agnew.) 


PENETRATING  FRACTURES  OF  THE  SKULL. 


707 


bone  was  torn  loose  from  all  its  connections.  Diastasis  of  the  sutures  is  rare, 
but  is  more  common  in  children.  (Fig.  642.)  The  fissures  in  fracture  of  the 
skull  are  generally  independent  of  the  sutures,  as  it  seems  that  the  denticij- 
lated  structure  of  the  sutures  interrupts  the  course  of  fissures. 

Varieties. — Fissured  Fractures. — Clean-cut  fissures  without  depres- 
sion are  most  commonly  seen  as  the  result  of  quick,  sharp  blows,  such  as 
might  be  giveja  by  a  light  club  held  in  the  hand,  the  motion  of  the  latter 
being  stopped  by  the  hand  at  the  instant  that  the  club  comes  in  contact  with 
the  head,  for  in  this  way  the  skull  can  be  cracked  with  no  tendency  to  the 
production  of  depression.  There  may  be  a  single  fissure,  or  several  radi- 
ating from  the  point  struck,  sometimes  with  concentric  fissures  also. 

Fig  643 
Fit,  642 


Fracture  through  the  frontal  suture 
(After  Agnew.) 


Fracture  of  the  skull  i.iudueed  by  a  bludgeon.     (After 
Agnew.) 


Comminuted  Fractures. — When  the  lines  of  fracture  intersect  so  that 
portions  of  the  bone  are  entirely  detached,  the  fracture  is  called  com- 
minuted. These  injuries  are  generally  produced  by  the  head  striking  broad 
surfaces.     (Fig.  643.) 

Penetrating  Fractures. — When  a  pointed  or  sharp-edged  body  strikes 
the  skull,  the  outer  table  gives  way,  and  the  diploe  may  also  be  injured. 
If  the  force  is  then  exhausted,  the 

inner  table  may  not  be  injured,  but  ig.  i    . 

if  the  force  continues  to  act,  the 
inner  table  may  be  fractured  also 
If  the  momentum  is  sufficient,  the 
inner  table  may  be  perforated,  frag 
ments  from  it  being  displaced  like 
those  of  the  outer  table  or  driven 
far  inward  and  left  detached  in  the 
brain.  In  these  penetrating  frxc 
tures  the  opening  may  be  clean  cut 
and  without  any  surrounding  fis 
sures.  Perforating  wounds  made 
by  missiles  of  high  velocity,  such  as  bullets,  present  the  same  difl^rence  in 
the  inner  and  outer  tables  as  similai'  wounds  of  the  soft  parts  (Pig.  644), 


I 


t        of    1  esk   11 
b,  internal  splmternig 


{ 


i\        ir  1 
(Agnew.) 


708 


DEPRESSED  FRACTURES   OF  THE  SKULL. 


the  wound  of  entrance  being  smaller  than  the  wound  of  exit.  The  outer 
table  will  be  less  extensively  injured  than  the  inner  as  the  bullet  enters  the 
skull,  and  the  inner  table  less  extensively  injured  as  the  bullet  lea^'es  it. 
Occasionally  considerable  depression  of  the  inner  table  will  be  found  associ- 
ated with  a  simple  fissure  or  a  punctured  fracture  of  the  outer  table.  Injury 
to  the  inner  table  without  fracture  of  the  outer  is  a  very  rare  occurrence. 
The  fact  that  the  inner  table  is  frequently  more  extensively  injured  than  the 
outer  was  formerly  supposed  to  be  due  to  a  difference  in  their  resisting 
power,  and  the  inner  table  was  called  the  vitrea,  or  glass-like  table.  The 
external  table  is  somewhat  thicker  than  the  inner,  but  one  is  not  more 
brittle  than  the  other,  and  the  apparent  difference  between  them  is  easily 
explained  by  certain  mechanical  principles  : 

(1)  When  the  skull  is  struck  by  a  moderately  sharj)-poiuted  object  with 
a  violence  just  short  of  that  necessary  to  i^erforate  it,  the  inner  table  must 
suffer  more  than  the  outer,  because  the  force  of  the  blow  tends  to  spread  in 
a  wedge-shaped  direction  on  all  sides  as  it  enters  the  bone,  just  as  a  nail 
splinters  a  board  on  the  farther  and  unsui^xjorted  side  when  driven  through 
it.  The  outer  table  is  held  in  \Aace  by  the  diploe  and  is  merely  perforated, 
but  the  inner  table  is  not  supj^orted  and  splinters  widely.  (2)  If  a  stick 
be  bent  across  the  knee  until  it  breaks,  the  fracture  will  begin  on  the  side  of 
the  stick  away  from  the  knee,  because  that  is  the  convex  side  of  the  curve. 
In  the  same  way  a  blow  on  the  skull  first  dej)resses  the  latter  and  reverses 
the  curve,  so  that  the  inner  table  becomes  the  convex  side  and  must  yield, 
like  the  convex  layer  of  the  bent  stick.     (Fig.  645.)     Any  force  which  acts 


Fig.  645. 


From  the  y  iuil  sj  ti_imeii  JJepressed  fracture 
of  internal  table  coriespondnig  to  the  external 
fissure.    (Agnew.) 


from  without  and  bends  the  skull  inward  has  a  tendency  to  press  together 
the  particles  of  the  outer  table,  while  those  of  the  inner  table  are  driven 
apart.  This  bending  inward  of  the  skull  depends  upon  its  elasticity,  for  if 
it  were  not  elastic  it  would  be  splintered  into  fragments  or  crushed.  (3) 
Another  proof  of  the  fact  that  the  inner  table  is  not  more  brittle  than  the 
outer  is  to  be  seen  in  certain  pathological  specimens  of  skulls  in  which  gun- 
shot wounds  have  been  produced  by  a  ball  which  penetrated  the  skull  on 
one  side,  hwt  was  arrested  on  striking  the  other  side  and  did  not  perforate 
it.  At  the  second  imi^act  the  blow  is  first  felt  by  the  internal  table,  and 
produces  slight  effect  upon  it,  while  the  splintering  of  the  outer  table  at 
that  point  is  similar  to  that  which  is  usually  seen  in  the  inteinal  table  when 


REPAIR  OF  FRACTURES   OF  THE  SKULL. 


709 


Fig.  6^6. 


Depressed  fracture  of  the  skull  produced  by  a 
hammer.    (After  Agnew.) 


a  non-penetrating  blow  has  been  received  by  the  external  table,  as  is  usually 
the  case. 

Depressed  Fractures. — When  one  or  more  of  the  fragments  project 
into  the  interior  of  the  skull  the  injury  is  known  as  a  depressed  fracture. 
(Figs.  64:5  and  646.)  The  force  which 
produces  the  fractures  continues  to  act 
after  the  bone  has  been  broken,  and 
drives  the  fragments  inward,  and  they 
are  often  impacted  so  that  it  is  not  easy 
to  elevate  them.  Depressed  fractures 
constitute  the  most  serious  of  these 
lesions,  because  of  the  probability  of 
associated  injury  to  the  brain,  and  the 
great  liability  to  infection  and  necrosis 
on  account  of  the  poor  drainage  and 
loose  fragments. 

Compound  Fractures. — Fractures 
of  the  skull  complicated  with  external 
wounds  are  more  serious  than  other  com- 
pound fractures,  because  in  addition  to 
the  danger  from  inflammation  of  the  bone 
there  is  the  possibility  of  deeper  infection.  When  the  infection  is  limited  to 
the  bone  it  results  in  limited  suppuration,  death  of  the  fragments,  separation 
of  the  periosteum,  and  consequent  necrosis.  Abscesses  form,  with  phlegmo- 
nous inflammation  of  the  scalp,  the  discharge  from  the  wound  increases  and 
becomes  serous,  the  edge.s  become  swollen  and  oedematous,  burrowing  takes 
place  in  various  directions,  and  an  acute  osteitis  of  the  skull  bones  follows. 
Not  only  is  there  danger  of  this  infection  spreading  to  the  meninges,  but 
there  is  great  likelihood  that  a  phlebitis  may  be  set  up  on  account  of  the 
intimate  relations  of  the  veins  in  the  diploe  to  the  sinuses,  and  the  infection 
may  then  extend  to  the  brain.  Meningitis  and  encephalitis  are  among  the 
most  common  results  of  these  infected  compound  fractures. 

Repair  of  Fractures. — The  repair  of  fractures  of  the  skull  is  effected 
like  that  of  fractures  of  other  bones,  except  that  a  very  small  amount  of 
callus  is  thrown  out.  The  limited  bone  reproduction  is  chiefly  efi'ected  by 
the  diploe,  the  periosteum  taking  but  little  part  in  the  formation  of  new 
bone,  and  the  dm-a  mater  even  less.  That  the  bones  of  the  skull  are  capable 
of  reproducing  bone  is  shown  by  the  manner  in  which  fragments  entirely 
isolated  from  the  periosteum  attach  themselves  to  the  surrounding  bone,  and 
by  the  fact  that  flaps  of  the  liericranium  turned  up  with  only  the  outer 
layer  of  bone-cells  will  form  new  bone  ;  but,  as  a  rule,  the  production  of 
bone  is  so  slight  that  large  openings  remain  permanently.  The  amount  of 
bone  which  may  be  lost  in  consecjuehce  of  compound  fracture  or  of  the  subse- 
quent necrosis  is  surprising,  some  individuals  having  borne  the  loss  of  one- 
half  of  the  vertex,  or  one-flfth  of  the  entire  skull,  without  serious  incon- 
venience. The  gaps  left  by  loss  of  bone  may  be  filled  by  implanting  a 
celluloid  plate  or  by  a  j)lastic  operation.  Konig  cuts  a  flap  from  the  peri- 
cranium at  the  side  of  the  opening,  shaving  off  a  thin  layer  of  bone  with 

46 


710  DIAGNOSIS   OF  FRACTITRES  OF  THE   SKULL,. 

it,  tarns  it  over  in  the  defect  witli  the  bony  side  upj)ermost,  and  covers  this 
with  a  flap  of  skin. 

Any  deformity  which  exists,  particularly  any  depression  at  the  seat  of 
the  fracture,  is  likely  to  be  permanent.  Sometimes  spiculje  of  bone  are  found 
attached  at  one  end  near  an  old  fracture  from  which  they  originated  and 
projecting  far  into  the  substance  of  the  brain  at  their  free  extremity,  with 
no  sign  of  absorption  or  spontaneous  removal.  For  these  reasons  it  is 
important  that  all  fractures  with  depression  should  be  elevated  when  first 
seen,  because  of  the  dangerous  results  which  are  liable  to  develop  later  in 
life,  such  as  brain  abscess  or  epilepsy,  due  to  displaced  fragments,  to 
adhesions  of  the  brain  to  the  dura,  or  to  other  causes  of  irritation. 

Symptoms. — When  a  severe  blow  has  been  received  on  the  head,  the 
surgeon  must  examine  every  part  with  his  fingers  to  detect  fissures  and 
depressions,  and  seek  for  signs  of  injury  to  the  base  of  the  skull,  and  for 
wounds  connected  with  the  fracture.  The  cerebral  functions  should  be  tested 
also.  The  local  signs  of  fracture  of  the  skull  are  not  so  marked  as  in  frac- 
tures of  other  bones ;  the  deformity  is  usually  slight,  unless  lai-ge  areas  of 
the  skull  are  affected  or  there  is  marked  depression.  Mobility  is  a  much 
more  constant  sign,  for  small  fragments  can  often  be  made  to  move  when  the 
bone  is  comminuted.  Crepitus  is  seldom  found.  Local  pain  and  tenderness 
are  in  some  cases  quite  definite,  and  Phelps  lays  great  stress  on  this  symptom. 
In  the  early  stages  a  hematoma  forms,  and  oedema  may  persist  during  the 
stage  of  repair.  A  simple  fissure  in  the  skull  without  depression  cannot  be 
discovered  through  the  scalp,  but  compound  fractures  are  generally  easily 
recognized.     There  may  be  symptoms  of  cerebral  or  nerve  injury. 

Diagnosis. — The  diagnosis  of  fractures  of  the  vertex  is  in  some  cases 
very  easy,  in  others  difficult,  or  even  impossible.  A  subcutaneous  vein  or 
a  sature  may  feel  like  a  fissure  without  depression.  A  narrow  fissure  in 
the  bone  may  be  difficult  to  discover,  even  when  the  surface  of  the  bone  is 
exposed  for  inspection.  It  can  sometimes  be  recognized  by  the  fact  that 
the  coagulated  blood,  which  can  be  wiped  from  small  grooves  on  the  skull 
or  from  the  sutures,  remains  fixed  in  the  crack.  The  edges  of  a  fissure  are 
even  and  not  toothed  like  the  sutures.  Fractures  with  depression  are  usu- 
ally easy  to  discover,  but  a  htematoma  of  the  scalp,  or  blood  effused  under 
the  pericranium  like  the  caput  succedaneum  of  the  new-born  child,  often 
resembles  a  depressed  fracture,  for  the  centre  of  the  tumor  is  soft  and  fluid 
while  on  the  edge  the  clot  may  be  hard,  or  new  bone  may  be  formed  in  a 
circular  ridge.  The  distinction  can  be  made  by  pressing  in  the  centre  with 
the  finger,  which  will  be  able  to  feel  bone  at  the  bottom  of  the  hollow  in  the 
clot,  but  not  in  the  depression  of  a  fracture.  A  careful  examination  of  the 
edges  will  also  assist,  for  in  cases  of  depressed  fracture  the  surface  of  the 
skull  can  generally  be  followed  up  to  the  edge  of  the  depression  without  any 
change  in  level,  whereas  in  the  case  of  a  hsematoma  the  finger  as  it  passes 
over  the  surface  of  the  skull  is  raised  at  the  edge  of  the  tumor  before  it 
sinks  into  the  hollow  in  the  centre.  A  fresh  blood-clot  can  often  be  dissi- 
pated by  massage,  so  that  the  true  relations  are  evident. 

Cephalhaematoma. — Some  cases  of  fracture  present  pulsating  tumors 
which  can  be  felt  at  the  site  of  the  fi-acture,  consisting  of  blood  or  cerebro- 


FRACTURE  OF  THE  BASE   OF  THE  SKULL.  711 

spiual  fluid,  with  an  opening  sufficiently  large  to  transmit  to  them  the  pulsa- 
tions of  the  brain  beneath.  These  flat  tumors  are  seldom  tense,  and  the 
pulsation  disappears  in  the  course  of  a  few  hours  or  a  few  days.  They  are 
known  by  the  name  of  cephalhpematoma,  or  traumatic  meningocele,  the  latter 
name  being  badly  chosen,  for  even  when  they  contain  cerebro-spiual  fluid 
there  is  no  protrusion  of  the  membranes.  Protuberances  on  the  outside  of 
the  skull,  such  as  syphilitic  nodes,  congenital  deformities,  or  perios- 
teal thickening  may  be  misleading,  but  a  careful  study  of  the  case,  with 
examination  of  the  other  side  of  the  head,  where  similar  abnormalities  will 
often  be  found,  ought  to  settle  all  doubts.  The  diagnosis  of  fractiire  of  the 
skull  in  many  cases  depends  upon  the  symptoms  caused  by  an  accompanying 
injury  of  the  brain.  In  doubtful  cases,  in  which  it  seems  important  to 
determine  the  diagnosis  at  once,  an  exploratory  incision  may  be  made, 
but  these  incisions  should  be  limited  to  those  cases  in  which  the  symptoms 
of  cerebral  injury  seem  to  demand  surgical  treatment.  Although  under 
antiseptic  precautions  these  incisions  are  not  dangerous,  the  general  rule 
that  no  fracture  should  be  converted  from  a  simple  to  a  compound  one  with- 
out some  adequate  cause  is  to  be  obser\'ed. 

Fracture  of  the  Base  of  the  Skull. — In  fractrires  of  the  base  some 
of  the  most  important  symptoms  are  the  escape  of  blood  from  the  ear,  nose, 
or  mouth,  its  appearance  under  the  conjunctiva,  or  under  the  mucous  mem- 
brane of  the  glim  or  the  pharynx,  the  escape  of  the  cerebrospinal  fluid 
from  the  same  orifices,  the  discharge  of  brain  fragments,  and  the  indications 
of  injury  to  the  trunks  of  the  nerves. 

Hemorrhage. — Hemorrhage  from  the  ear  occurs  in  one-half  of  the  frac- 
tures of  the  petrous  portion  of  the  temporal  bone.  It  may  be  slight  or  very 
copious,  but,  as  a  rule,  it  is  of  short  duration.  Examination  of  the  ear 
with  the  speculum  should  also  be  made,  for  fissures  may  be  seen  in  the 
drum  membrane  after  the  hemorrhage  has  ceased.  Sometimes  there  is  no 
rupture  of  the  membrane,  and  the  blood  escapes  from  the  middle  ear  by  the 
Eustachian  tube.  A  few  drops  may  follow  a  simple  rupture  of  the  drum, 
and  blood  may  also  collect  in  the  middle  ear  behind  an  unruptured  drum 
after  a  severe  blow  on  the  head  without  fracture  of  the  skull.  Bleeding 
from  the  nose  or  the  mouth  due  to  fracture  of  the  base  is  very  apt  to  be 
confounded  with  ordinary  eijistaxis  or  hemorrhage  from  other  injuries.  A 
fracture  of  the  cribiform  plate  of  the  ethmoid  causes  nasal  hemorrhage. 
Blood  issuing  from  the  mouth  may  have  run  down  from  the  nose,  or  may 
have  come  from  the  ear  by  way  of  the  Eustachian  tube.  When  hemorrhage 
is  found  under  the  conjunctiva,  aj>pearing  some  time  after  the  injury,  it 
indicates  some  deep  orbital  injury,  and  usually  implies  fracture  of  the  base, 
for  ecchymosis  due  to  injury  of  the  conjunctiva  itself  forms  immediately. 
Hemorrhage  into  the  lids  with  ecchymosis  is  not  so  certain  a  sign,  although 
if  it  appears  long  after  subconjunctival  hemorrhage  has  been  noted  it  is 
safe  to  conclude  that  it  has  been  caused  by  fractui'c.  In  a  small  proportion 
of  cases  so  much  blood  finds  its  way  into  the  orbit  as  to  cause  exophthal- 
mos. Ecchymosis  appearing  in  front  of  the  mastoid  process  and  spreading 
upward  and  backward  is  characteristic  of  a  fracture  of  the  posterior  fossa 
of  the  base. 


712  DIAGNOSIS   OF  FRACTURES   OF  THE  SKULL. 

Escape  of  Cerebro-Spinal  Fluid. — Cerebro-spinal  fluid  escapes  most 
frequently  from  the  ear,  and  occasioually  from  the  nose.  It  is  rarely 
detected  in  the  mouth,  although  it  may  reach  the  latter  through  the  Eusta- 
chian tube  or  from  a  fissure  opening  in  the  sphenoidal  cells.  It  would 
find  its  way  to  the  nose  from  a  fissure  through  the  ethmoidal  cells,  but  to 
reach  the  ear  it  must  escape  through  a  fracture  involving  both  the  internal 
auditory  canal  and  the  middle  ear  which  has  torn  the  dura  mater  or  the  arach- 
noid where  they  are  prolonged  into  sheaths  around  the  auditory  nerve,  and 
also  ruptured  the  drum  membrane.  It  has  been  asserted  that  cerebro-spinal 
fluid  may  flow  from  the  ear  without  a  ruptm-e  of  the  tympanum,  for  frac- 
tures of  the  roof  of  the  external  auditory  canal,  or  fractures  through  the 
middle  ear  which  detached  the  soft  parts  from  the  bone  without  rupture  and 
lacerated  the  lining  of  the  canal  more  externally,  might  allow  the  escape  of 
the  fluid.  Cerebro-spinal  fluid  is  recognized  by  the  large  amount  of  salt 
which  it  contains  and  by  its  low  percentage  of  albumin,  which  distinguishes 
it  from  blood-serum.  The  amount  lost  is  sometimes  very  great,  even  as 
much  as  one  thousand  grammes ;  as  a  rule,  however,  there  is  only  just 
enough  to  moisten  the  pillow.  It  usually  appears  when  the  hemorrhage 
from  the  ear  has  ceased,  although  it  may  not  escape  for  twenty-four  hours. 
The  flow  may  continue  for  ten  days,  but  generally  lasts  only  two  or  three. 
It  is  said  to  be  increased  by  compression  of  the  internal  jugulars,  and  by 
strong  expiratory  effort ;  and  these  facts  maj^  be  useful  in  the  diagnosis.  If 
the  tympanic  membrane  should  not  be  ruptured  the  fluid  would  probably 
find  its  way  to  the  pharynx  by  means  of  the  Eustachian  tube,  when  there 
would  be  great  diificulty  in  recognizing  it,  and  even  in  the  nose  it  resem- 
bles the  thin  discharge  from  the  Schueiderian  membrane.  The  escape  of 
cerebro-spinal  fluid  from  the  ear  is  one  of  the  commonest  and  most  reliable 
symptoms  of  fracture  of  the  base  of  the  skull.  The  fluid  is  usually  clear, 
but  may  become  serous  or  even  purulent.  It  has  been  erroneously  claimed 
by  some  that  cases  of  fracture  of  the  base  with  escape  of  cerebro-spinal  fluid 
are  always  fatal,  but  Park  has  observed  three  cases  in  which  recovery  took 
place  although  the  fluid  became  purulent. 

Fragments  of  brain-tissue  often  escape  from  the  wound  in  cases  of 
compound  fracture  of  the  skull,  and  they  have  occasionally  been  observed 
in  the  discharge  from  the  ear  and  from  the  nose.  A  microscopic  examina- 
tion of  the  fragments  would  settle  the  diagnosis  in  any  suspicious  case. 
Although  the  discharge  of  brain- fragments  indicates  that  the  laceration  of 
the  brain-tissue  has  been  tolerably  extensive,  it  is  by  no  means  incompatible 
with  life,  for  in  many  such  cases  recovery  has  taken  place. 

Injury  to  the  Nerves. — In  fractures  of  the  base  important  nerves  may 
be  divided  or  pressed  upon  and  a  limited  paralysis  produced  on  the  same 
side  as  the  injury,  and  the  exact  situation  of  the  fissure  may  thus  be  deter- 
mined. Phelps  was  able  to  recognize  a  fracture  passing  through  the  Fallo- 
pian aqueduct  from  the  presence  of  facial  paralysis.  Deafness,  blindness, 
facial  paralysis,  and  paralysis  of  the  palatine,  of  the  abducens,  or  of  the 
oculo-motor  nerves  have  all  been  observed  as  the  result  of  fracture  of  the 
base.  Heer  found  the  facial  nerve  most  frequently  affected.  Damage  to  the 
optic  nerve  behind  the  point  of  entrance  of  the  artery  causes  late  atrophy  of 


TREATMENT  OF  FBACTURES   OF  THE  SKULL.  713 

the  optic  disk,  but  in  front  of  tbat  point  it  produces  changes  as  immediate 
as  those  of  embolism.  Paralysis  of  the  facial  nerve  may  also  develop  imme- 
diately or  late  (from  two  to  eight  days  after  the  fracture,  the  latter  cases  being 
caused  by  periostitis  or  inflammation  of  the  middle  ear),  and  the  late  paral- 
ysis is  likely  to  recover  spontaneously. 

Prognosis. — The  prognosis  of  an  injury  to  the  skull  will  depend  upon 
the  accompanying  injury  to  its  contents  and  upon  the  presence  or  absence 
of  infection.  Without  brain  injury  and  without  infection  the  prognosis  is 
excellent,  even  if  the  skull  is  extensively  fractured.  If  the  brain  has  been 
injured,  the  prognosis  depends  upon  the  severity  of  that  injury.  If  infec- 
tion has  taken  place,  the  result  depends  upon  its  extent  and  intensity,  and 
the  prognosis  is  doubtful  because  the  infection  may  caiise  phlebitis,  menin- 
gitis, or  encephalitis.  These  complications  may  appear  a  long  time  after  an 
injury  which  has  apparently  healed  without  infection.  The  prognosis  of 
fracture  of  the  base  is  not  so  bad  as  is  generally  supposed,  for  many  cases 
ending  in  recovery  probably  escape  recognition.  Although  statistics  give 
nearly  seventy  per  cent,  mortality  for  this  injury,  Konig  saw  eight  recov- 
eries in  ten  cases,  and  other  surgeons  report  equally  good  results.  The 
recovery,  however,  may  not  be  complete,  and  blindness,  deafness,  or  other 
permanent  nerve  injury  may  result.  The  mortality  of  fractures  confined  to 
the  ethmoid  or  orbital  plates  is  only  about  one  in  seven. 

Treatment. — The  treatment  of  fractures  of  the  skull  depends  chiefly 
upon  two  considerations, — first,  whether  the  contents  of  the  skull  have  been 
injured,  and  secondly,  whether  the  fracture  is  simple  or  compound. 

Simple  Fracture. — The  treatment  of  a  simple  fracture  of  the  skull  will 
vary  according  as  it  is  a  fissure  or  a  depressed  fracture.  A  simple  fissured 
fracture  without  brain  symptoms  requires  no  treatment,  except  to  keep  the 
patient  quiet  with  an  ice-bag  to  the  head.  A  depressed  fracture  with  symp- 
toms of  injury  of  the  brain  demands  immediate  operation.  Some  assert  the 
advisability  of  trephining  in  every  case  of  fracture  of  the  skull,  but  we 
should  always  bear  in  mind  that  the  resulting  gap  in  the  skull  may  make  a 
scar  which  will  be  as  injurious  as  the  lesion  we  seek  to  remedy.  On  the 
other  hand,  the  old  rule  not  to  operate  unless  symptoms  are  present,  even 
when  there  is  depression,  is  incorrect,  because  we  expose  the  patient  to 
serious  danger  of  subsequent  epilepsy  by  leaving  depressed  bone  in  place. 
In  cases  where  there  are  no  immediate  symptoms  due  to  depression,  the  oijer- 
ation  may  be  postponed  until  the  patient  has  recovered  from  the  shock  of 
the  injury  ;  and  it  should  be  remembered  that  the  depression  may  disappear 
spontaneously  meanwhile,  especially  in  children. 

Compound  fractures  should  be  most  carefully  examined,  and  if  there 
is  no  depression  any  loose  fragments  should  be  removed  and  the  wound 
cleansed  and  treated  like  an  open  wound  elsewhere.  If  the  wound  is  thor- 
oughly aseptic  it  may  be  sutured,  but  if  there  is  any  possibility  of  infection 
it  should  be  left  open  and  packed  with  gauze.  When  depressed  bone  is 
found  in  a  compound  fracture  the  fragments  should  be  elevated  with 
aseptic  precautions,  as  described  on  page  737.  In  many  of  these  cases  an 
anesthetic  is  not  necessary,  the  coma  being  so  deep  that  the  patient  is 
insensible  to  pain. 


714  GUNSHOT  FRACTURES  OF  THE  SKULL. 

Punctured  Fractures. — Fractures  caused  by  small  or  pointed  objects 
striking  the  skull  -with  great  violence,  sucli  as  a  pointed  hammer-head  or 
the  end  of  a  heavy  stick,  should  always  be  explored  by  trephining,  since  it 
has  been  shown  that  punctured  fractures  are  almost  invariably  followed  by 
much  more  damage  to  the  internal  table  and  to  the  brain  than  would  be 
supposed  from  the  slight  injury  found  on  the  outside  of  the  skull.  All 
foreign  bodies  must  be  carefully  removed,  the  edges  of  the  bone  being  chis- 
elled away  if  necessary  to  release  them. 

Fractures  of  the  Base. — The  treatment  of  fractures  of  the  base  is  symp- 
tomatic, with  the  exception  of  maintaining  the  ear  and  nose  in  as  aseptic  a 
condition  as  possible,  for  infection  from  these  cavities  is  one  of  the  prin- 
cipal dangers  of  such  fractures.  The  ear  should  be  thoroughly  wiped  out 
with  moist  cotton,  and  the  parts  examined  with  the  speculum.  No  irriga- 
tion should  be  employed,  because  of  the  possibility  of  carrying  infection 
into  the  fissures.  The  canal  should  be  carefully  stuffed  with  iodoform  gauze 
or  sterilized  cotton.  The  nose  should  be  cleansed  by  the  spray  and  with 
moist  cotton,  and  irrigation  avoided  for  the  same  reason.  Punctured  frac- 
tures of  the  orbit  must  be  thoroughly  explored,  the  soft-  parts  being  incised 
and  the  orbital  ridge  trephined  if  necessary  to  gain  access  to  the  base  of  the 
brain,  and  free  drainage  provided. 

In  fractm-e  of  the  base  involving  any  of  the  air-containing  cavities,  such 
as  the  nose  or  the  frontal  sinuses,  the  occurrence  of  emphysema  or  j)neuma- 
tocele  should  be  avoided  by  forbidding  strong  expiratory  efforts  on  the  part 
of  the  patient,  especially  sneezing,  and  by  applying  a  firm  bandage  to  the 
head,  with  a  pad  over  the  fissure  if  it  is  accessible. 

Gunshot  Fractures  of  the  Skull. — Mechanics. — We  have  already 
seen  that  gunshot  wounds  of  entrance  and  exit  show  in  the  skull  the  same 
peculiarity  as  in  the  soft  parts, — that  is,  the  wound  is  smaller  at  the  point 
of  entrance  than  at  the  point  of  exit ;  and  this  is  true  whether  the  ball  enters 
the  skull  and  fractures  the  external  table  first  or  leaves  it  and  penetrates  the 
same  table  last.  Bullets  which  strike  the  skull  at  a  tangent  may  produce 
very  serious  internal  elfects  without  inflicting  much  external  damage,  for 
there  may  be  merely  a  groove  on  the  surface  of  the  bone,  and  yet  the 
internal  table  may  be  deeply  depressed,  the  dura  separated,  and  the  brain 
severely  contused.  The  effect  produced  by  a  ball  depends  largely  upon  its 
velocity.  With  the  older  fire-arms  a  velocity  of  two  hundred  metres  per 
second  was  obtained,  and  this  was  sufScient  to  produce  sharply  cut  open- 
ings in  the  skull  without  any  fissuring.  With  the  modern  weapons,  how- 
ever, in  which  a  velocity  of  from  four  hundred  to  six  hundred  metres  per 
second  is  attained,  very  peculiar  effects  are  produced  at  short  range,  resem- 
bling those  which  would  follow  an  explosion  taking  place  within  the  skull, 
the  fissures  extending  in  all  directions  from  the  points  of  entrance  and  exit, 
and  the  brain-matter  being  forced  out  of  these  openings. 

An  empty  can  or  an  empty  fresh  skull  struck  by  one  of  these  bullets  is 
simply  perforated  without  further  damage.  But  if  the  bullet  is  fired  into  a 
sealed  metal  can  completely  filled  with  fluid,  as  the  fluid  is  incompressible 
and  the  ball  enters  so  suddenly  as  to  give  no  opportunity  for  the  can  to  alter 
its  shape  or  increase  its  capacity  in  any  way,  the  sudden  addition  of  the 


•  GUNSHOT  FEACTURES  OF  THE  SKULL.  715 

bullet  to  the  contents  of  the  can  and  the  violent  waves  of  force  transmitted 
by  it  to  the  fluid  have  the  effect  of  au  explosive  discharged  within  tlie  can, 
and  blow  it  to  pieces.  The  contents  of  the  skull  in  life  are  incompressible 
and  have  the  physical  chaiacteristics  of  a  fluid,  and  these  bullets  produce 
upon  it  a  similar  explosive  action.  Explosi^'e  effects  have  also  been  observed 
in  such  organs  as  the  liver,  in  which  a  mass  of  soft  tissue  is  enclosed  in  a 
capsule.  That  the  explosive  effect  depends  entirely  ujjon  the  velocity  of 
the  missile  is  proved  by  the  fact  that  it  does  not  occur  unless  a  certain 
velocity  is  attained.  It  should  be  noted  that  complete  closure  of  the  can  or 
the  skull  in  this  experiment  is  not  necessary,  the  same  effects  being  pro- 
duced when  the  bullet  is  fired  into  a  skull  filled  with  water  and  standing 
with  the  open  foramen  magnum  uppermost. 

Clinical  Effects. — The  most  serious  gunshot  wounds  are  those  of  the  ear, 
the  orbit,  or  the  mouth,  especially  when  inflicted  at  short  range  with  suicidal 
intent,  as  is  frequently  seen  in  civil  practice.  Wounds  of  the  orbit  are  less 
dangerous  when  the  roof  is  injured  than  when  the  apex  is  involved,  the 
mortality  in  the  latter  case  being  eighty  per  cent.  (Berlin.)  Wounds  of 
the  ear  may  cause  injury  to  any  of  the  imijortant  structures  connected  with 
or  situated  near  that  organ,  deafness,  facial  paralysis,  or  interference  with 
the  motions  of  the  jaw  being  common.  Loss  of  equilibrium  may  result  from 
injury  to  the  semicircular  canals.  Severe  hemorrhage  is  common  in  such 
wounds,  on  account  of  the  proximity  of  the  great  vessels.  The  effects  of 
shots  in  the  mouth  will  vary  with  the  position  of  the  head,  according  as  the 
latter  is  thrown  far  back  and  the  barrel  of  the  weapon  directed  against  the 
roof  of  the  mouth,  or  as  the  barrel  points  directly  backward  while  the  head 
is  held  horizontally.  Wounds  of  the  frontal  and  other  anterior  sinuses  are 
likely  to  occur  in  the  first  position,  and  will  be  indicated  by  the  presence  of 
ecchymosis  of  the  eyelids  or  of  emphysema,  while  in  the  other  position  the 
injuries  will  be  similar  to  those  of  severe  fractures  of  the  base. 

Treatment. — The  treatment  of  gunshot  fractures  is  the  same  as  that  of 
other  compound  fractures,  their  only  peculiarities  being  their  extent  and 
the  frequent  occurrence  of  foreign  bodies  in  them.  Foreign  bodies  should 
be  removed  if  easily  r-eached,  but  not  otherwise.  The  bullet  may  traverse 
the  brain  and  rebound  from  the  other  side  of  the  skull  at  any  angle,  or  if  it 
be  arrested  in  the  brain  it  may  settle  down  by  gravity,  quite  out  of  line  with 
the  canal  of  entrance,  and  it  may  be  impossible  to  find  it  even  at  autopsy. 
A  long  search  would  be  necessary  in  such  cases  if  an  attempt  were  made  to 
remove  it  by  an  operation,  and  might  result  in  more  damage  than  would  be 
caused  by  the  foreign  body.  The  latter  should,  however,  be  removed,  if  not 
too  difficult  of  access,  for  Wharton  has  shown  in  a  large  series  of  cases  that 
the  mortality  was  nearly  twice  as  great  when  the  bullet  w;is  left  in  the 
skull,  even  in  pre-antiseptic  times.  In  searching  for  bullets  a  light  alumi- 
num probe  (Fluhrer)  should  be  emj)loyed.  If  the  i^robe  is  passed  in  nearly 
to  the  oijposite  side  of  the  head,  the  nearest  spot  to  the  end  within  the  skull 
can  be  determined  by  securing  several  threads  to  the  projecting  end  and 
bringing  them  around  the  skull  on  different  sides,  like  the  meridian  lines  of 
a  globe.  If  all  of  these  are  kept  exactly  in  the  same  plane  as  the  probe, 
their  point  of  junction  on  the  opposite  side  of  the  skull  will  indicate  the 


716  CONCUSSION  OF  THE  BKAIN. 

spot  nearest  to  the  inner  end  of  the  instrument.  (Bryant.)  A  ball  or  other 
metallic  body  is  easily  found  by  Girdner'  s  telephonic  probe.  (See  page  183. ) 
The  Eontgen  rays  will  also  reveal  the  presence  of  bullets  and  of  certain 
foreign  bodies  within  the  skull.  The  greater  ease  with  which  they  can  be 
detected  does  not  alter  the  old  rule  that  it  is  better  to  leave  harmless  bullets 
in  the  tissues  than  to  undertake  formidable  operations  for  their  removal. 

THE    BEAIjST    and    MEMBRANES. 

Injuries  of  the  Brain  and  Membranes.— Concussion  and  Com- 
pression.— The  two  conditions  most  frequently  met  with  and  most  important 
in  cases  of  injuries  of  the  brain  are  concussion  and  comx>ression.  By  con- 
cussion is  meant  a  set  of  symptoms  which  are  due  to  the  severe  physical 
commotion  of  the  brain-tissues  at  the  time  of  injiiry,  although  the  shock 
may  not  be  severe  enough  to  produce  any  anatomical  lesions.  By  compres- 
sion, on  the  other  hand,  is  meant  a  set  of  symptoms  which  are  due  to  the 
pressure  on  the  brain  exerted  by  depressed  bone  or  various  other  causes. 

Concussion. — It  is  impossible  to  distinguish  clinically  between  instances 
of  pure  concussion  and  those  cases  in  which  similar  symptoms  are  due  to 
very  slight  lesions  of  the  brain,  such  as  contusions,  lacerations,  or  small 
capillary  hemorrhages,  and  all  these  conditions  must  therefore  be  studied 
together.  There  can  be  no  question  that  these  slight  injui-ies  to  the  brain 
can  be  produced  by  light  blows  upon  the  skull,  for  thin  microscopic  cover- 
glasses  inserted  in  the  brain  of  a  cadaver  can  be  broken  by  blows  upon  the 
skull  which  do  not  break  the  latter.  It  has  been  found  that  the  glass  is 
broken  only  when  it  lies  near  the  inner  surface  of  the  cranium,  and  that  the 
force  appears  to  operate  most  strongly  in  the  line  of  application  of  the  blow, 
more  damage  being  produced  to  the  pieces  of  glass  in  that  line  than  else- 
where (Deucher,  Kocher).  These  experiments  show  an  analogy  with  the 
laws  governing  fractures  of  the  skull,  and  prove  that  the  principal  injury  to 
the  brain  is  near  the  skull  in  cases  of  concussion,  a  conclusion  which  is  in 
harmony  with  the  clinical  fact  that  unconsciousness  is  the  chief  sym]3tom 
in  concussion,  indicating  a  disturbance  of  the  functions  of  the  cortex  as  the 
main  cause  of  that  condition. 

According  to  Dui-et  and  Miles,  concussion  is  the  result  of  the  mechanical 
driving  of  the  cerebro-spinal  fluid  into  the  fourth  ventricle  from  the  larger 
cranial  cavities  by  the  force  of  the  blow  upon  the  elastic  skull,  and  of  the 
pressure  of  the  fluid  in  that  situation  on  the  important  centres  of  respiration 
and  circulation.  Polls,  who  succeeded  in  producing  fatal  concussion  in 
animals  by  a  single  blow  without  any  visible  lesions,  accepts  Duret's  con- 
clusions in  part.  But  he  considers  the  effect  of  such  a  blow  to  be  double, 
as  it  acts  upon  the  blood-vessels  as  well  as  upon  the  nerve-cells,  causing 
cerebral  anaemia  at  the  same  time  that  the  shock  suspends  or  weakens  the 
functional  activity  of  the  cells. 

According  to  Scagliosi,  a  blow  on  the  head  may  suspend  the  function  of 
the  nerve-cells,  cause  vasomotor  paralysis,  and  produce  more  or  less  per- 
manent alterations  in  the  ganglionic  cells  which  can  be  demonstrated  by  the 
microscope.  Death  may  ensue  without  any  more  obvious  lesions.  Slightly 
greater  force  produces  the  minute  contusions  and  lacerations  often  found  in 


SYMPTOMS   OF  CONCUSSION   OF  THE  BRAIN.  717 

fatal  cases  of  concussion  of  the  brain.  The  very  temporary  effect  of  slight 
concussion  shows  that  the  disturbance  is  merely  functional  in  such  cases, 
while  the  cases  of  insanity,  epilepsy,  and  other  neurotic  conditions  following 
concussion  are  explained  by  the  degenerative  changes  of  the  ganglionic  cells 
just  mentioned. 

Symptoms. — The  grade  of  the  symptoms  depends  upon  the  extent  of 
the  injury.  In  any  injury  to  the  brain,  when  the  nerve-centres  are  slightly 
damaged,  we  find  symptoms  of  irritation  ;  and  when  the  injury  is  so  severe 
as  to  suspend  the  function  of  the  centres,  or  destroy  them  entirely,  paralysis 
sets  in.  The  various  centres  differ  greatly  in  their  susceptibility  to  stimulus, 
so  that  a  lesion  which  causes  merely  abnormal  excitability  in  one  will 
exhaust  the  excitability  of  another  and  paralyze  it.  Concussion  affects  all 
the  intracranial  nerve-centres,  but  they  respond  differently  according  to 
their  susceptibility.  Consciousness  is  lost  even  in  slight  concussion  because 
the  highest  centres  are  most  easily  paralyzed.  The  centres  of  respiration 
are  stimulated  in  slight  concussion,  as  shown  by  the  irregular  breathing, 
but  may  be  paralyzed  when  the  shock  is  severe.  The  cardiac  centres  are 
seldom  ijaralyzed,  but  show  their  irritation  by  a  slow  pulse.  A  rapid  pulse 
indicates  their  exhaustion  and  approaching  death.  The  circulatory  and 
other  symptoms  of  concussion  can  also  be  produced  by  sudden  complete 
cerebral  anaemia,  such  as  is  brought  about  experimentally  in  animals,  in 
which  the  pneumogastric  nerves  are  dissected  out  and  the  head  then  sud- 
denly cut  off  without  injury  to  the  nerves.  But  in  concussion  there  are 
other  factors  than  mere  antemia.  While  the  pulse  is  slow  the  general 
blood-pressure  rises,  but  it  falls  when  the  rapid  heart  action  begins. 

Clinically  three  grades  of  concussion  can  be  recognized.  In  the  slightest 
form  the  patient  is  weak,  drowsy,  relaxed,  but  iDulse  and  respiration  are  not 
affected.  In  moderately  severe  cases  the  patient  is  unconscious,  with 
irregular  respiration  and  a  slow  i^ulse.  Vomiting  is  generally  present,  but 
only  of  the  contents  of  the  stomach,  and  usually  ceases  when  that  organ  has 
been  emptied.  There  is  no  true  paralysis,  even  of  sensation,  but  the 
bladder  and  rectum  may  be  evacuated  unconsciously  on  account  of  the 
relaxation  of  the  sphincters.  The  pupils  may  be  contracted  or  dilated,  or 
unequal,  but  they  react  to  light.  In  severe  cases  the  vitality  of  the  patient 
seems  suspended,  and  it  may  be  impossible  to  arouse  him  ;  the  respiration 
is  irregular,  superficial,  sighing,  and  may  be  of  the  Cheyne-Stokes  variety ; 
the  pulse  is  feeble  and  rapid  ;  copious  perspiration  appears  ;  vomiting  may 
be  persistent,  and  convulsions  may  occur.  The  temperature  in  these  cases 
is  subnormal,  becoming  normal  on  recovery,  and  occasionally  when  recovery 
takes  place  there  is  a  reaction  to  101°  F.  (38°  C),  or  even  103°  F.  (39.5°  C). 
This  stage  of  reaction  may  be  marked  by  great  irritability,  delirium,  or 
mental  disturbance  which  may  last  for  days  or  weeks,  or  even  permanently. 
In  some  cases  there  is  nervous  excitement  from  the  beginning,  the  iDatient 
crying  out  and  throwing  the  body  and  limbs  about,  although  he  appears 
unconscious  of  his  surroundings.  He  may  lie  quietly  upon  his  side  with  his 
knees  drawn  up,  and  may  resist  with  a  show  of  anger  any  attemj)t  to  change 
his  position.  This  cerebral  irritability  (Erichsen)  is  most  frequently  found 
with  slight  laceration  of  the  brain. 


718  COMPRESSION   OF  THE  BRAIN. 

The  diagnosis  of  concussion  from  alcoholism  and  apoplexj'  is  imjjortant. 
In  apoplexy  the  temx^erature  is  subnormal,  but  it  maj^  rise  to  the  normal  or 
higher  if  the  issue  threatens  to  be  fatal,  and  there  will  be  symj^toms  of  com- 
pression. In  alcoholism  the  prostration  will  be  less,  and  the  pulse  will  be 
more  rapid.  The  prognosis  is  genoi-ally  good  unless  grave  lesions  exist 
which  are  masked  hj  the  condition  of  concussion,  although  some  cases  end 
fatally.  The  symptoms  seldom  last  long  and  usually  subside  by  degrees,  the 
patient  falling  into  a  gentle  sleep  and  awaking  quite  restored,  but  often 
feeble  and  tremulous.  Vertigo,  headache,  and  marked  loss  of  memory  may 
persist  for  some  time. 

Treatment. — The  treatment  consists  of  rest,  the  application  of  an  ice- 
cap to  the  head,  and  hot  bottles  to  the  feet.  In  eA^eiy  case  of  deep  uncon- 
sciousness caused  by  concussion  it  may  be  considered  certain  that  some 
serious  lesion  has  been  j)roduced,  and  we  must  avoid  active  treatment  which 
might  aggravate  it.  The  feeble  pulse  demands  the  recumbent  position,  but 
the  head  should  be  elevated  as  soon  as  the  improvement  in  the  pulse  allows, 
in  order  to  favor  the  arrest  of  any  hemorrhage  which  may  be  going  on. 
Artificial  respiration  should  be  employed  if  the  breathing  is  very  feeble  or 
irregular.  (Polls.)  If  the  vomiting  j)revents  feeding  by  the  mouth,  nutri- 
ment must  be  administered  by  the  rectum.  The  too  free  use  of  stimulants 
is  to  be  avoided,  on  account  of  the  liability  of  setting  up  too  much  excite- 
ment in  the  stage  of  reaction,  and  ammonia  or  ether  is  i^referable  to  alcohol 
for  the  same  reason,  as  their  effect  is  more  evanescent.  Morphine  or  the 
bromides  may  be  used  with  discretion  for  restlessness,  and  calomel  with 
morphine  or  Dover's  powder  in  small  doses  will  act  as  sedatives.  A  patient 
who  has  suffei-ed  from  a  severe  concussion  of  the  brain  should  be  kept  in 
bed  on  light  diet  and  free  from  all  excitement  for  ten  daj^s  or  a  fortnight. 

Compression. — Pathology. — When  the  internal  capacity  of  the  skull 
is  diminished  in  any  way,  as  by  a  depressed  fracture,  a  hemorrhage,  the 
entrance  of  a  foreign  bodj"^,  the  accumulation  of  pus,  or  the  growth  of  a 
tumor,  a  condition  may  develop  which  is  known  as  compression  of  the  brain. 
The  brain-tissue  is  incompressible,  and  the  only  variable  contents  of  the 
skull  are  the  cerebrospinal  fluid  and  the  blood  contained  in  the  blood- 
vessels. The  cerebrospinal  fluid  surrounds  the  brain,  and  a  large  quantity 
of  it  is  also  contained  iu  the  ventricles.  The  first  effect  of  increased  press- 
ure within  the  skull  is  to  drive  out  a  part  of  the  cerebro-spinal  fluid,  some 
of  which  finds  a  ready  escape  by  way  of  the  foramen  magnum,  passing  down 
along  the  sjDinal  cord.  The  membranes  between  the  vertebral  arches  are 
somewhat  distensible,  and  this  escape,  therefore,  affords  considerable  relief 
to  the  pressure  within  the  skull.  The  cerebro-spiual  cavities,  such  as  the 
arachnoid  and  the  ventricles,  all  communicate  with  the  lymphatic  system, 
and  whenever  the  pressure  becomes  extreme,  absorption  of  the  fluid  is 
increased.  It  has  been  shown  that  the  blood  capillaries  take  uj)  the  cerebro- 
spinal fluid  with  even  greater  rajjidity  than  the  lymphatics.  The  quantity 
of  cerebro-spinal  fluid  within  the  skull  is  thus  reduced,  some  additional 
space  is  gained,  and  the  compression  is  equalized.  This  relief  is  evidently 
limited,  and  a  certain  amou.nt  of  the  fluid  must  remain  in  the  ventricles, 
because  the  increasing  jDressure  forces  the  brain  downward  against  the  base 


COMPEESSION  OF  THE  BRAIN.  719 

of  the  skull  and  closes  the  passages  leading  from  them  ;  even  in  the  severest 
cases  of  compression  an  autopsy  always  reveals  some  fluid  remaining  in  these 
cavities.  The  next  effect  of  the  pressure  is  to  lessen  the  amount  of  blood  in 
the  brain  by  compressing  the  veins  and  even  the  sinuses,  but  this  at  once 
increases  the  capillary  blood-pressure  because  of  the  increased  resistance 
caused  by  the  compressed  veins.  This  resistance  may  increase  without 
marked  changes  until  it  equals  the  normal  arterial  blood-pressure,  but  the 
moment  it  reaches  this  point  no  blood  can  enter  the  skull ;  the  centres  of 
circulation  are  then  stimulated  by  the  stagnation  of  the  blood,  the  heart- 
beat becomes  more  forcible,  the  pulse  growing  very  slow  but  strong,  and  the 
circulation  in  the  brain  becomes  restored  in  spite  of  the  increased  resistance, 
and  therefore  a  certain  amount  of  blood  must  always  remain  in  the  cerebral 
vessels.  It  has  been  show^n  that  the  arterial  blood-pressure  in  the  carotids 
may  be  nearly  doubled  in  such  cases.  Up  to  the  point  of  inci-easing  the 
normal  arterial  blood-pressure,  then,  the  space  occuiiied  by  the  compressing 
body  may  be  equalized  by  the  less  amount  of  blood  contained  in  the  blood- 
vessels. But  this  compensation  is  also  limited  in  amount,  and  if  the  pressure 
is  further  increased  it  acts  upon  the  tissue  of  the  brain.  As  the  brain  is  a 
semifluid  body,  the  pressure  is  diffused  through  the  whole  mass  with  prac- 
tical equality,  and  the  effect  xii'oduced  is  general  compression  of  the  brain, 
for  the  pressure  does  not  act  upon  any  particular  function  or  local  centre. 
But  if  the  comijressing  object  be  of  limited  area  and  situated  over  some  one 
centre,  one  of  the  motor  centres  in  the  cortex  for  instance,  as  the  brain  is 
not  entirely  fluid  and  does  not  yield  j)erfectly  before  the  compressing  body, 
the  part  directly  uuder  the  latter  will  especially  feel  the  pressure,  and  there- 
fore local  symptoms  of  paralysis  or  irritation  will  be  produced. 

GhoJced  Disli. — A  double  sheath  extends  downward  over  the  optic  nerve 
as  it  passes  through  the  optic  foramen,  the  outer  sheath  being  formed  from 
the  dura  mater  and  the  inner  from  the  arachnoid,  a  free  space  existing 
between  the  two  sheaths,  and  also  between  the  inner  sheath  and  the  nerve. 
The  A'essels  pass  through  the  centre  of  the  nerve  to  the  retina.  When  the 
IDressure  of  the  cerebrospinal  fluid  is  increased  it  may  escape  along  the  optic 
nerve  in  the  space  between  the  arachnoid  and  the  dura,  or  in  that  under  the 
arachnoid  ;  or  if  there  is  an  efi'usion  of  blood  into  the  subdural  or  the  sub- 
arachnoid spaces  it  maj^  also  find  its  way  beneath  the  sheath  and  the  nerve 
through  the  optic  foramen.  In  either  case  the  fluid  or  blood  compresses  the 
nerve  where  it  is  confined  by  the  edges  of  the  bone  and  interferes  with  the 
circulation,  xiarticularly  in  the  vein,  causing  a  venous  congestion,  followed 
by  oedema  of  the  retina.  At  the  same  time,  however,  the  artery  is  com- 
pressed, and  arterial  anaemia  is  to  be  observed  in  the  retina.  These  changes 
are  known  by  the  name  of  choked  disk,  on  account  of  the  swollen  condition  of 
the  optic  disk.  (Fig.  647.)  They  finally  result  in  neuritis,  atrophy  of  the 
nerve,  and  complete  loss  of  sight.  The  old  theory  that  interference  with  the 
venous  outflow  from  the  skull  may  directly  cause  venous  congestion  in  the 
optic  nerve  in  spite  of  the  free  venous  anastomosis  has  been  revived  recently. 

Symptoms. — The  symptoms  of  compression  of  the  brain  vary  with  the 
intensity  of  the  pressure  and  the  area  of  the  compressing  body.  Before  the 
pressure  is  severe  enough  to  cause  paralysis  it  irritates  the  centre  and  causes 


720 


COMPEESSION   OF  THE  BRAIN. 


epileptic  convulsions  in  the  muscles  connected  with  it.  If  the  compressing 
body  be  of  small  area,  the  point  of  a  depressed  fracture,  a  small  clot,  or  a 
small  tumor,  the  size  of  which  is  not  sufficient  to  diminish  seriously  the 
capacity  of  the  skull,  the  symptoms  may  be  limited  to  that  part  of  the  brain 
upon  which  the  tumor  or  fractiu'e  presses.     If  the  point  of  pressru-e  be  over 

Fig.  647. 


A,  normal  retina ;  B,  retina  in  choked  disk.    (Bramwell.) 


one  of  the  motor  centres,  a  limited  paralysis  of  one  limb  or  of  the  face  may 
be  produced  without  other  symptoms  of  cerebral  compression  ;  but  even  when 
the  pressure  affects  the  most  limited  area  there  is  apt  to  be  a  little  mental 
dulness  and  some  choked  disk.  When  the  pressure  is  general  over  the 
entire  brain,  the  symptoms  vary  according  to  its  severity  and  also  according 
to  the  rajjidity  of  its  production,  very  serious  symptoms  being  produced  by 
pressure  suddenly  applied,  while  the  brain  appears  to  grow  accustomed  to 
quite  severe  pressure  if  apijlied  slowly.  In  cases  in  which  the  compression 
is  suddenly  applied,  the  symptoms  begin  with  a  stage  of  irritation,  shown  by 
restlessness,  insomnia,  delirium,  or,  rarely,  convulsions.  Headache  gradu- 
ally develops,  and  the  pulse  may  be  hard  and  slow,  indicating  the  irritation 
of  the  centres  of  circulation.  In  the  second  or  paralytic  stage  the  delirium 
gives  way  to  drowsiness,  the  pulse  is  very  slow,  and  may  even  be  reduced  to 
forty  beats  in  the  minute,  but  is  hard  and  full,  the  face  is  iiushed,  and  the 
respiration  slow  and  stertorous.  The  patient  can  still  be  roused,  and  will 
answer  questions,  although  slowly  and  after  a  considerable  interval,  and  he 
will  be  apt  to  fall  asleep  in  the  middle  of  a  word  while  talking.  If  the  chief 
point  of  pressure  is-  well  forward  over  the  frontal  region,  there  may  be 
diminished  mental  power  and  loss  of  memory.  The  pupils  are  apt  to  be 
sluggish,  in  the  first  stage  contracted,  later  dilated  oh  one  or  both  sides,  but 
especially  on  the  side  where  the  pressure  is  exerted.  Local  convulsions, 
paralysis,  or  even  hemiplegia  are  observed,  and  sometimes  the  extent  of  the 
lesion  may  be  determined  by  the  situation  of  the  paralysis  if  it  be  strictly 
localized.  In  uncomplicated  cases  the  temperature  is  normal.  The  stupor 
gradually  develops  into  coma,  and  finally  the  stage  of  dissolution  appears,  in 
which  the  slow,  full  pulse  becomes  rapid  and  small,  the  respiration  grows 
quicker  and  shallower,  and  the  flushed  face  becomes  pale.  The  coma  may 
be  so  deep  that  operations  can  be  performed  without  ansesthesia,  with  no 
evidence  of  sensation  on  the  part  of  the  patient.     The  respiration  usually 


WOUNDS   OF  THE   BRAIN.  721 

ceases  before  the  heart,  and  the  unconsciousness  continues  up  to  the  last 
moment,  gradually  increasing. 

Diagnosis. — Compression  of  the  brain  may  exist  without  the  character- 
istic symptoms  of  the  pulse  and  respiration,  and,  as  Kocher  puts  it,  the 
surgeon  who  delays  action  until  the  full  development  of  the  typical  pulse 
and  respiration  will  often  be  too  late  to  save  his  patient.  The  diagnosis 
must  frequently  be  made  simj)ly  from  the  fact  of  unconsciousness  in  connec- 
tion with  the  history  and  the  method  of  its  development.  In  concussion  the 
unconsciousness  appears  at  once  ;  it  tends  to  lessen  with  the  lapse  of  time, 
and  it  is  not  quite  so  deep  as  in  compression.  In  compression  the  uncon- 
sciousness may  not  appear  for  a  considerable  interval  after  the  accident,  and 
it  usually  has  a  tendency  to  grow  worse  rather  than  better.  The  siargeon 
should  consider  not  only  the  condition  in  which  the  patient  lies  at  the  time, 
but  the  exact  mode  of  development  of  that  condition. 

Prognosis. — If  not  relieved  by  operation,  the  symptoms  of  compression 
usually  grow  worse  and  terminate  fatally.  The  pressure  may  be  relieved 
spontaneously,  however,  or  the  brain  may  grow  accustomed  to  it  and  a  slow 
recovery  may  follow.  The  symptoms  may  also  remain  stationary,  being 
finally  relieved  by  oi)eration.  The  prognosis  is  good  if  the  cause  is  capable 
of  removal  and  is  removed  early,  and  it  is  especially  good  in  cases  of 
depressed  fracture  if  there  is  no  other  lesion  of  the  brain. 

Treatment. — The  only  possible  treatment  is  the  mechanical  removal  of 
the  cause  of  compression  by  an  operation.  The  operation  should  be  done  in 
the  first  stages,  if  possible,  when  the  only  symptoms  are  those  of  irritation, 
such  as  restlessness  and  local  twitchings  of  muscles,  and  before  the  retinal 
changes  have  gone  beyond  venous  congestion.  If  the  pressure  is  allowed  to 
continue  longer,  the  brain  is  liable  to  suffer  from  atrophy,  degeneration  of 
the  nerve-cells,  or  complete  softening,  and  damage  will  be  caused  which 
cannot  be  repaired. 

Wounds  and  Contusion  of  the  Brain. — In  considering  the  effect  of 
incised  wounds  of  the  braiu,  the  direction  of  the  cut  is  of  the  greatest 
importance.  The  cortex  consists  of  a  mass  of  cells  with  pi'olongations 
which  extend  directly  downward  into  the  centrum  ovale  of  the  brain  to  con- 
nect with  their  proper  nerves.  Incised  wounds  of  the  cortex,  therefore,  so 
long  as  they  are  directed  vertically  to  the  surface,  even  if  they  extend  deeply 
into  the  centrum  ovale,  cause  little  injury,  merely  destroying  a  few  fibres  or 
cells.  Incised  wounds,  however,  which  pa.ss  through  the  cortex  jjarallel  or 
nearly  parallel  with  the  external  surface,  entirely  cut  off  the  connection 
between  the  cortical  parts  and  the  fibres  of  the  centrum  ovale.  Wounds 
through  the  centrum  ovale  in  this  direction  would  also  divide  a  very  large 
number  of  fibres,  and  so  throw  out  of  action  an  equally  large  part  of  the 
cortex.  Considerable  loss  of  substance  may  occur  in  the  brain  as  the 
result  of  injury  or  operation,  and,  if  no  important  centres  exist  in  the  region 
involved,  the  effect  is  not  serious,  as  is  shown  by  the  well-known  case  in 
which  a  crowbar  was  driven  endwise  entirely  through  the  head  and  the 
patient  recovered  with  but  slight  loss  of  his  faculties. 

Contusion. — The  anatomical  changes  produced  in  the  brain  by  con- 
tusion consist  of  small  capillary  hemorrhages,  and  the  brain  looks  red  and 


722  PROGNOSIS  AND  TREATMENT  OF  BEAIN  INJURIES. 

cedematous  and  feels  pulijy  and  softened.  If  infection  from  without  takes 
place,  an  abscess  is  formed.  It  is  possible  also  for  bacteria  carried  by  the 
circulating  blood  to  infect  the  injured  tissues  and  produce  an  abscess,  but 
this  is  a  very  rare  occurrence.  Contusion  may  be  the  direct  effect  of  the 
blow,  which  may  drive  the  skull  inward  upon  the  brain,  and  a  fatal  injury  may 
follow  such  a  blow  even  without  fracture,  owing  to  the  elasticity  of  the  bone. 
Contusion  has  been  seen  as  the  result  of  contre-coup,  and  it  is  supposed  by 
some  that  a  severe  blow  might  drive  the  soft  brain  from  one  side  of  the  skull 
to  the  other,  so  as  to  cause  even  greater  injury  to  it  there  than  upon  the  side 
struck  by  the  blow.  Others,  however,  prefer  the  explanation  that  the  distal 
injury  occurs  because  it  is  in  the  line  of  the  direction  of  the  force,  as  in  the 
experiments  with  glass  implanted  in  the  brain  as  described  above.  Severe 
contusions  may  destroy  large  portions  of  the  brain  and  result  in  paralysis 
or  loss  of  mental  power.  Cheyne-Stokes  respiration  is  a  common  symptom 
of  severe  contusion,  and  is  occasionally  associated  with  albuminuria  and 
glycosuria  from  injury  to  the  fourth  ventricle.  If  hemorrhage  occurs  it  is 
apt  to  cause  signs  of  compression,  which  are  absent  in  simjjle  contusion ; 
but  contusion  without  hemorrhage  is  quite  rare.  Bronchopneumonia  and 
other  lung  complications  are  frequent. 

Laceration. — Laceration  of  the  brain,  if  extensive,  appears  like  any 
other  brain  wound,  and  slight  laceration  is  shown  by  the  existence  of  minute 
multiple  capillary  hemorrhages.  Laceration  has  also  been  found  as  the 
result  of  contre-coup.  The  symptoms  of  laceration  of  the  brain  in  the 
slighter  grades  resemble  those  of  concussion.  The  severer  forms  produce 
the  same  effects  as  extensive  wounds,  and  are  usually  fatal  on  account  of  the 
hemorrhage. 

Prognosis. — The  dangers  of  injury  to  the  brain  by  incision,  contusion, 
or  laceration  are  various.  (1)  The  part  affected  is  important,  for  an  injury 
to  the  motor  centres  causes  paralysis,  while  an  injury  to  the  frontal  lobe 
seems  to  be  of  comparatively  little  significance,  although  when  very  exten- 
sive it  results  in  loss  of  mental  power.  (2)  Hemorrhage  may  cause  death  by 
compression  as  well  as  by  loss  of  blood.  (See  next  section.)  (3)  Infection 
may  take  place  in  any  wound  that  is  exposed,  this  danger  being  naturally 
greatest  when  the  brain-tissue  has  been  badly  injured  by  contusion  or  lacer- 
ation. (4)  (Edema,  apparently  due  to  a  traumatic  Avascular  paralysis  extend- 
ing throughout  the  brain,  may  occur  and  cause  fatal  compression.  (5) 
Fungus  cerebri  may  form  in  a  wound  in  which  the  brain  is  exposed,  the 
granulating  tissues  beginning  to  grow  out  through  the  skull,  and  producing 
a  tumor  with  a  pale,  somewhat  sloughing  surface,  which  bleeds  readily. 
A  true  hernia  cerebri  occasionally  takes  place  through  a  gap  in  the  skull 
when  the  intracranial  pressure  is  abnormally  great,  especially  if  the  dura 
mater  has  been  destroyed.  A  considerable  mass  of  brain-tissue  may  pro- 
trude, and  the  danger  of  infection  is  great.  (6)  Severe  injuries  of  the  brain 
are  followed  by  mental  disease  (insanity,  dementia)  in  about  eight  per  cent. 
of  the  cases.  (Stolper.)  The  symptoms  may  appear  immediately  after  the 
injury  or  later,  and  in  the  former  case  they  may  be  temporary. 

Treatment. — -Contusions  of  the  brain  should  be  treated  like  concussion. 
Every  penetrating  wound  of  the  brain  should  be  thoroughly  examined  by 


INTRACRANIAL  liEMORRHAGE. 


723 


cutting  awaj^  the  edges  of  the  opening  in  the  skull,  in  ordei'  to  remove 
foreign  bodies  and  blood-clots  and  afford  free  drainage,  and  to  ascertain  the 
exact  extent  of  the  injury  and  the  condition  of  the  parts,  which  are  then  to 
be  treated  as  described  elsewhere.  The  hemorrhage  from  wounds  of  the 
brain  is  often  considerable,  and  is  difficult  to  control,  because  the  vessels 
have  such  delicate  walls  and  lie  in  such  friable  tissue  that  it  is  imjjossible  to 
apply  ligatures.  It  can  be  arrested  by  passing  ligatures  around  the  vessel, 
introducing  them  with  curved  needles,  or  by  packing  the  wound  with  sterile 
gauze.  The  wound  should  be  thoroughly  covered  and  a  tight  bandage 
applied,  otherwise  hernia  cerebri  may  develop.  The  treatment  of  hernia 
cerebri  consists  in  cutting  away  the  mass,  cautei'izing  the  base,  and  applying 
pressure  by  a  flat  metal  or  other  plate.  This  complication  in  pre-antiseptic 
times  appears  to  have  had  a  very  high  mortality,  but  it  is  no  longer  so 
common  or  so  dangerous. 

Intracranial  Hemorrhage.— Hemorrhage  within  the  skull  may  be 
extradural,  between  the  dura  and  the  bone  ;  intradural,  between  the  brain 
and  the  dura  mater ;  or  cerebral.  Cerebral  hemorrhage  is  of  compara- 
tively little  interest  to  the  surgeon,  although  Dennis  has  recommended  the 
use  of  the  trephine  and  evacuation  of  clots  in  certain  cases,  and  Keen  has 
advised  ligation  of  the  carotid  in  progressive  apoplexy  with  hemiplegia.  It 
is  seldom  that  a  hemorrhage  in  the  brain  can  be  localized.  Hemorrhage 
beneath  the  dura  may  take  place  in  the  meshes  of  the  subarachnoid  space, 
and  small  clots  are  then  seen  lying  in  the  various  fissures.  It  may  also  occur 
between  the  pia  and  the  dura,  the  brain  usually  receding  and  leaving  a 
space,  so  that  the  blood  is  apt  to  settle  at  the 
base.  Occasionally,  however,  the  hemor- 
rhage may  be  limited  by  adhesions  or  some 
other  cause,  and  a  large  clot  may  form  on 
the  surface,  which  may  produce  symptoms 
similar  to  those  of  extradural  hemorrhage. 

Extradural  hemorrhage  occurs  from 
the  middle  meningeal  arteries,  particularly 
their  anterior  branches,  and  in  rare  cases 
from  the  sinuses.  The  artery  sometimes 
runs  in  a  complete  canal  in  the  bone,  and  is 
generally  injured  by  a  direct  blow  in  the  line 
of  its  course,  but  a  fissure  starting  elsewhere 
may  extend  across  the  canal.  The  artery  is 
often  lacerated  by  a  blow  not  sufficiently 
severe  to  cause  fracture,  and  there  are  au- 
thentic cases  in  which  the  injury  has  been 
caused  by  contre-coup,  a  blow  on  the  right 
side  of  the  head,  for  instance,  causing  a  rup- 
ture of  the  artery  upon  the  other  side.  It  is  not  difficult  to  believe  that  if 
the  dura  is  torn  from  the  bone  by  the  effect  of  contre-couj)  the  artery  might 
be  injured  when  it  does  not  lie  in  a  bony  canal.  The  escaping  blood  in  such 
an  injury  collects  between  the  dura  and  the  bone,  forming  a  clot  which  may 
attain  a  considerable  thickness.     (Fig.  648.) 


Fig.  648. 


Trinh\  cr<;e  'section  ot  skull  and  dui  i 
mater  <;liouing  extradural  clot  at  ( 
(Agnew.) 


724  INTRACRANIAL  HEMORRHAGE. 

Symptoms  and  Diagnosis. — The  symptoms  of  hemorrhage  into  the 
brain  or  between  the  brain  and  the  dura  vary  according  to  the  rapidity  and 
extent  of  the  extravasation.  If  the  amount  of  blood  is  great  and  it  is  sud- 
denly thrown  out,  there  is  immediate  unconsciousness,  with  symptoms  of 
shock  and  of  concussion.  The  coma  may  gradually  deepen  until  death 
occurs,  or  it  may  cease  and  the  patient  may  recover,  with  absorption  and 
shrinkage  of  the  clot.  The  jjuijils  are  generally  contracted  at  first,  then 
dilated,  particularly  upon  the  side  on  which  the  clot  lies,  and  they  are  slug- 
gish in  responding  to  light.  After  reaction  has  set  in,  a  rise  of  temperature 
is  probable,  reaching  to  100°  or  101°  F.  (37.8°  or  38.3°  C).  In  the  case 
of  multiple  small  hemorrhages,  as  has  already  been  noticed,  the  symptoms 
are  similar  to  those  of  concussion  of  the  brain.  Extradural  bleeding  occurs 
slowly,  and  although  the  clot  lies  near  the  motor  centres  it  is  not  until  it  has 
attained  a  considerable  size  that  symptoms  of  paralysis  appear.  It  is  there- 
fore characteristic  of  this  kind  of  hemorrhage  for  the  symptoms  to  appear 
some  hours  or  even  days  after  the  injury,  the  patient  seeming  quite  well  in 
the  mean  time.  In  typical  cases  after  the  free  interval  there  is  a  period  of 
local  pressure,  gradually  advancing  to  a  general  compression  of  the  brain. 
The  first  stage  is  marked  by  limited  local  paralysis  or  localized  convulsions. 
The  arm  is  affected  first  and  most  seriously,  while  the  leg  is  seldom  para- 
lyzed alone. 

The  paralysis  in  extradural  hemorrhage  appears  upon  the  opposite  side 
from  the  situation  of  the  clot,  except  in  a  very  small  percentage  of  cases 
which  are  as  yet  inexplicable.  Choked  disk  may  develop  uj)on  the  side 
where  the  clot  is  situated.  The  presence  of  aphasia  indicates  an  extension 
of  the  clot  forward,  while  anesthesia  indicates  a  backward  extension.  The 
paralysis  increases,  stupidity,  convulsions,  and  coma  follow,  with  all  the 
symptoms  of  compression  of  the  brain.  In  exceptional  cases  the  symptoms 
have  begun  immediately  after  the  injury,  and  it  is  evident  that  there  may  be 
early  symptoms  due  to  other  causes,  such  as  concussion  of  the  brain,  which 
may  mask  the  free  interval.  Although  the  interval  without  symptoms  is 
generally  considered  diagnostic,  the  same  course  is  occasionally  seen  in 
hemorrhage  under  the  dura,  when  the  clot  remains  localized,  so  that  an  abso- 
lute diagnosis  may  be  impossible.  Subdural  hemorrhage  often  causes  paral- 
ysis of  the  cranial  nerves  of  the  same  side  as  the  blood  settles  to  the  base 
and  presses  on  the  nerves  themselves  and  not  on  their  centres,  a  fact  which 
may  aid  in  determining  the  site  of  the  clot. 

Prognosis. — The  prognosis  of  intracranial  hemorrhage  is  very  grave 
even  in  the  extradural  form,  where  the  oi^portunities  for  spontaneous  arrest 
are  the  best,  for  only  about  ten  per  cent,  of  recoveries  by  expectant  treat- 
ment are  found  in  this  variety.  Two-thirds  of  the  cases  can  be  saved  by 
operation.  Small  blood-clots  may  be  absorbed,  but  large  clots,  es]3ecially  in 
the  brain,  are  apt  to  be  converted  into  a  loose  cellular  tissue  with  cj^sts  in  its 
meshes,  sometimes  of  very  large  size.  These  cysts  result  in  atrophy  of  the 
brain  and  are  common  causes  of  epilepsy. 

Treatment. — In  extradural  hemorrhage  the  clot  may  be  reached  by  a 
trejihine  opening  at  the  meeting-point  of  a  line  drawn  two  finger-breadths 
above  the  zygoma  with  a  second  line  one  finger- breadth,  or  rather  more. 


WOUNDS  OF  THE  VENOUS  SINUSES. 


725 


\ 


/ 


behind  the  jiosterior  edge  of  the  malar  boue  at  its  junction  with  the  zygoma. 
This  opening  strikes  the  anterior  branch  of  the  meningeal  artery,  and  will 
be  likely  to  reach  the  clot  above  this  point  or  below,  the  two  favorite  situa- 
tions for  these  extradural  clots.  (Pig.  649,  II.)  Steiner  recommends  draw- 
ing a  line  from  the  glabella  to  the 
tip  of  the  mastoid  process,  and 
a  second  line  perpendicular  to  the 
former  at  its  middle  point.  The 
anterior  branch  of  the  artery  will 
be  found  at  the  junction  of  this 
second  line  with  a  horizontal  line 
drawn  through  the  glabella.  (Fig. 
649. )  The  point  where  the  last- 
mentioned  line  intersects  a  verti- 
cal through  the  tip  of  the  mastoid 
is  the  proper  place  to  apj)ly  the 
trephine  for  hemorrhage  from  the 
posterior  branch.  These  cases 
may  also  be  treated  by  turning 
down  an  osteoplastic  flap  and  thus 
thoroughly  exposing  the  vessels. 
The  hemorrhage  will  have  ceased 
at  the  time  of  operation,  and  the 
clot  should  be  washed  out  and 
another  trephine  opening  made 
at  the  most  de]3endent  portion  of 
the  cavity,  if  necessary,  to  obtain 

thorough  drainage.  If  no  blood  is  found  external  to  the  dura,  when  the 
skull  is  opened,  the  dura  should  be  incised.  Intradural  hemorrhage  usually 
arises  from  the  middle  cerebral  artery,  and  the  clot  will  be  situated  so  as  to 
be  accessible  from  the  anterior  opening  described  above. 

Wounds  of  the  Venous  Sinuses. — These  dangerous  lesions  may 
be  caused  by  accidental  injuries,  or  in  the  course  of  operations.  Fracture 
of  the  skull  is  rarely  complicated  by  them.  They  are  most  common  in  the 
lateral  sinus  during  the  usual  mastoid  operation,  and  fortunately  are  then 
least  serious.  There  is  danger  of  air  embolism  in  open  wounds,  and  of  sep- 
tic complications  later.  Symptoms. — If  there  is  an  open  wound,  free  venous 
hemorrhage  will  be  observed.  If  not,  symptoms  of  compression  of  the 
brain  will  develop  as  in  cases  of  injury  to  the  meningeal  arteries,  but  the 
lower  venous  blood- pressure  renders  them  less  severe.  Treatment. — 
Signs  of  compression  of  the  brain  developing  after  an  injury  demand  imme- 
diate trephining.  When  there  is  an  external  wound  it  should  be  freely 
enlarged  by  removing  the  bone  until  the  source  of  the  bleeding  is  found. 
The  wound  iu  the  sinus  should  be  closed  by  suture  or  comjiressed  by  simple 
aseptic  gauze  packing.  Ligature  of  the  sinus  and  forceps  pressure  are  not 
so  useful  (Wharton).  The  wound  should  be  kept  covered  with  blood  or 
salt  solution  during  the  manipulations,  to  avoid  the  entrance  of  air  in  the 
sinus. 

47 


Trephine  openings  for  hemorrhage  from  the  meningeal 
artery  :  m,  anterior  trunk  ;  a,  a,  a,  its  branches ;  p,  poste- 
rior trunk;  j/  (dotted),  abnormal  course  of  same;  /., 
Vogt's  trephine  opening ;  II.,  Kronlein's  two  openings  ; 
III.,  Witherle's;  the  two  large  circles  show  Steiner's 
openings.    (Steiner.) 


726 


CONGENITAL  DEFORMITIES. 


Hydrencephaloeele,    Encephalocele,    and    Meningocele.— 

These  congenital  deformities  were  formerly  considered  true  hernial  protru- 
sions of  the  brain  and  membranes.  They  have  been  shown  to  be  due  to 
defective  development  of  the  cerebral  coverings,  the  growing  together  of 
the  cranial  iDlates  in  the  foetus  being  hindered,  probably  by  amniotic  adhe- 
sions. A  portion  of  the  brain  protrudes  under  the  skin,  uncovered  by  mem- 
branes, for  these  are  also  defective.  It  contains  a  central  cavity  which  is 
usually  connected  with  one  of  the  ventricles.  This  complete  form  is  called 
a  hydrencephaloeele.  If  the  central  cavity  disappears  subsequently,  leaving 
only  solid  brain-substance  in  the  tumor,  the  latter  is  called  an  encephalocele. 
In  other  cases,  especially  when  the  connection  with  the  ventricle  is  lost,  the 
central  cavity  enlarges  and  the  layer  of  brain  enclosing  it  becomes  very  thin, 
and  may  be  reduced  to  a  single  layer  of  cells,  representing  the  ependyma  of 
the  ventricles.  These  tumors  are  the  so-called  meningoceles.  Von  Bergmann 
doubts  if  in  any  case  a  sac  is  formed  by  the  membranes  as  formerly  sup- 
posed. 

These  deformities  are  seen  in  all  grades,  beginning  with  the  monster 
foetus  in  which  the  entire  brain  is  exposed.  Even  in  viable  infants,  espe- 
cially in  occipital  encephalocele,  the  mass  outside  of  the  skull  may  be  as 
large  as  the  brain  within  it,  and  idiocy  and  early  death  may  follow.     In  the 

frontal  cases  of  medium  size  the  individual 
may  reach  adult  life,  and  in  some  cases  the 
brain  power  has  been  normal,  but  cerebral 
atrophy,  ei^ilepsy,  and  idiocy  are  the  rule. 
These  tumors  are  most  frequently  found  at 
the  root  of  the  nose  or  near  the  posterior 
fontanelle.  The  variety  formerly  known  as 
meningocele  is  the  most  common.  (Fig. 
650. )  These  tumors  vary  from  the  size  of  a 
walnut  to  that  of  an  orange,  and  are  gener- 
ally flaccid,  although  sometimes  tense.  They 
fluctuate,  and  very  rarely  pulsate  with  the 
brain.  The  skin  covering  them  is  thin  and 
sometimes  altered  into  a  cicatricial  mem- 
brane, particularly  over  the  vertex  of  the 
tumor.  Yon  Bergmann  has  pointed  out 
that  in  many  of  these  cases  the  skin  over  the  tumor  undergoes  angiomatous 
degeneration,  so  that  the  mass  appears  like  an  ordinary  cavernous  angioma 
of  unusual  size.  The  tumor  is  frequently  translucent.  Although  any  attempt 
to  remedy  this  condition  is  dangerous,  the  prognosis  without  operation  is  so 
j)oor  that  some  treatment  is  generally  indicated.  When  the  tumor  is  very 
small,  pressure  has  been  successful  in  a  very  few  cases,  but  removal  by  an 
operation  similar  to  that  for  spina  bifida  is  generally  necessary.  Large 
masses  of  extruded  brain  have  been  removed  without  ill  effect. 

Inflammation  of  the  Brain  and  its  Membranes.— Meningitis. 
— The  inflammations  of  the  dura  mater  are  of  little  surgical  interest,  although 
pachymeningitis  syphilitica  may  cause  hemorrhage,  and  some  successful 
operations  in  such  cases  are  on  record.     Pachymeningitis  may  produce  adhe- 


MENINGITIS.  727 

sions  between  the  brain  and  the  dura  mater,  demanding  surgical  interference 
because  of  epileptic  attacks,  severe  headache,  or  localized  paralysis.  By  the 
term  meningitis  is  generally  understood  an  inflammation  of  both  the  pia  and 
the  arachnoid,  for  clinically  we  cannot  distinguish  between  them.  Septic 
meningitis  usually  arises  from  infection  through  a  compound  fracture  or 
other  injury  to  the  head,  or  from  suppuration  of  the  middle  ear.  The  inflam- 
mation may  be  limited  to  a  small  area  or  may  extend  over  the  entire  surface 
of  the  brain. 

The  pathological  changes  in  meningitis  are  dilatation  of  the  vessels, 
serous  effusion,  cellular  infiltration,  cloudy  thickening  of  the  membranes, 
and  the  formation  of  adhesions  with  the  cortex  and  the  dura  mater  on  either 
side.  In  the  later  stages  sux^puration  may  occur,  the  pus  collecting  in  the 
sulci  under  the  pia  or  spreading  diffusely  over  the  brain,  with  a  tendency  to 
collect  at  the  base.  When  the  disease  remains  strictly  localized,  as  is  fre- 
quently the  case  when  the  infection  takes  place  from  an  infected  wound  or 
from  suppuration  of  the  middle  ear,  adhesions  form  which  may  limit  the 
extension  of  the  pus,  as  in  similar  conditions  in  other  serous  cavities,  and 
the  symptoms  are  less  severe,  although  they  may  still  be  very  serious. 

Symptoms. — Meningitis  is  almost  always  accompanied  by  some  encepha- 
litis in  surgical  cases ;  hence  the  clinical  picture  is  a  compound  of  the  two 
conditions.  The  symptoms  of  meningitis  may  be  divided  into  a  stage  of 
excitement  and  a  stage  of  paralysis.  They  begin  with  headache,  gradual 
rise  of  temperature,  hyperesthesia  of  all  the  senses,  esi^ecially  tenderness  of 
the  scalp  and  photoijhobia,  with  gradually  increasing  restlessness  alternating 
with  fits  of  drowsiness.  The  pupils  are  at  first  contracted  and  then  dilated, 
being  sluggish  in  either  case,  and  they  may  be  unequal.  A  chill  is  rare,  and 
the  pulse  remains  slow.  The  drowsiness  gives  way  to  delirium,  and  mus- 
cular twitchings  succeed,  with  local  and  general  convulsions.  Occasionally 
a  localized  paralysis  is  found  in  meningitis  of  the  convexity,  even  in  the  first 
stage  (Von  Bergmann),  and  it  may  be  the  first  symj)tom  of  the  disease. 
The  symptoms  of  the  first  stage  are  a  combination  of  compression  of  the 
brain  by  the  exudate,  and  of  local  and  constitutional  septic  poisoning  caused 
by  the  absorption  of  the  infectious  materials.  The  pulse-rate  increases  and 
fever  appears,  being  of  the  continuous  type,  or  with  a  morning  remission, 
but  just  before  death  the  temperature  may  fall.  A  marked  leucocytosis 
will  be  present.  In  the  second  stage  the  signs  of  pressure  predominate. 
The  drowsiness  increases  to  actual  coma.  Total  paralysis  is  common  in 
meningitis  of  the  vertex,  and  the  sphincters  are  paralyzed  or  so  relaxed  that 
the  fsBces  and  urine  may  be  j)assed  unconsciously.  Tonic  convulsioas  also 
occur.  In  meningitis  of  the  base  there  are  no  local  paralyses,  but  the 
inflammation  is  very  apt  to  extend  to  the  cord,  the  neck  becoming  stiff,  and 
Cheyne-Stokes  respiration  appearing  on  account  of  the  proximity  of  the 
inflammation  to  the  respiratory  centre  in  the  medulla. 

Diagnosis. — In  meningitis  this  is  not  always  easy  in  the  first  stage,  espe- 
cially if  concussion  or  compression  of  the  brain  is  also  present  and  we  are 
dependent  upon  the  rise  of  temperature  and  leucocytosis  to  guide  us,  the 
nerve  symptoms  being  masked  by  the  general  depression  of  the  cerebral 
functions.     The  diagnosis  from  pytemia  may  be  made  by  the  absence  of 


728  PHLEBITIS  OF  THE  SINUSES. 

chills.  An  exploratory  lumbar  puncture  might  give  positive  proof  if  the 
spinal  meninges  were  also  involved. 

Treatment. — The  surgical  treatment  of  meningitis  would  naturally  be 
drainage,  but  drainage  is  very  unsatisfactory  because  of  the  adhesions.  The 
operative  treatment  is  practically  limited  to  those  cases  which  originate 
from  infected  penetrating  wounds  of  the  skull  and  from  suppurative  disease 
of  the  ear,  and  if  the  treatment  can  be  applied  early  enough  there  is  a 
possibility  of  recovery.  Infected  wounds  must  be  thoroughly  cleansed, 
sinuses  laid  open,  and  free  drainage  instituted,  any  necessary  amount  of 
bone  being  cut  away.  When  the  infection  originates  in  ear  disease  the 
usual  opening  into  the  mastoid  is  made,  and  if  the  lesions  found  there  are 
not  sufficient  to  account  for  the  .symptoms,  or  if  the  latter  continue  in  spite 
of  the  operation,  the  lateral  sinus  should  be  inspected.  If  no  phlebitis  is 
found,  the  dura  should  be  opened  after  cutting  away  more  of  the  bone  above, 
and  the  membranes  examined. 

Tubercular  Meningitis. — The  tubercular  is  the  only  form  of  chronic 
meningitis  that  is  of  interest  to  surgeons.  It  occasionally  forms  well-limited 
foci,  giving  localizing  symptoms  and  permitting  definite  diagnosis  and 
surgical  treatment.  Even  when  the  disease  is  general  and  marked  by  con- 
siderable serous  effusion  into  the  ventricles  or  on  the  surface  of  the  brain, 
good  results  have  been  obtained  by  drainage,  which  relieves  the  brain  of  the 
pressure,  at  least  temporarily.  The  lesions  of  tubercular  meningitis  consist 
in  the  appearance  of  miliary  tubercles  scattered  through  the  membranes, 
and  sometimes  massed  into  tumors  of  considerable  size,  or  forming  abscesses 
surrounded  by  a  cheesy  wall,  depressing  the  cortex  or  invading  it  by  ulcera- 
tion. In  other  cases  the  amount  of  serous  effusion  appears  to  be  entirely 
out  of  proportion  to  the  gravity  of  the  lesions  found,  there  being  no  adhe- 
sions and  but  few  miliary  tubercles.  The  lateral  ventricles  have  been 
drained  for  tuberculous  disease  (Keen)  through  that  part  of  the  brain  where 
they  are  nearest  to  the  surface  on  the  side  of  the  head,  or  by  trephining  the 
occipital  bone,  lifting  u]d  the  cerebellum,  and  draining  the  fourth  ventricle 
just  beneath  it  (Quincke).     (See  Hydrocephalus,  page  734.) 

Phlebitis  of  the  Sinuses. — The  sinuses  of  the  brain  are  particularly 
liable  to  infection  because  of  their  intimate  connections  with  the  ear,  the 
orbit,  and  the  veins  of  the  skull  and  scalp,  where  suppurating  processes  are 
so  frequent,  and  it  is  from  these  three  sources  that  phlebitis  generally  origi- 
nates. The  pathological  changes  are  similar  to  those  of  phlebitis  elsewhere, 
the  endothelium  is  thickened,  there  is  a  deposit  of  fibrin,  and  thrombosis 
sets  in,  with  liability  to  purulent  softening.  Particles  of  clot  are  especially 
likely  to  be  swept  off  by  the  blood-current  because  of  the  rigidity  of  the 
walls,  so  that  pysemia  is  a  frequent  result  of  sinus  phlebitis.  The  phlebitis 
often  extends  to  the  veins  outside  of  the  head,  inflammation  of  the  lateral 
sinuses  especially  extending  into  the  internal  jugular.  In  ear  disease,  the 
right  sinus  is  affected  more  frequently  than  the  left.  Symptoms. — When 
sinus  phlebitis  complicates  suppuration  of  the  ear,  the  orbit,  or  some  wound 
of  the  scalp,  in  addition  to  the  symptoms  of  the  original  condition  there 
appears  some  sluggishness  of  cerebral  action,  perhaps  some  headache,  but 
mainly  a  sharp  rise  of  temperature  to  103°  F.  (39.5°  C.)  or  more,  with  hectic 


ENCEPHALITIS  ,AND   ABSCE8S  OF  THE  BRAIN.  729 

variations,  rigors  being  seldom  seen.  Leucocytosis  is  present.  Tliere  may 
be  some  oedema  of  the  scalp  near  the  affected  sinus.  If  the  internal  jugular 
is  involved,  there  is  tenderness  and  a  little  fulness  along  its  course.  Pyeemia 
with  all  its  consequences  follows,  and  a  complicating  meningitis  may  develop. 
In  some  cases  choked  disk  is  present,  or  paralysis  of  the  pneumogastric, 
spinal  accessory,  or  glosso-pharyngeal  nerves  due  to  pressure  upon  them  by 
the  swollen  vein  in  the  jugular  foramen.  Treatment. — "When  the  lateral 
sinus  is  involved,  the  vessel  should  be  exjiosed  by  extending  the  ordinary 
mastoid  operation  and  laid  open.  The  jugular  vein  can  be  ligated  in  the 
neck  beyond  the  seat  of  infection  and  opened  above  the  ligature,  when 
irrigation  can  sometimes  be  made  through  the  sigmoid  sinus  and  the 
jugular.     About  two-thirds  of  the  cases  can  be  cured. 

Encephalitis  and.  Abscess  of  the  Brain. — Encephalitis  is  inflam- 
mation of  the  brain.  An  aseptic  injury  to  the  brain  cannot  cause  inflamma- 
tion, for  this  can  originate  only  from  bacterial  infection,  and  injury  merely 
produces  conditions  which  are  favorable  for  infection.  Thus,  a  portion  of 
the  brain  may  be  contused,  or  there  may  be  a  hemorrhage  into  it,  and 
if  there  is  a  compound  fracture  in  connection  with  this  injury  infection 
readily  causes  inflammation,  because  the  vitality  of  the  tissues  has  been 
impaired.  Infectious  agents  circulating  in  the  blood  might  reach  such 
a  focus  even  without  any  external  injury  of  the  head  and  cause  inflam- 
mation, but  authentic  cases  of  this  kind  are  rare.  In  the  early  stages  of 
encephalitis  we  have  the  usual  changes  of  inflammation,  which  are  followed 
by  multiplication  of  the  connective-tissue  cells  and  a  round-cell  infiltration, 
the  nerve- cells  undergoing  degeneration.  The  gross  appearances  are  a 
manifest  softening,  at  first  of  a  pinkish  hue,  later  dark  red  or  yellow.  The 
inflammatory  changes  result  in  the  production  of  pus  or  the  comj)lete  soften- 
ing and  degeneration  of  the  nerve-tissues.  When  an  abscess  is  produced 
its  wall  consists  of  brain-tissue  thickly  infiltrated  with  round  cells,  and  no 
true  capsule  of  connective  tissue  is  formed,  so  that,  although  the  process 
may  remain  stationary  for  many  years,  the  patient  is  in  constant  danger 
from  rupture  of  the  abscess  or  its  further  extension.  The  infection  often 
arises  from  an  infected  wound,  and  in  such  cases  the  abscess  is  apt  to  be 
situated  in  or  near  the  cortex.  The  presence  of  a  foreign  body  in  the  brain 
renders  the  liability  to  infection  much  greater.  Fracture  of  the  base  also 
affords  an  opportunity  for  infection,  by  opening  the  Eustachian  tube  or 
other  cavities  lined  with  mucous  membrane.  The  most  common  source  of 
infection,  however,  is  supj)uration  of  the  middle  ear,  followed  by  perfora- 
tion of  the  tympanum  or  inflammation  of  the  mastoid,  which  is  apt  to  cause 
abscesses  in  the  temporo-sphenoidal  lobe.  The  great  majority  of  these 
abscesses  are  situated  beneath  the  cortex  in  the  white  substance,  and  have 
no  direct  communication  with  the  source  of  pus  in  the  ear. 

Cerebral  abscesses  are  often  the  result  of  pyaemia,  but  they  are  also  fre- 
quently its  cause.  Metastatic  abscesses  in  the  brain  are  generally  the  result 
of  chronic  suppuration  of  the  pulmonary  organs.  These  abscesses  were 
formerly  believed  to  be  multiple,  but  in  nearly  one-half  of  a  large  series 
of  cases  Martins  found  a  single  abscess  only,  and  nearly  all  of  these  were 
in  the  left  temporo-sphenoidal  lobe  and  near  the  cortex.     Abscesses  are  most 


730  ABSCESS   OF  THE  BKAIX. 

common  in  tlie  temporo-sphenoidal  lobe  (especially  on  the  right  side),  and 
are  then  usually  secondary  to  ear  disease,  the  frontal  and  parietal  lobes  being 
more  apt  to  be  affected  by  abscesses  of  traumatic  origin.  Otitis  may  also 
originate  abscesses  in  the  cerebellum.  The  location  of  an  abscess  of  the 
brain  can  sometimes  be  determined  by  the  order  in  which  the  local  symp- 
toms appear,  for  if  they  begin  in  the  face  and  spread  to  the  arm  the  abscess 
will  lie  near  the  cortical  part  of  the  brain,  pressing  on  the  motor  centres, 
while  the  opposite  order,  beginning  in  the  leg  and  extending  to  the  face, 
indicates  an  accumulation  of  pus  in  the  central  part  of  the  brain,  in  the 
internal  capsule,  where  it  would  press  upon  the  fibres  passing  from  these 
centres  in  a  reverse  order  in  its  extension  (Macewen).  In  abscesses  of  the 
frontal  and  temporo-sphenoidal  lobes  the  eye-symptoms  may  be  diagnostic 
of  the  location,  paralysis  of  the  third  nerve,  with  internal  strabismus  and 
dilated  pupil,  indicating  disease  upon  the  same  side  as  the  eye  affected. 

Syraptoins. — In  the  traumatic  cases  the  encephalitis  is  generally  corti- 
cal, and  when  acute  it  is  almost  always  associated  with  meningitis.  Enceph- 
alitis complicating  meningitis  may  be  suspected  if  the  signs  of  inflammation 
do  not  appear  at  once,  and  especially  if  paralytic  symptoms  affecting  the 
face,  the  extremities,  or  the  speech  are  well  marked  in  the  early  stages.  It 
is  very  necessary  to  sei^arate  this  superficial  inflammation  with  early  symp- 
toms from  the  more  common  chronic  abscesses  deep  in  the  brain  which 
develop  at  a  later  date,  whether  from  traumatism  or  from  ear  disease.  The 
symptoms  of  the  chronic  abscesses  are  the  result  of  three  causes, — the  septic 
infection,  the  general  pressure  on  the  brain,  and  the  local  pressure.  The 
first  stage  of  abscess  of  the  brain  is  often  obscure.  The  temperature  is  the 
most  reliable  symptom,  and  there  may  be  a  slight  rise,  particularly  at  night, 
with  chilly  sensations,  and  perhaiDS  an  actual  chill,  the  patient  also  exhibit- 
ing signs  of  mental  depression.  At  a  later  stage  there  may  be  earache,  if 
the  trouble  be  the  result  of  disease  of  the  ear,  and  headache  is  one  of  the 
most  reliable  symptoms  in  all  cases.  When  the  temperature  rises  there  is 
more  pain,  especially  on  that  side  of  the  head  where  the  abscess  lies.  If 
there  has  been  a  discharge  from  the  ear,  it  usually  ceases.  Vomiting  may 
be  present,  with  or  without  nausea.  One  of  the  characteristic  signs  of 
abscess  of  the  brain  is  the  great  variation  in  the  symj)toms  from  time  to 
time,  and  they  sometimes  completely  disappear  for  an  interval  of  days  or 
weeks.  It  is  seldom  that  the  first  stage  with  elevated  tempei:atm-e  comes 
under  medical  observation. 

In  the  stage  of  active  extension  all  the  symjitoms  are  increased,  especially 
the  pain  and  the  mental  dulness,  the  latter  resembling  the  dulness  of  opium- 
poisoning,  according  to  Macewen.  The  patient  lies  in  a  drowsy,  indifferent 
state,  answers  questions  very  slowly,  goes  to  sleep  while  in  the  middle  of  a 
sentence,  and  in  attempting  any  voluntary  action  shows  a  decrease  of  will- 
power. The  temperature  is  usually  97°  F.  (36°  C),  or  ranges  between  that 
and  99°  F.  (37°  C.)  ;  the  pulse  is  very  slow,  below  sixty,  and  even  down  to 
thirty,  beats  a  minute.  The  respiration  is  natural  or  slow,  but  in  cerebellar 
abscesses  it  may  be  irregular,  with  Cheyne-Stokes  phenomena ;  and  in  the 
last  stages  it  may  be  reduced  to  eleven  respirations  in  the  minute,  and  may 
cease  before  the  heart.     Vomiting  is  present,  being  brought  on  by  sitting  up 


ABSCESS  OF  THE  BRAIN.  731 

in  bed,  and  convulsions  may  occur,  but  the  latter  are  rare  in  abscesses  of  the 
temporo-sphenoidal  region.  There  may  be  distinct  local  paralysis.  The 
pupils  may  be  alfected,  and,  as  a  rule,  the  pupil  on  the  same  side  is  dimin- 
ished when  the  abscess  is  small  and  dilated  when  it  grows  larger,  but  in 
either  case  it  is  apt  to  be  sluggish  and  not  to  react  to  light  as  well  as  the 
other  side.  Authorities  vary  as  to  the  frequency  of  choked  disk,  but  the 
weight  of  evidence  is  in  favor  of  the  existence  of  a  low  grade  of  optic 
neuritis  in  all  cases.  In  the  final  stage  coma  may  set  in  or  meningitis  may 
develop,  the  former  being  due  to  the  increasing  pressure  of  the  abscess,  the 
latter  to  infection  or  to  perforation  of  the  abscess  upon  the  surface  of  the 
brain.  An  immediately  fatal  accident  is  the  bursting  of  the  abscess  into  the 
ca-^'ity  of  the  ventricles,  shown  by  the  slow  pulse  becoming  suddenly  very 
rapid,  the  respiration  growing  shallow  or  deep  and  stertorous,  and  death 
resulting  within  twelve  hours  in  convulsions  or  coma. 

Prognosis. — Operation  afibrds  the  jonly  real  oi3portunity  for  recovery, 
although  very  small  abscesses  may  doubtless  remain  latent  for  long  periods, 
and  it  is  possible  that  they  may  be  absorbed.  In  abscesses  of  traumatic 
origin,  three-quarters  of  the  cortical,  and  over  one-half  of  the  deep  abscesses 
end  in  recovery  after  oiieration  (Delvoie).  In  abscesses  secondary  to  ear 
disease  one-half  can  be  cured  by  operation  (Korner).  The  destruction  of 
brain-tissue  is  permanent,  and  paralysis  or  epilepsy  may  result  from  the 
adhesions  produced  by  the  scar. 

Diagnosis. — The  diagnosis  of  abscess  of  the  brain  is  exceedingly  diffi- 
cult except  in  simple  cases,  and  even  in  such  cases  it  may  be  confused  with 
phlebitis  of  the  sinuses.  In  phlebitis  there  is  a  rapid  pulse,  high  fever,  the 
pupils  remain  normal  unless  the  cavernous  sinus  is  involved,  and  if  the 
inflammation  extends  into  the  jugular  vein,  tenderness  is  present  over  that 
vessel.  Meningitis  is  marked  by  symptoms  of  cerebral  irritation,  and  an  acute 
febrile  movement  which  is  easily  distinguished  from  the  chronic  abscess. 
But  when  the  encephalitis  is  superficial  and  associated  with  meningitis,  it 
may  be  difficult  to  prove  that  the  brain  itself  is  involved.  Even  in  these 
cases  the  presence  of  encephalitis  is  indicated  by  a  later  beginning  a,nd  a 
somewhat  less  acute  course  thau  in  simple  meningitis,  and  by  localizing 
nerve  symptoms.  In  tumors  of  the  brain  the  paralysis  is  more  distinct,  the 
development  is  slower,  and  the  symptoms  are  more  constant,  than  in  abscess. 
The  greatest  difficulty  in  the  diagnosis  of  abscess  is  the  tendency  of  the 
disease  to  become  latent. 

Treatment. — In  the  early  stages  of  an  acute  encephalitis  originating 
from  an  infected  wound  the  establishment  of  thorough  antisepsis  and  drain- 
age of  the  wound  and  the  removal  of  all  sloughs  are  the  first  steps  in  the 
treatment.  Sedatives  may  be  administered,  and  ice  applied  to  the  head. 
Abscesses  must  be  evacuated  as  early  as  it  is  possible  to  make  the  diagnosis. 
Even  the  metastatic  abscesses  offer  some  chance  of  a  cure  by  operation.  When 
a  wound  on  the  head  is  the  source  of  the  infection,  the  brain  abscess  must  be 
sought  for  in  that  neighborhood,  a  free  opening  being  made  in  the  skull. 
To  open  the  temporo-sphenoidal  abscesses  we  may  follow  Von  Bergmann's 
rule:  "The  field  of  operation  is  indicated  by  four  lines,  the  upper  limit 
being  a  line  five  centimetres  above  the  zj^goma  and  parallel  to  it,  the  pos- 


732  EPILEPSY. 

terior  limit  vertical  to  the  base-line  of  the  skull  aud  situated  at  the  posterior 
border  of  the  mastoid,  the  anterior  limit  a  line  parallel  to  the  second,  drawn 
through  the  temporo-maxillary  articulation  ;  and  the  lower  border  of  the 
opening  should  be  not  less  than  one  centimetre  from  the  root  of  the  zygoma." 
The  opening  is  to  be  a  liberal  one,  at  least  three  centimetres  wide.  If  no 
pus  is  found  between  the  dura  and  the  bone,  the  dura  should  be  opened.  If 
pus  is  found  outside  of  the  dura,  the  pus-cavity  must  be  thoroughly  cleansed 
before  the  dura  is  incised.  If  it  seems  probable  that  the  symptoms  are  due 
only  to  the  extradural  collection  of  pus,  the  dura  should  be  left  untouched, 
but  it  should  be  opened  if  there  is  absence  of  pulsation,  or  if  fluctuation 
can  be  felt  underneath.  The  presence  of  pulsation,  however,  is  no  proof 
that  an  abscess  does  not  exist  beneath  the  cortex.  When  the  dura  is  opened 
we  may  find  a  localized  collection  of  pus  on  the  surface  of  the  brain  beneath 
the  dura,  but  this  is  rare,  a  deep  abscess  being  the  rule.  The  brain-sub- 
stance must  be  explored  with  the  most  careful  asepsis.  It  is  better  to  make 
this  exploration  with  some  blunt  instrument,  like  a  nari*ow  director,  than 
with  an  aspirating  needle,  because  the  latter  may  cause  troublesome  hemor- 
rhage. If  pus  is  obtained,  the  opening  should  be  enlarged  by  dilatation 
and  the  cavity  drained  with  a  tube  or  wick  of  gauze.  It  is  unwise  to  use 
irrigation.     The  meningeal  cavity  is  protected  by  gauze  packing. 

Epilepsy. — Epilepsy  may  be  the  result  of  some  general  condition  or  of 
a  limited  cerebral  lesion.     In  the  latter  case  the  irritation  is  only  local  at 
first,  but  the  tendency  is  for  the  general  disease  to  be  developed,  and  when 
the  "epileptic  habit"  has  become  established  the  convulsions  continue  even 
after  the  local  cause  has  been  removed.     Epileptic 
Fig.  651.  convulsions  are  among  the  symptoms  of  various  dis- 

eases, such  as  tumors,  abscesses,  and  other  conditions, 
which  cause  diminution  of  the  space  within  the  skull. 
Kocher  fully  endorses  the  theory  that  increased  intra- 
cranial pressure  is  the  principal  cause  of  epilepsy.     It 
may  be  the  result  of  peripheral  nervous  irritation  set 
up  by  an  adherent  or  jsainful  scar  on  the  head  or 
Trephine  button  from  skull    li^bs,  and  many  cures  have  been  produced  by  the 
of  epileptic,  showing  depres-    rcmoval  of  such  scars.     It  is  also  causcd  by  adhesions 
TelTyl^slJZ^y.    between  the  brain  and  the  membranes,  by  cicatricial 
(Agnew.)  tissue  in  the  brain,  or  by  the  pressure  of  a  bony  point 

the  result  of  a  depressed  fracture.  (Fig.  651.)  In 
many  cases  a  clear  history  of  previous  injiuy  can  be  obtained,  and  a  scar  or 
depression  is  found  on  the  outside  of  the  skull. 

General  Epilepsy. — Symptoms. — The  epileptic  convulsion  may  be 
preceded  by  an  aura,  the  patient  being  aware  that  something  is  about  to 
happen  by  some  peculiar  sensation,  but  this  is  often  absent.  When  the 
attack  begins  the  patient  suddenly  assumes  a  rigid  position,  followed  by 
convulsive  movements  sometimes  limited  to  one  part  of  the  body,  some- 
times general,  and  he  falls  to  the  floor  unconscious,  his  muscles  working 
without  control.  The  movements  continue  for  several  minutes  and  gradu- 
ally cease,  but  the  patient  remains  unconscious,  pale,  and  occasionally 
vomits.     Gradually  he  regains  consciousness  and  feels  very  weak  from  the 


EPILEPSY.  733 

strenuous  muscular  exertion,  but  lie  is  often  unaware  that  anything  has 
happened. 

Treatment. — The  surgical  treatment  of  general  epilepsy  has  consisted 
in  trephining  to  relieve  the  intracranial  pressure,  the  removal  of  irritating 
peripheral  scars,  or  the  resection  of  the  cervical  sympathetic  ganglia  in 
order  to  influence  the  cerebral  circulation.  Only  in  rare  cases  has  perma- 
nent benefit  been  obtained. 

Local  Epilepsy. — Symptoms. — Local  convulsions,  or  so-called  Jack- 
sonian  epilepsy,  may  be  confined  to  twitchings  of  the  muscles  of  one  finger 
or  toe  or  one  part  of  the  face,  but,  as  a  rule,  an  attack  which  begins  in  this 
extremely  limited  way  spreads  to  adjoining  muscles,  gradually  advancing 
up  the  arm  or  leg  to  the  face,  or  in  the  opposite  direction.  A  general  con- 
vulsion with  loss  of  consciousness  may  follow  exactly  like  that  of  general 
epilepsy,  such  attacks  being  sometimes  given  the  name  of  "  focal"  epilepsy, 
while  those  without  loss  of  consciousness  and  with  limited  spasms  are  called 
true  Jacksonian  epilepsy.  The  limited  spasms  are  due  to  the  fact  that  some 
cause  of  irritation  is  situated  directly  over  the  motor  centres  and  makes 
them  the  most  susceptible  part  of  the  brain,  the  excitement  spreading  like 
a  wave  in  regular  succession  from  this  centre  to  those  adjoining  it. 

Prognosis. — The  progress  of  the  disease  is  invariably  from  bad  to  worse, 
although  the  course  may  be  very  slow.  The  success  of  any  operation 
depends  upon  its  performance  before  the  epileptic  habit  is  formed  and  upon 
the  possibility  of  removing  the  exciting  cause. 

Diagnosis. — Convulsions  due  to  uraemia  and  chronic  cerebral  lead 
poisoning  must  be  excluded  by  the  absence  of  indications  of  renal  disease 
and  of  lead  in  the  tissues  or  urine.  The  existence  of  tumors  and  abscesses 
must  be  excluded.  When  it  has  been  decided  that  the  epilepsy  is  due  to  a 
local  lesion,  the  exact  situation  of  the  latter  is  to  be  sought  for  ;  if  that  can 
be  determined,  an  ex^iloratory  incision  is  indicated,  even  if  the  nature  of 
the  lesion  cannot  be  ascertained. 

Treatment. — A  scar  on  the  scalp  or  on  the  surface  of  the  bone  may 
assist  in  the  localization,  but  scars  are  often  the  result  of  falls  in  the  fits, 
and  not  of  the  original  injury.  When  localization  is  possible  the  skull  is 
opened  and  a  search  made  for  adhesions,  tumors,  or  other  causes  of  irri- 
tation of  the  brain.  Even  when  nothing  whatever  can  be  found,  if  the 
attacks  have  been  strictly  Jacksonian  in  character  it  is  allowable  to  excise 
the  cortical  centre  of  the  part  in  which  the  attack  has  usually  begun,  the 
motor  centre  for  the  upper  extremity  being  entirely  removed  when  the 
attack  begins  in  the  fingers,  for  instance.  Horsley  advises  the  excision  of 
the  centre  in  every  case,  in  addition  to  the  removal  of  any  obvious  cause  of 
irritation,  such  as  the  projecting  bone  in  an  old  depressed  fracture,  in  order 
to  get  rid  of  a  part  of  the  brain  which  may  have  already  formed  the  epi- 
leptic habit.  Paralysis  ensues  in  the  parts  supplied  by  the  centre  removed, 
but  the  paralysis  is  temporary,  and  in  a  few  weeks  the  function  is  restored. 
The  results  of  these  operations  for  ei^ilepsy,  of  which  many  hundreds  have 
been  performed,  are  decidedly  unsatisfactory  ;  but  the  condition  is  otherwise 
hopeless,  and  to  have  a  small  chance  of  cure  or  even  a  respite  of  a  few 
months  will  repay  the  patient  for  undergoing  the  operation. 


734  HYDROCEPHALUS. 

Hydrocephalus. — Hydrocephalus  is  the  distention  of  the  ventricles  by 
cerebrospinal  fluid  caused  by  the  obstruction  of  the  passages  through  which 
the  fluid  escapes.  It  may  be  congenital  or  acquired,  and  may  be  due  to  an 
interference  with  the  venous  circulation  of  the  pampiniform  jjlexus,  or  to  a 
tubercular  infection.  It  occurs  almost  invariably  in  children,  the  child's 
head  becoming  very  large,  the  fontaiielles  remaining  open,  the  sutures 
widely  separating  and  leaving  the  membranes  jaulsating  between  the  edges 
of  the  bones.  The  frontal  bones  are  particularly  distended,  and  the  forehead 
projects  beyond  the  eyebrows.  The  general  symptoms  are  mental  irritabil- 
ity, with  headache,  strabismus,  optic  neuritis,  vomiting,  A^ertigo,  and  slow 
pulse,  especiallj''  after  the  sutures  have  become  ossified.  There  is  often 
in  the  early  stages  a  certain  precocity,  but  later  the  cerebral  faculties  are 
decidedly  impaired.     Convulsions  are  sometimes  seen. 

Treatment. — For  the  congenital  form  nothing  can  be  done.  Attempts 
to  cure  hydrocephalus  by  aspiration  were  made  many  years  ago.  Keen  has 
recommended  direct  drainage  through  the  parietal  bones  at  the  point  where 
the  ventricles  lie  nearest  the  surface,  one  and  a  half  inches  behind  the 
external  auditory  meatus  and  the  same  distance  above  the  base-line  of  the 
skull,  the  trocar  being  directed  upward.  Kocher  maintained  open  drainage 
through  a  silver  tube  for  two  years  with  good  results  in  one  case.  Quincke 
recommends  drainage  by  tapping  the  spinal  cord  below  and  applying  press- 
ure to  the  head  at  the  same  time.  It  has  also  been  suggested  by  Parkin  to 
drain  the  subarachnoid  space  by  trephining  the  occiput  and  placing  a  drain 
under  the  cerebellum.  Hill  suggested  making  a  permanent  opening  for 
drainage  between  the  ventricles  and  the  subdural  space,  closing  the  external 
wound,  and  some  cases  thus  drained  with  catgut  have  shown  improvement. 
Permanent  drainage  from  the  ventricle  through  a  trephine  opening  into 
the  subcutaneous  tissue  of  the  scalp,  the  wound  in  the  latter  being  closed, 
has  also  been  successfully  maintained  for  some  mouths.  The  results  are, 
however,  very  rarely  permanent. 

Microcephalus. — Idiotic  individuals  often  have  small  heads,  and  the 
theory  has  been  advanced  that  the  x>i'euiature  ossification  of  the  sutures 
prevents  the  projier  development  of  the  brain,  but  it  is  incorrect,  for  the 
sutures  do  not  ossify  earlier  in  idiotic  than  in  normal  children.  The  opera- 
tion of  craniectomy,  which  was  intended  to  give  the  skull  and  brain  an 
opportunity  to  expand,  has  been  performed  on  a  large  number  of  cases,  but 
without  mental  improvement.  A  strip  of  bone  one-quarter  of  an  inch  wide, 
including  the  entire  thickness  of  the  skull,  was  removed  on  one  side  of  the 
longitudinal  sinus,  and  oblique  strips  were  also  cut  from  the  parietal  bones. 

Intracranial  Tumors.— Pathology.— Whether  an  intracranial  tumor 
grows  from  the  bones  of  the  skull,  from  the  membranes,  or  from  the  brain 
itself,  the  chief  effects  produced  by  it  are  mechanical  and  due  to  its  presence 
within  the  cranial  cavity.  The  clinical  history  of  the  different  varieties  is 
very  similar,  excej)t  that  the  more  rapid  growth  of  malignant  tumors  inten- 
sifies the  symptoms,  and  they  are  liable  to  recur  after  a  successful  removal 
by  operation.  The  dura  mater  is  subject  to  sarcomata  and  to  fibrous 
growths,  but  unless  the  malignant  tumors  penetrate  the  skull  and  appear 
externally,  as  they  are  apt  to  do,  it  is  impossible  to  distinguish  neoplasms  in 


INTRACRANIAL  TUMORS.  735 

this  situation  from  growths  originating  in  tlie  brain.     Cerebral  malignant 
tumors  are  generally  secondary  to  malignant  tumors  elsewhere. 

Primary  intracranial  tumors  are  rare,  the  most  common  being  sarcoma, 
glioma,  and  fibroma.  Tuberculous  and  syphilitic  granulation  masses  are 
more  common  in  the  brain  than  true  neoplasms  (twenty-five  to  fifty  per 
cent,  of  cerebral  tumors  being  tubercular)  and  cause  similar  symi:)toms. 
Both  tubercle  and  sji^hilis  are  usually  associated  with  similar  lesions  else- 
where in  the  body,  and  the  diagnosis  is  made  from  this  clue.  The  tubercu- 
lous masses  are  generally  multiple,  and  therefore  occasion  a  great  variety 
of  symptoms,  but  sometimes  there  is  but  one.  Hydatid  cysts  of  the  brain 
are  extremely  rare  in  America.  The  cysts  usually  found  are  due  to  degen- 
eration of  tumors  or  are  the  result  of  cerebral  hemorrhage.  In  adults 
cerebral  tumors  are  most  frequently  situated  in  the  coi'tex,  while  in  children 
they  occupy  the  central  part  of  the  brain  or  the  cerebellum.  They  may  be 
minute  or  may  fill  one-quarter  of  the  cranial  cavity. 

Symptoms. — The  symptoms  of  those  tumors  which  ai-e  within  the 
reach  of  the  surgeon  depend  upon  cerebral  pressure,  causing  irritation,  fol- 
lowed by  paralysis.  Mental  disturbance,  or  at  least  somnolence  and  indiffer- 
ence, are  found  in  one-half  of  the  cases.  The  patient  falls  asleep  while 
talking,  is  very  slow  in  answering  questions,  loses  his  mental  power  and 
memory,  and  is  unable  to  apply  himself  to  any  occupation.  Vertigo,  nausea, 
and  vomiting  are  present  in  a  large  proportion  of  cases,  and  are  especially 
marked  in  cerebellar  tumors.  Headache  is  a  very  constant  symptom,  and 
may  be  associated  with  tenderness  of  the  skull  over  the  tumor.  The  pupils 
are  sluggish  in  reacting  to  light,  contracted  at  first,  then  widely  dilated, 
especially  on  the  affected  side.  Choked  disk  is  almost  invariable.  The 
nerve  symptoms  are  a  combination  of  irritation  and  paralysis,  for  a  tumor 
pressing  slightly  upon  the  nerve-centres  irritates  them,  and  as  the  pressure 
increases  or  the  disease  involves  the  centres  themselves  it  suspends  or 
destroys  their  functions,  the  first  stage  being  shown  by  convulsions,  the 
second  by  paralysis  if  the  motor  centres  are  involved.  Convulsions  are 
present  in  about  one-quarter  of  the  cases,  and  may  be  limited  at  first,  or 
general  from  the  beginning.  Typical  Jacksonian  convulsions  are  seen  in 
some  tumors  of  the  base  as  well  as  in  those  of  the  cortex.  The  paralysis 
may  be  local  or  there  may  be  hemiplegia,  and  it  may  be  so  slight  as  to  be 
detected  only  by  a  careful  examination.  The  symptoms  are  constant  and 
progressive,  unless  the  tumor  is  very  vascular,  when  alterations  in  the 
blood-pressure  may  cause  variations  in  its  symptoms.  Superficial  tumors 
penetrate  the  skull  in  rare  cases.     Death  is  the  inevitable  termination. 

Diagnosis. — Tumors  of  the  base  of  the  brain  are  by  far  the  most  fi-e- 
queut,  and  are  recognized  by  their  definite  symptoms,  such  as  divergent 
strabismus,  conjugate  deviation  of  the  eyes,  and  paralysis  of  the  third,  fifth, 
sixth,  seventh,  and  twelfth  nerves  without  any  preceding  signs  of  irritation. 
Anaesthesia  is  common,  and  hemiijlegia  may  be  accompanied  by  rigidity, 
while  convulsions  are  comparatively  rare.  There  may  be  symptoms  of  com- 
pression, due  to  acute  hydrocei^halus.  It  is  imjjossible  to  distinguish 
between  tumors  of  the  cortex  and  those  just  below  it  in  the  centrum  ovale 
and  the  ventricles.     The  exact  situation  of  a  tumor  near  the  cortex  may  be 


736  OPERATIONS   UPON  THE   SKULL  AND   BRAIN. 

determined  by  paralysis  when  it  involves  one  of  the  well-known  motor 
centres,  by  aphasia  if  the  lesion  is  on  the  left  side,  and  sometimes  by  partial 
anaesthesia.  In  the  occipital  region  hemianopsia  may  be  present.  Tumors 
of  the  temporo-sphenoidal  lobe  have  no  local  symptoms,  except  occasionally 
word- deafness.  A  tumor  in  the  cerebellum  (which  is  generally  tubercular) 
may  be  suspected  when  the  symptoms  develop  very  rapidly,  with  a  staggering 
gait.  A  staggering  gait  is  also  present  in  disease  of  the  semicircular  canals 
and  even  in  certain  tumors  of  the  frontal  lobes,  but  both  conditions  are  rare. 
Treatment. — Eemoval  by  operation  is  the  only  possible  treatment  for 
tumors  of  the  brain,  with  the  exception  of  gumma,  and  even  gumma  should 
be  removed  when  it  proves  obstinate  to  the  usual  remedies.  Of  six  hun- 
dred cases  of  intracranial  tumors  only  six  per  cent,  were  found  suitable  for 
operation  by  Starr,  and  other  observers  agree  as  to  this  percentage.  An 
early  recurrence  makes  operation  useless  for  tuberculous  tumors,  as  was  the 
case  in  a  solitary  tubercular  mass  of  large  size  removed  by  us.  In  cases  of 
doubt  as  to  the  existence  of  syphilis,  antisyphilitic  treatment  may  be  given 
for  from  six  to  eight  weeks,  but  only  when  the  patient's  general  condition 
remains  so  satisfactory  that  the  time  can  be  spared. 

An  opening  is  made  in  the  skull,  preferably  by  the  osteoplastic  flap 
method,  and  the  tumor  removed,  after  ligation  of  the  cerebral  vessels  which 
supply  it,  by  ligatures  passed  around  them  with  needles.  OEdema  of  the 
brain  may  follow  the  removal  of  a  tumor,  but  may  be  prevented  by  absolute 
asepsis  and  the  maintenance  of  pressure.  The  mortality  of  these  operations 
appears  to  be  about  thirty  per  cent. 

The  General  Technique  of  Operations  upon  the  Skull  and 
Brain. — The  entire  scalp  should  be  shaved,  if  the  brain  is  to  be  exposed, 
and  sterilized  in  the  usual  way.  During  all  operations  on  the  skull  the 
patient's  head  should  be  elevated,  in  order  to  lessen  the  hemorrhage. 

Trephining. — The  term  trephining  is  used  for  any  operation  for  opening 
the  skull,  whether  the  trephine  or  some  other  instrument  is  employed.  The 
pin  of  the  trephine  is  set  so  as  to  project  slightly  and  made  to  penetrate  the 
bone.  (Fig.  652.)  When  the  crown  of  the 
trephine  touches  the  bone  it  should  be  made 
to  cut  evenly  into  the  latter  on  all  sides  by  regular 
rotation,  and  when  a  groove  has  been  cut  the 
pin  should  be  withdrawn.  The  crown  is  then 
made  to  saw  slowly  through  the  bone  until  the 
diploe  is  divided  and  the  inner  table  reached, 
which  will  be  evident  from  the  greater  resistance 
of  the  latter.  The  groove  is  then  very  slowly 
deepened,  and  the  bottom  of  it  tested  from  time 
to  time  by  a  needle  or  the  flat  end  of  a  probe, 
to  determine  when  the  bone  has  been  completely 
divided.  If  the  latter  is  divided  first  on  one 
side,  the  crown  must  be  slightly  tilted  in  the 
opposite  direction,  so  as  to  avoid  injury  to  the 
dura  while  dividing  the  remaining  bone.  The  central  portion  of  the  bone, 
known  as  the  button,  is  to  be  removed  by  prying  it  out  of  place.     The  ordi- 


OSTEOPLASTIC  RESECTION  OF  THE  SKULL. 


737 


nary  trephine  is  uow  used  only  for  small  openings  not  over  an  inch  in  diam- 
eter. If  a  larger  opening  is  necessary,  that  made  by  the  trephine  may  be 
enlarged  by  cutting-forceps  or  gouge.  For  certain  operations  the  gouge  and 
mallet  may  be  employed,  the  gouge  being  applied  obliquely  and  very  thin 
chips  removed.  This  cuts  away  the  bone  very  gradually  without  danger  of 
wounding  the  dura  and  lessens  the  shock  caused  by  the  blows  of  the  mallet. 
Various  saws  operated  by  electricity  or  the  dental  engine  may  also  be  used 
for  trephining. 

Depressed.  Bone. — In  cases  of  compound  fracture  a  wound  is  already 
present,  and  it  is  oply  necessary  to  enlarge  it  in  the  most  suitable  directions 
to  make  a  flap.  Loose  fragments  are  easily  raised,  and  impacted  fragments 
may  be  released  by  cutting  away  the  bone  with  the  gouge  or  rongeur,  or  the 
trephine  may  be  applied  with  a  paTt  of  its  circle  projecting  over  the  edge 
of  the  fractured  bone.  When  a  depressed  fracture  exists,  without  any 
external  wound,  a  flap  must  be  cut  so  as  to  expose  the  point  of  fracture. 
As  a  rule,  in  operations  upon  the  skull  flaps  are  made  of  a  horseshoe  or  rec- 
tangular shape,  with  the  base  below.  The  pericranium  is  stripped  from  the 
bone  with  the  flap. 

Osteoplastic  Flap.— The  osteoplastic  method  of  Wagner- Wolff  makes 
a  flap  of  bone  and  skin  which  can  be  reflected  during  the  operation  and 
restored  so  as  to  close  the  opening  in  the  skull  afterwards.  It  is  performed 
as  follows  :  A  horseshoe-shaped  incision  is  made,  and  the  edges  are  allowed 
to  retract.     A  groove  is  then  cut  in  the  bone  following  the  line  to  which  the 

skin  of  the  flap  has  retracted.    (Fig.  6.53.) 

This  groove  may  be  cut  with  a  chisel  or 

&5\i.     'with  a  circular  saw  run  by  an  electro- 


FiG  b53 


Osteoplastic  resection  of  the  skull :  cutting  the 
bone-flap  with  a  chisel.    (After  Treves.) 


Osteoplastic  resection  of  the  skull :  flap  turned  down, 
exposing  the  dura  mater.    (After  Treves.) 


motor,  and  should  be  oblique,  so  that  the  outer  table  of  the  flap  shall  rest  on 
the  inner  table  of  the  skull  when  the  bone-flap  is  turned  back  into  place.  The 
bone  is  then  cut  partly  through  under  the  base  of  the  flap  as  far  as  possible 
with  the  chisel  without  disturbing  the  soft  parts  any  more  than  is  necessary, 
and  the  remaining  bone  at  the  base  is  broken  and  the  flap  turned  back,  the 
scalp  acting  as  a  hinge.     (Fig.  654. )     The  wire  saw  invented  by  Gigli  as  a 


738  OPERATIONS  UPON  THE  BRAIN. 

substitute  for  the  chain  saw  may  also  be  employed.  Two  small  trephine 
openings  are  made,  a  flat  director  introduced  to  separate  the  dura  and  the 
bone  between  them,  and  the  wire  saw  drawn  through  by  a  thread  passed 
from  one  opening  to  the  other  by  a  probe.  The  bridge  of  bone  is  then  sawed 
through.  Any  desired  amount  of  bone  can  be  removed  by  making  three  or 
four  trephine  openings  and  sawing  between  them.  To  make  an  osteoplastic 
flap,  the  skin  is  left  undivided  on  one  side  and  adherent  to  the  bone  flap, 
and  the  saw  is  made  to  cut  the  bridge  of  bone  between  the  trephine  openings 
obliquely  so  as  to  bevel  the  edges  of  the  flap.  The  bone  at  the  base  of  the 
flaj)  can  be  divided  easily  without  injury  to  the  skin. 

Hemorrhage  from  the  Bone. — Hemorrhage  from  the  veins  of  the 
diploe  can  be  controlled  by  pressure,  by  breaking  in  the  bone  around  the 
opening  with  a  blunt-pointed  instrument,  by  stuffing  a  little  catgut  into  the 
bleeding  vessel,  or  by  filling  the  open  vessels  with  a  mixture  of  bees- wax  and 
paraffin  sterilized  by  heat.  (See  page  331. )  If  the  hemorrhage  or  shock  of 
exposing  and  exi^loring  the  brain  threatens  to  be  too  great,  the  wound  may  be 
packed,  or  closed  temporarily,  and  the  operation  resumed  a  few  days  later. 

The  Brain. — When  the  dura  is  incised  it  should  be  opened  by  a  semi- 
circular flap,  and  not  by  a  crucial  incision.  If  it  is  necessary  to  divide  the 
cortex  or  to  remove  a  part  of  it  (for  ejjileijsy,  for  instance),  the  vessels  must 
first  be  secured  by  fine  ligatures  passed  around  them  by  blunt-pointed 
curved  needles.  If  one  of  the  sinuses  is  wounded,  hemorrhage  may  be  con- 
trolled by  suture  of  the  wall  or  by  simple  j)ressure  with  gauze,  the  end  of 
the  latter  being  brought  out  of  the  wound.  When  the  normal  brain  is 
exj)osed  it  usually  bulges  into  the  opening  and  pulsates,  unless  the  heart- 
action  is  feeble.  Unusual  protrusion  indicates  pressure  by  an  over-distended 
ventricle,  a  tumor,  a  clot,  or  an  abscess,  and  lack  of  pulsation  shows  that 
the  tumor,  blood,  or  pus  is  close  to  the  opening  in  the  skull.  In  exijloration 
for  pus  or  fluid  a  blunt  instrument  like  a  small  director  is  to  be  preferred  to 
an  aspirating-needle,  as  the  latter  is  apt  to  provoke  troublesome  hemorrhage. 
The  various  motor  centres  can  be  accurately  located  by  touching  them  with 
a  double-ended  sterilized  electrode  through  which  a  very  weak  current  is 
passed,  and  observing  the  muscles  affected.  A  tumor  may  be  recognized  by 
the  hard  resistance  felt  in  the  depth,  and  a  cyst  or  an  abscess  may  give  a 
sense  of  fluctuation.  An  encapsulated  tumor  may  be  shelled  out  with  the 
fingers  or  blunt  instruments,  but  this  is  to  be  done  cautiously,  because  it  is 
imijossible  to  control  any  bleeding  from  the  bottom  of  such  a  wound  by 
ligatures.  If  there  is  much  hemorrhage  after  the  removal  of  the  tumor,  the 
wound  may  be  packed.  A  sti'ip  of  gauze  is  to  be  placed  in  the  bottom  of 
the  cavity  and  the  end  led  out  through  the  opening,  a  second  strip  is  placed 
next  to  the  first,  and  so  on,  the  end  of  every  strip  being  carried  down  to  the 
bottom.  Firm  pressure  is  then  applied  by  a  dressing.  Quite  severe  hemor- 
rhage may  be  controlled  in  this  way  without  producing  symptoms  of  com- 
pression, if  the  gauze  is  properly  inserted. 

Closing  the  Wound. — If  there  is  no  oozing,  the  wound  may  be  closed, 
the  dural  flap  being  turned  down  and  secured  by  interrupted  or  continuous 
sutures  if  there  is  not  too  much  tension.  If  the  dura  has  been  removed, 
pieces  of  rubber  tissue,  gold-leaf,  or  celluloid  have  been  inserted  with  sue- 


CEREBRAL  LOCALIZATION.  739 

cess  to  prevent  tlie  formation  of  too  strong  adhesions  between  the  brain  and 
the  bone  or  the  skin-flap.  Keen  has  suggested  that  a  flap  of  pericranium 
be  dissected  up  and  inverted  into  the  wound,  with  the  bone-producing  side 
uppermost.  If  there  seems  to  be  oozing,  or  if  there  is  any  likelihood  of 
retention  of  secretions,  a  small  drain  should  be  inserted.  If  a  bone-flap  has 
been  formed,  it  may  be  returned  to  its  place  and  secured  by  sutures ;  if  a 
trephine  button  has  been  removed  and  loose  fragments  have  been  taken  from 
the  edge,  they  may  be  replaced,  the  large  button  being  broken  into  pieces 
about  half  an  inch  square.  The  bone  should  be  placed  in  warm  sterilized 
salt  solution  immediately  on  removal  if  it  is  intended  to  replace  it. 

Removal  of  the  Gasserian  Ganglion. — This  ganglion  may  be 
removed  by  the  osteoplastic  operation,  as  suggested  by  Hartley  and  Krause. 
A  horseshoe-shaped  osteoplastic  flap  is  made  in  the  temporal  region  with 
its  base  at  the  zygoma.  A  little  more  of  the  bone  at  the  base  of  the  skull  is 
gnawed  away  with  rongeurs,  and  then,  while  the  bone-flap  is  strongly 
retracted  and  turned  down  towards  the  cheek,  and  the  brain  covered  by  the 
uninjured  dura  is  drawn  inward  by  a  very  broad  retractor,  the  Gasserian 
ganglion  is  seen  at  the  bottom  of  the  wound.  The  ganglion  is  to  be  seized 
with  strong  forceps  after  being  separated  by  blunt  dissection,  the  second  and 
third  divisions  of  the  nerve  cut  across  as  close  as  possible  to  the  foramina  of 
exit,  and  the  central  nerve-root  and  the  first  division  slowly  twisted  out  by 
rotating  the  forceps.  The  mortality  from  this  operation  is  still  high  (ten 
per  cent.),  on  account  of  its  difficulties  and  the  feeble  state  of  the  patients, 
but  the  results  as  to  a  permanent  cure  promise  to  be  excellent. 

Localization. — The  doctrine  of  localization  is  briefly  this  :  Each  func- 
tion of  the  brain  is  carried  on  by  some  particular  j^art,  called  a  centre,  and 
the  removal  or  destruction  by  disease  of  any  centre  causes  the  loss  of  the 
corresponding  function.  It  is  possible  in  some  cases  for  other  parts  of  the 
brain  to  take  up  the  work  of  certain  centres  when  destroyed,  but  this  sub- 
stitution is  so  slow  and  imperfect  that  it  can  be  disregarded  in  making  a 
diagnosis.  The  centre  for  speech,  for  example,  is  usually  situated  on  the 
left  side  of  the  head  in  right-handed  persons,  and  an  injury  upon  that  side 
of  the  head  appears  sufficient  to  produce  complete  aphasia,  which  may 
remain  permanently  in  some  persons,  but  in  the  majority  the  i^ower  of 
speech  returns  after  an  interval,  because  of  the  education  of  the  similar  part 
of  the  brain  on  the  other  side. 

The  chief  motor  centres  are  shown  in  Fig.  6.55  as  they  lie  clustered  about 
the  fissure  of  Eolando,  those  of  the  leg  being  near  the  vertex,  and  those  of 
the  arm  and  the  face  lower  down.  Their  position  may  be  defined  by  certain 
external  landmarks.  Technical  names  have  been  given  to  certain  points 
upon  the  skull,  such  as  the  nasion,  the  junction  of  the  nasal  and  frontal 
bones ;  the  glabella,  the  protuberance  just  above  the  root  of  the  nose  ;  the 
inion,  the  occipital  i>rotuberance ;  the  pterion,  the  meeting-point  of  the 
sphenoid  with  the  frontal,  parietal,  and  temporal  bones ;  the  bregma,  the 
junction  of  the  sagittal  and  coronal  sutures  ;  the  stephanion,  where  the  tem- 
poral ridge  crosses  the  coronal  suture  ;  the  asterion,  the  meeting-point  of  the 
parietal,  occipital,  and  temporal  bones  ;  and  the  lambda,  the  junction  of  the 
sagittal  and  lambdoid  sutures. 


740 


CEREBRAL  LOCALIZATION. 


Reid's  base-line,  which  is  used  in  certain  measurements,  is  a  line  indi- 
cated by  a  plane  passing  through  the  infra-orbital  ridge  and  the  centre  of 
the  external  auditory  meatus  on  either  side  of  the  head  and  continued  back- 


Motor  centres. 


ward  towards  the  occiput.     (Fig.  656,  h,  h'.)    The  transverse  fissure  lies  just 
above  this  plane  across  the  back  of  the  head. 

To  find  the  fissure  of  Rolando  (Thane,  Hare),  the  distance  from  the 
glabella  to  the  inion  is  measured,  and  .557  of  this  distance  measured  back- 


External  guides  to  the  lateral  sinus,  etc.  From  the  Lancet,  in  Sajous's  "  Annual  of  the  Universal  Medi- 
cal Sciences."  g*,  external  auditory  meatus  ;  h,  h',  Reid's  base-line  marked  in  one-eighth  inch  spaces ;  x,  x, 
level  of  tentorium ;  /,  lateral  sinus';  TS,  anterior  end  of  the  temporo-sphenoidal  bone.  Trephine  openings  : 
A,  for  lateral  sinus  ;  B,  to  explore  roof  of  tj'mpanum  ;  C,  for  mastoid  antrum  ;  D,  for  temporo-sphenoidal 
abscess ;  E,  for  cerebellar  abscess. 

ward  from  the  point  of  the  glabella  will  mark  the  upper  end  of  the  fissure 
of  Eolando.  In  most  skulls  this  is  half  an  inch  behind  the  middle  point  of 
the  measured  line.  The  fissure  runs  forward,  making  an  angle  of  sixty- 
seven  degrees  with  the  middle  line  (Fig.  655),  and  this  angle  can  be  laid  off 
by  the  use  of  the  cyrtometer,  which  is  a  strip  of  flexible  metal  marked  with 


CEKEBRAL  LOCALIZATION. 


741 


a  scale  of  inches  or  centimetres  and  having  a  similar  striji  fixed  at  an  angle 
of  sixty-seven  degi'ees.  (Figs.  657  and  658. )  Eeid  has  given  an  easy  prac- 
tical way  of  finding  the  angle  of  sixty-seven  degrees  for  the  fissnre  of 
Eolando.     If  a  j)iece  of  paper  is  cut  with  an  angle  of  ninety  degrees,  and 


Fig.  657. 


Fig.  658. 


Wilson's  cyrtometer.    (Bramwell.) 


Wilson's  cyrtometer  applied.    (Bramwell.) 


folded  so  that  the  two  sides  of  the  right  angle  lie  together  and  the  crease 
runs  straight  to  the  ijoint,  each  of  these  angles  will  measure  forty-five 
degrees.  One  side  of  the  paper  is  then  doubled  again,  so  that  its  edge  lies 
parallel  to  the  folded  edge,  forming  an  angle  of  twenty-two  and  a  half 
degrees.  The  first  doubling  is  then  unfolded,  and  the  sum  of  the  larger 
plus  one  of  the  smaller  triangles  makes  sixty-seven  and  a  half  degrees 
(45  -f  22  J  =  671),  which  is  near  enough  for  i^ractical  purposes. 

To  find  the  fissure  of  Sylvius  (Pig.  655)  Dana  gives  the  rule  :  imagine 
a  vertical  line  from  the  stephanion  to  the  middle  of  the  zygoma,  and  then 
a  horizontal  line  from  the  external  angular  process  to  the  highest  part 
of  the  squamous  suture.  The  point  of  junction  of  these  two  lines  will  be 
the  beginning  of  the  fissure  of  Sylvius,  and  the  vertical  line  will  indicate 
nearly  the  position  of  the  anterior  or  vertical  branch  of  the  fissure.  The 
motor  centre  of  speech  lies  just  in  front  of  the  vertical  branch  of  the  fissure. 
(Fig.  655.)  The  temporal  lobe,  of  which  the  fissure  of  Sylvius  is  the 
anterior  or  ui^per  boundary,  extends  nearly  as  far  forward  as  the  posterior 
edge  of  the  orbital  process  of  the  malar  bone.  (Fig.  656,  TS. )  The  parieto- 
occipital fissure,  or  upper  border  of  the  occipital  lobe,  lies  just  above  the  ■ 
lambda.  The  lower  border  of  the  temporal  lobe  corresj^onds  to  a  line  drawn 
from  a  point  twelve  millimetres  above  the  zygoma  and  the  external  auditory 
meatus  to  the  asterion  (Dana).  The  temporal  lobe  is  about  four  centimetres 
wide  at  the  external  auditory  meatus,  and,  according  to  Von  Bergmann,  a 
trephine  aj)plied  half  an  inch  above  the  meatus  would  enter  the  lower  part 
of  the  lobe.  (Fig.  656,  B.)  The  middle  meningeal  artery  follows  nearly 
the  course  of  the  squamous  suture  anteriorly,  and  its  anterior  branch  is 
given  off  at  the  pterion.     (See  page  725.) 


48 


CHAPTEE   XXIX. 

INJURIES  AND   SURGIOAL   DISEASES  OF  THE  FACE. 
By  B.  Faeqtjhae  Cuetis,  M.D. 


Wounds. — Incised  wounds  of  the  face  bleed  freely,  but  heal  very 
rapidly,  leaving,  as  a  rule,  smooth  scars.  Contused  and  lacerated  wounds 
may  also  be  sutured,  for  the  great  vascularity  of  the  skin  of  the  face  enables 
it  to  live  even  when  severely  contused  or  stripped  up  in  thin  flaps.  Contu- 
sions of  the  face  are  marked  by  the  formation  of  a  considerable  hsematoma, 
with  oedema,  and  eechymosis,  especially  about  the  eyelids. 

Treatment. — Accurate  apposition  is  important  in  facial  wounds  to 
avoid  disfigurement,  hence  the  vermilion  border  of  the  lip  should  be  accu- 
rately maintained,  the  cartilages  and  the  skin  of  the  nose  must  be  carefully 
brought  into  place,  and  sutures  should  be  so  placed  as  to  prevent  inversion 
of  the  thin  skin  of  the  eyelid.  Very  fine  silk  sutures  are  to  be  introduced 
close  together  by  fine  needles,  and  they  should  be  removed  on  the  fourth 
day  if  the  wound  is  aseptic  and  there  is  no  tension,  in  order  to  avoid  a  scar. 

Foreign  Bodies. — Foreign  bodies  should  be  carefully  removed  from 
all  wounds,  for  wounds  of  the  face  are  ijarticularly  liable  to  reflex  irritation 
on  account  of  the  abundant  nerve-supply,  and  j)ainful  scars  and  even  epi- 
lei)tic  attacks  may  be  the  consequence  of  neglected  foreign  bodies.  Occa- 
sionally a  foreign  body  becomes  impacted  in  the  tissues,  and  the  wound 
refuses  to  heal  until  it  has  been  extracted.  Wounds  of  the  cheek  may 
involve  the  parotid  duct  and  result  in  a  salivary  fistula. 

Burns. — Burns  of  the  face  are  very  common.  To  avoid  the  disfigure- 
ment caused  by  deep  burns,  the  latter  should  be  treated  in  the  stage  of 
granulation  by  Thiersch's  skin-grafts.  Plastic  operations  are  frequently 
necessary  on  account  of  the  later  contraction  of  these  scars,  and  especially 
to  correct  e version  of  the  eyelids. 

INFLAMMATIONS. 

Dermatitis. — Dermatitis  of  the  face  often  occasions  great  oedema  of  the 
eyelid,  and  conjunctivitis  is  frequently  associated  with  it. 

Furuncles. — Furuncles  are  especially  common  on  the  upper  lip  and 
in  the  nose,  especially  on  the  septum.  They  are  serious  affections  because 
of  the  close  connection  between  the  facial  veins  and  the  sinuses  of  the  brain 
by  way  of  the  veins  of  the  orbit,  and  if  phlebitis  begins  in  the  face  it  may 
travel  backward  and  involve  the  brain,  with  fatal  results.  Furuncles  in 
this  situation  therefore  should  be  incised  very  early,  before  suppuration 
occurs.  Anthrax  is  quite  common  on  the  face,  and  many  cases  of  supposed 
carbuncle  are  due  to  this  infection. 
742 


CONGENITAL  DEFORMITIES   OF  THE   FACE.  743 

Celullitis  and  Erysipelas. — Cellulitis  and  erysipelas  of  the  face  are 
fi-equeut,  but  the  cellulitis  is  usually  limited.  Erysipelas  occurs  in  two 
forms,  the  mild  form,  which  develops  apparently  without  any  primary 
lesion,  and  the  suppurative  form,  in  which  the  infection  involves  the  sub- 
cutaneous tissue  as  well  as  the  skin.  The  mild  form  spreads  slowly  and 
causes  no  great  constitutional  disturbance.  It  is  a  very  treacherous  disease, 
however,  as  at  any  time  cerebral  complications  may  develop,  so  that  even 
the  lightest  cases  need  careful  watching. 

Abscesses. — Abscesses  of  the  face  are  due  to  the  infection  of  fresh 
woiinds,  to  suppurative  processes  beginning  in  the  bones  and  extending  into 
the  subcutaneous  tissue,  and  to  infection  and  suppuration  of  the  lymphatic 
glands  or  the  parotid  glands. 

Treatment. — The  lines  of  incision  for  abscesses  and  inflammatory  con- 
ditions should  be  planned  to  correspond  with  the  natural  lines  and  folds  of 
the  face,  so  as  to  cause  as  little  disfigurement  as  possible.  They  should  also 
be  so  placed  as  to  avoid  injury  to  the  branches  of  the  facial  nerve  and  to 
Steuo's  duct.     The  treatment  is  similar  to  that  of  inflammation  in  general. 

Lympliatic  Glands. — The  lymphatic  glands  of  the  face  are  not 
numerous,  and  the  most  important  are  situated  (1)  in  the  depth  of  the  cheek 
near  the  mucous  membrane  of  the  mouth,  (2)  near  the  course  of  the  facial 
artery  just  above  the  border  of  the  lower  jaw,  and  (3)  just  in  front  of  the  ear 
over  the  facial  nerve.  The  last-mentioned  gland  is  generally  affected  in 
inflammations  about  the  ear.  The  gland  at  the  border  of  the  lower  jaw  is 
not  infrequently  enlarged  secondary  to  cancer  of  the  lip. 

Suppurative  and  Syphilitic  Osteitis. — luflammatiou  of  the  bones 
of  the  face  is  exceedingly  common,  particularly  in  the  jaws,  on  account  of 
infection  from  diseased  teeth.  The  bones  of  the  nose  are  frequently  the  seat 
of  necrosis  as  the  result  of  syphilis.  A  periostitis  may  be  caused  by  infec- 
tion fi-om  an  ulcer  in  the  early  stages,  or  a  gumma  may  attack  either  the 
j)eriosteum  or  the  bone  itself  in  the  tertiary  period.  In  the  first  place  there 
will  be  an  acute  inflammatory  condition,  with  the  formation  of  abscesses 
and  sequestra,  but  in  the  second  the  bone  may  be  absorbed  and  disappear  in 
the  course  of  a  chronic  purulent  discharge  from  the  nose  with  only  slight 
external  signs.  Hereditary  syphilis  affects  the  bones  like  the  tertiary  form. 
The  treatment  of  osteitis  here  is  the  same  as  elsewhere, — early  incision  of 
abscesses,  removal  of  sequestra,  and  curetting  of  softened  bone. 

Facial  Tetanus. — That  peculiar  variety  of  tetanus  known  as  facial 

tetanus  should  be  borne  in  mind  in  connection  with  wounds  of  the  face. 

(See  page  72.)  . 

CONGENITAL  DEFOKMITIES. 

Etiology. — In  considering  the  congenital  deformities  of  the  face  we 
must  bear  in  mind  the  development  of  the  parts  in  the  early  period  of  foetal 
life.  A  central  process  grows  downward  from  the  frontal  bone,  forming  the 
bridge  of  the  nose,  and  two  lateral  j)rocesses  also  descend  on  each  side  of  the 
central  one  and  form  the  sides  of  the  nose,  while  from  the  sides  of  the  head 
shoot  forward  two  processes  which  go  to  form  the  upper  jaws.  (Fig.  659.) 
The  vomer  grows  downward  behind  the  nasal  process  from  the  frontal  bone, 
forming  the  septum  of  the  nose,  and  at  its  end  it  carries  a  small  bone  known 


744 


HARELIP. 


as  the  iutermaxillary  bone  (Fig.  660),  in  which  the  incisor  teeth  develop. 
This  small  bone  often  ijrojects  far  beyond  the  line  of  the  gums,  and  adds 


Fig.  659. 


Development  of  the  foBtal  face.    (Coste.) 


Fig.  660. 


greatly  to  the  difidculty  of  any  plastic  operation  undertaken  to  correct  cleft 
palate.  The  upper  lip  is  formed  of  three  parts,  the  lateral  being  sup- 
plied by  the  processes  of  the  upper  jaw,  and  the  central  part,  or  philtrum, 
growing  from  the  vomer  and  the  intermaxillary 
bone.     Thus  the  cleft  of  harelip  is  always  lateral. 

In  a  small  number  of  cases  heredity  seems  to  be 
active,  but  children  with  harelip  and  cleft  palate 
are  often  born  in  healthy  families,  and,  conversely, 
many  individuals  with  harelip  have  perfectly  well- 
formed  offspring.  The  most  generally  received 
theory  is  that  of  the  mechanical  prevention  of  de- 
velopment by  amniotic  bands  and  adhesions.  Amni- 
otic bands  may  become  interijosed  in  a  cleft  and 
prevent  union  of  its  sides,  or  they  may  lie  across 
one  of  the  processes  and  hinder  its  growth  to  normal 
size  and  its  union  with  its  fellow,  or  they  may  be 
adherent  to  tlie  process  and  to  some  other  part  of 
the  foetus  and  by  their  traction  prevent  the  growth  of  the  former.  Broad 
adhesions  may  form  between  the  amnion  and  part  of  the  foetus,  and  thus 
check  the  growth  of  the  latter. 

Harelip. — The  commonest  of  the  congenital  deformities  of  the  face  is 
harelip  (Fig.  661),  by  which  is  understood  a  cleft  of  the  upper  lip.  It  may 
be  only  a  notch  on  the  red  border,  may  extend  half-way  through  the  lip,  or 
may  be  complete ;  and  in  about  one-half  the  cases  it  is  associated  with  cleft 
palate.  There  may  be  a  cleft  on  one  side  only,  or  one  on  each  side.  (Fig. 
662.)  In  very  extensive  harelip  and  cleft  palate  there  may  be  an  absence 
of  the  central  part  of  the  lip  with  the  intermaxillary  bone  and  part  of  the 
vomer,  so  that  the  cleft  appears  to  be  median,  but  it  is  really  a  bilateral  cleft 
with  absence  of  the  central  piece.  Congenital  median  clefts  have  been 
observed  in  the  upper  lip  in  very  rare  instances,  due  to  fissure  of  the  central 
part,  but  they  are  usually  a  slight  furrow  or  a  sinus.  Harelip  occurs  in 
one  case  in  2400  births. 


Double  cleft  palate  with 
intermaxillary  bone  attached 
to  vomer.    {From  Agnew.) 


HARELIP. 


745 


Prognosis. — The  prognosis  of  tliis  deformity,  if  cleft  jDalate  coexist,  is 
rather  serious.     In  these  cases  the  passage  from  the  nose  to  the  mouth  is 


single  harelip. 


rimiljle  harelip  with  cleft  palate,  showing 
intermaxillary  bone. 


left  open,  and  the  child  is  very  liable  to  respiratory  diseases,  because  the  air 
is  not  filtered  through  a  normal  nose.  The  children  also  swallow  badly,  and 
foreign  bodies,  such  as  food,  easily  find  their  way  into  the  lungs,  causing 
infectious  pneumonia.  For  this  reason  operation  should  be  done  early, 
usually  at  the  age  of  about  three  months,  but  in  strong  infants  it  may  be 
performed  earlier. 

Treatment. — The  numerous  operations  suggested  for  harelip  consist  in 
freshening  the  sides  of  the  cleft  and  bringing  them  together.  Some  operators 
take  off  only  the  border  of  the  cleft,  while  others  cut  away  the  entire  cen- 
tral piece,  even  in  the  unilateral  cases,  claiming  that  in  this  way  they  get  a 
more  symmetrical  union  with  the  scar  in  the  middle  line.  But  the  oiiera- 
tions  most  frequently  employed  are  three  or  four  in  number.    In  very  slight 

Fig.  B64. 


Ndlaton's  operation  for  harelip. 


Mirault's  operation  for  harelip. 


cases,  with  only  a  notch  in  the  vermilion  bordei',  the  method  of  N^laton 
may  be  selected.  A  V-shaped  incision  is  made  above  the  cleft  in  the  lip, 
the  apex  of  the  cleft  is  seized  with  forceiis  and  drawn  down,  and  the  ends  of 
the  incision  (a,  b,  Pig.  663)  are  sutured  across  the  gap,  so  that  the  transverse 


746 


TREATJMEiS'T  OF  HARELIP. 


angular  line  becomes  a  vertical  straight  one.  The  little  teat  of  mucous 
membrane  made  by  drawing  the  flap  down  is  left  projecting  at  the  edge,  and 
is  taken  up  afterwards  by  the  contraction  of  the  scar.  The  method  most 
commonly  useful  is  the  operation  of  Mirault,  in  which  one  side  of  the  cleft 
is  freshened  (cib,  Fig.  664),  but  on  the  other  side  a  small  flap  is  cut  {cd)  with 
its  base  below.  The  flap  (cd)  is  drawn  down  and  across  to  the  other  side 
(the  apex  c  being  united  to  6),  and  the  sutures  inserted.  If  cicatricial  con- 
traction takes  place,  it  simjily  tends  to  straighten  out  the  angle  in  the  line 
of  the  wound,  and  does  not  produce  a  notch  at  the  point  of  union  in  the 
vermilion  border.  The  operation  of  Hagedorn  will  be  best  understood  by 
referring  to  Fig.  665,  in  which  the  incisions  are  marked  in  A,  and  the  figures 
indicate  the  parts  to  be  brought  in  apposition  to  produce  the  result  shown 


Hagedorn's  operation  for  harelip.    (After  Konig.) 

in  B.  In  certain  cases  the  operation  of  Giraldes  will  be  most  useful.  (Fig. 
666.)  The  incisions  being  made  as  indicated,  three  flaps  are  formed,  AB, 
CD,  and  U.  AB  is  turned  up,  CI)  is  drawn  down,  and  E  is  drawn  towards 
the  middle  line.  AB  is  then  sutured  across  under  the  nostril  to  the  upper 
side  of  E.  CD  and  the  under  side  of  E  are  united  to  the  raw  surface  left  by 
turning  up  AB. 


Fig.  666.  b 


Fig.  667.  b 


Girald^s's  operation  for  harelip. 


Operation  for  double  harelip. 


In  the  majority  of  cases  it  will  be  necessary  to  separate  freely  the  attach- 
ment of  the  lips  to  the  gums,  in  order  to  relieve  the  tension  and  allow  of  easy 
adjustment  of  the  two  parts.  If  necessary,  the  cheeks  may  be  dissected  up 
from  the  jaws.  In  double  harelip  the  edges  of  the  central  part  are  pared 
and  flaps  cut  from  each  outer  margin.  (Fig.  667.)  "When  the  intermaxillary 
bone  i^rojects  in  the  cleft  it  may  be  cut  off,  but  a  better  method  is  to  split 
the  mucous  membrane  along  the  lower  edge  of  the  vomer  and  detach  the 
membrane  on  each  side,  then  to  excise  a  triangular  piece  of  the  cartilage, 
which  will  allow  the  projecting  bone  to  be  forced  back  into  line.  Wharton 
divides  the  operation  for  double  harelip  into  two  steps.  The  intermaxillary 
bone  is  separated  with  the  chisel,  forced  into  the  gap  in  the  alveolar  arch, 


TUMORS  OF  THE  FACE.  747 

and  -uired  in  xjlace.  Two  weeks  later  the  lip  is  restored,  but  the  skin  of  the 
intei'maxillary  piece  is  cut  away  except  a  narrow  strip  which  is  utilized  to 
form  a  columna  for  the  uose.  The  lip  is  united  by  two  deep  sutures  of  heavy 
silk  or  silkworm-gut,  which  should  be  passed  through  its  entire  thickness 
except  the  mucous  membrane,  and  by  finer  silk  sutures  through  the  skin  and 
mucous  membrane  only,  care  being  taken  to  adjust  the  vermilion  border 
accuratelj'.  When  there  is  great  tension,  harelip  pins  may  be  necessary, 
which  are  introduced  like  the  deep  sutures,  and  the  wound  is  then  drawn 
together  by  twisting  a  sterilized  thread  in  figure-of-eight  turns  over  the  ends 
of  each  jpin. 

Lateral  Clefts. — A  lateral  cleft  may  exist  at  the  ala  of  the  uose  where 
it  joins  the  cheek,  or  between  the  lateral  frontal  projection  and  the  projec- 
tion which  makes  the  upper  jaw.  The  first  of  these  lateral  clefts  is  neces- 
sarily small,  but  the  second  may  be  very  extensive,  for  in  early  foetal  life 
the  eye  is  found  at  the  upper  outward  angle  of  this  cleft,  and  the  deformity 
may  extend  up  to  the  eye  or  even  farther.  A  lateral  cleft  is  also  seen  at  the 
angle  of  the  mouth,  producing  the  coudition  known  as  macrostoma,  in  which 
the  mouth  is  abnormally  large,  extending  sometimes  as  far  back  as  the 
ramus  of  the  jaw.  Clefts  in  the  lower  lip  are  extremely  rare,  and  may  be 
associated  with  a  cleft  in  the  lower  jaw  and  even  in  the  tongue.  A  delayed 
closure  of  any  of  the  foetal  clefts  occasionally  takes  place,  producing  an 
unsightly  scar  indicating  the  line  of  the  fissure.  Sometimes  there  is  an 
over-production  of  tissiie  in  the  lines  of  the  clefts,  especially  at  the  angles 
of  their  junction,  and  small  fibrous  nodules  or  jjigmented  ntevi  are  formed. 
The  nodules  are  known  as  congenital  tubercles,  and  are  most  frequent  at 
the  root  of  the  nose  and  in  the  centre  of  the  cheek.  In  other  cases  a  sinus 
or  dimple  may  be  left,  and  in  the  lower  lip  a  double  sinus  is  occasionally 
seen,  with  two  minute  openings  symmetrically  iilaced. 

Such  deformities  as  absence  of  an  eye  or  of  the  nose,  or  congenital 
closure  of  the  eyelids  or  of  one  nostril,  or  too  great  narrowing  of  the  mouth 
(microstoma),  are  found,  but  thej^  are  very 
rare.  ^i«.  668. 

Tumors. — Nearly  all  varieties  of  tumors 
are  found  in  the  face. 

Fibroma. — Fibroma  forms   small,    hard 
nodules  or  moderately  soft  tumors  in  the  skin. 
These  should   not  be  confounded  with  con- 
genital  tubercles.      It   may   form    large   flat 
moles,  pigmented,  and  covered  with  hair, — 
the  so-called  hairy  nsevus.    (Fig.  668.)    These 
disfiguring  patches  are  congenital,  and  if  very 
large  cannot  be  treated  with  success.     The 
smaller  moles  may  be  excised.     They  are  lia- 
ble to  malignant  degeneration.    In  some  cases       "^'''>'  "=^''^'^  °^  "^«  ^'"^''-   <ca-'e  of 
a  soft  flbromatous  change  in  the  skin  pro- 
duces large  pendulous  masses,  which  hang  from  the  forehead,  draw  the  eye 
out  of  place,  displace  the  nose  by  pressure,  distort  the  mouth  by  the  swell- 
ing of  the  lips,  and  even  change  the  shape  of  the  bones  of  the  skull  by 


748  .    TUMORS  OF  THE  FACE. 

their  traction.     These  tumors  are  generally  congenital,  or  originate  very 
early  in  life. 

Lipoma. — Lipoma  occurs  on  the  face,  although  it  is  not  very  common. 
On  the  forehead  it  may  be  congenital,  and  in  such  cases  lies  under  the  fascia 
or  the  pericranium,  and  has  a  depression  in  the  skull  beneath  it,  like  the 
dermoids.     Lipoma  is  frequently  combined  with  angioma. 

Osteoma. — Bony  tumors  are  not  uncommon,  and  are  seen  in  the  shape 
of  small  and  very  dense  nodules  on  the  frontal  bone  and  on  the  jaws.  They 
also  occur  in  the  nose  and  the  adjoining  sinuses,  as  described  elsewhere. 

Chondroma. — A  chondroma  may  grow  from  the  various  bones  of  the 
face,  and  usually  ossifies.  Cartilage  is  also  found  as  a  part  of  the  so-called 
mixed  tumors  which  are  so  common  in  the  parotid  gland. 

Angioma.^ Angioma  is  one  of  the  most  common  tumors  of  the  face,  and 
occurs  in  all  varieties,  from  a  mere  telangiectasis  to  a  cavernous  mass.     The 

tumors  may  be  pedunculated  and  globular 
Fig.  669.  in  shape,  sometimes  hanging  from  the  end 

':  of  the  nose  and  attaining  a  considerable 

size.  On  the  forehead  angioma  forms,  as 
a  rule,  a  small  tumor ;  in  the  cheek  and 
lips,  however,  it  may  involve  their  entire 
thickness  and  affect  the  mucous  mem- 
brane. (Fig.  669.)  It  often  attacks  the 
muscles  in  these  situations,  their  capilla- 
ries being  degenerated,  so  that  a  thorough 
removal  necessitates  a  very  extensive 
operation.  The  most  suitable  mode  of 
treatment  of  angioma  of  the  face  is  ex- 
cision when  the  tumor  is  small  and  the 
Angioma  of  the  lip.  wound  Can  be  neatly  brought   together, 

placing  the  scar  in  a  situation  where  it 
will  not  be  noticeable.  In  other  cases  the  neoplasm  must  be  treated  by 
multiple  puncture  with  a  red-hot  needle  or  by  electrolysis.  (See  page  290.) 
Lymphatic  Tumors. — An  encapsulated  lymphangioma  occurs,  and 
also  a  general  dilatation  resembling  elephantiasis,  which  is  hable  to  affect 
the  lips,  producing  the  condition  known  as  macrocheilia.  Lymphangioma 
sometimes  becomes  cystic,  the  cavities  continually  growing  larger  and  the 
walls  between  them  breaking  down  until  a  single  large  cyst  is  produced, 
occasionally  with  little  trace  of  angiomatous  tissue  around  it. 

Papilloma. — Papilloma  is  Cjuite  common  in  the  skin  of  the  face,  forming 
small  tumors  which  do  not  differ  from  warts  in  other  situations,  except  that 
they  should  be  very  carefully  watched  for  fear  of  a  change  into  epithelioma. 
Adenoma. — Adenoma  may  originate  in  the  sebaceous  or  sweat  glands 
of  the  skin,  forming  small  tumors,  and  occasionally  masses  of  considerable 
size.  It  also  originates  in  the  mucous  glands  of  the  lip,  and  is  apt  to  he  cystic. 
Mixed  Tumors. — Mixed  tumors  resembling  those  of  common  occur- 
rence in  the  parotid  are  found  also  in  the  lip  and  cheek.  They  form  hard, 
nodular  masses,  growing  very  slowly,  but  with  a  tendency  to  become  sar- 
comatous, and  to  return  after  removal. 


CARCINOMA  OF  THE  LIP.  749 

Sarcoma. — Sarcoma  is  rare  in  the  face  except  as  it  originates  in  tlie 
various  bones,  in  the  salivary  glands,  or  in  the  contents  of  the  orbit. 

Carcinoma. — Carcinoma  is  one  of  the  most  frequent  tumors  of  the  face, 
certainly  the  most  frequent  in  adults.  It  usually  develops  in  the  skin  and 
has  the  characteristics  of  epithelioma  of  the  skin  else\yhere,  being  of  slow 
growth,  and  attacking  and  infecting  the  glands  late.  It  may  exist  for  ten, 
fifteen,  or  twenty  years,  and  cause  extensive  destruction.  The  mildest  form 
of  epithelioma  is  that  known  by  the  name  of  rodent  ulcer,  or  Jacob's  ulcer, 
which  tends  to  heal  in  some  parts  while  spreading  in  other  directions,  and 
has  a  tendency  to  contraction  in  its  base,  so  that  the  ulcer  does  not  spread 
rapidly,  and  the  surrounding  skin  is  drawn  in  around  it,  making  folds  and 
wrinkles.  Even  the  microscopic  appearances  are  deceptive,  but  true  epithe- 
lial "nests"  can  be  found  if  a  proper  search  be  made.  Epithelioma  of  the 
skin  in  this  region  is  very  apt  to  develop  from  a  seborrhoea,  a  chronic 
inflammation  of  the  sebaceous  glands,  which  forms  a  thickened  patch  in  the 
superficial  part  of  the  skin  from  a  quarter  of  an  inch  to  an  inch  in  diameter, 
covered  with  a  dry,  scaly  secretion  resembling  dandruff.  The  first  signs  of 
the  change  to  epithelioma  are  an  increased  thickening  of  the  skin  and  a  ten- 
dency to  ulceration,  and  when  these  appear  the  entire  patch  should  be 
excised.  Epithelioma  developing  in  these  glands  may  be  multiple,  appear- 
ing at  the  same  time  in  different  parts  of  the  face. 

Treatment. — Epithelioma  of  the  face  requires  comj)lete  extirpation. 
Although  this  may  be  done  with  caustics  or  the  cautery,  the  knife  is  the 
only  satisfactory  agent.  If  the  tumor  is  very  small  (less  than  half  an  inch  in 
diameter),  the  incision  may  be  made  one-quarter  of  an  inch  from  the  diseased 
tissue,  but  if  it  be  of  considerable  size,  half  an  inch  of  sound  skin  should  be 
sacrificed  on  all  sides.  The  gap  in  the  skin  can  be  filled  by  a  plastic  opera- 
tion or  by  Thiersch's  skin-grafts. 

Carcinoma  of  the  Lip. — Cancer  of  the  lip  is  a  disease  almost  exclu- 
sively limited  to  men,  particularly  to  those  who  are  much  exposed  to  the 
weather,  and  the  smoking  of  a  short  j)ipe  appears  to  be  a  frequent  exciting 
cause.  It  may  also  originate  in  neglected  ulcers  of  the  lip  following  some 
trifling  scratch,  or  herpes.  It  is  almost  invariably  an  epithelioma.  The 
disease  is  more  frequent  in  the  lower  lip.  When  it  occurs  in  the  upper  lip 
it  is  less  malignant,  being  very  often  in  the  form  of  an  ordinary  epithelioma 
of  the  skin,  which  involves  the  mucous  membrane  secondarily.  Epithe- 
lioma of  the  lip  is  rare  in  women,  but  when  it  does  occiir  in  them  it  is  quite 
as  likely  to  appear  in  the  upper  lip  as  in  the  lower. 

Clinical  Varieties. — The  disease  appears  in  several  different  tj'pes.  It 
may  begin  as  a  very  chronic  ulcer,  with  an  indurated  base,  causing  little 
annoyance.  In  other  cases  it  flrst  apiaears  as  a  fissure  of  the  lip,  extending 
quite  deeply  into  the  tissues  and  not  spreading  much  on  the  surface,  and  this 
form  usually  grows  more  rapidly.  Another  variety  is  a  sprouting  papil- 
lomatous growth,  which  tends  to  rise  above  the  level  of  the  lip,  rather  than 
to  attack  the  deeper  tissues.  A  fourth  form  appears  as  a  thickeued  patch 
in  the  mucous  membrane,  which  has  very  little  tendency  to  ulceration,  and 
may  remain  quiescent  for  a  long  time.  The  lymphatic  glands  are  involved 
rather  late  in  epithelioma  of  the  lip,  and  in  examining  for  them  it  is  well  to 


750 


carcinojma  of  the  lip. 


Fig.  670. 


insert  the  finger  and  press  on  the  floor  of  the  mouth,  while  the  other  hand 
feels  beneath  the  chin,  for  very  small  glands  may  be  found  in  this  way  which 
would  otherwise  escape  detection.  Occasionally  the  suaall  gland  which  lies 
on  the  border  of  the  jaw  near  the  facial  artery  is  affected.  Epithelioma  of 
the  lip  majr  sj^read  in  the  skin  or  in  the  mucous  membrane,  but  generally 
both  are  involved.  The  great  majority  of  these  tumors  are  situated  near 
one  angle  of  the  mouth,  and  occasionally  they  lie  directly  at  the  angle. 
Instances  have  been  reported  in  which  epithelioma  has  aj)i5eared  on  the 
upper  lip  at  the  point  of  contact  with  a  cancer  of  tlie  lower  lip,  apparently 
being  due  to  infection  or  grafting  of  the  malignant  tumor.  The  progress  of 
the  disease  is  not  rapid,  and  it  may  extend  slowly  for  four  or  five  years, 
until  the  entire  lower  lip  is  destroyed.  The  glands  of  the  neck  are  then 
genexally  very  much  enlarged  and  the  patient  suffers  much  pain,  but  in  the 
earlier  stages  pain  is  not  a  marked  symptom.  Hemorrhage  from  these 
tumors  is  rare. 

The  diagnosis  of  epithelioma  depends  upon  the  slow  growth  of  the 
tumor,  its  tendency  to  ulceration,  and  the  marked  hardness  of  its  tissues. 
The  primary  lesion  of  syphilis  occasionally  leads  to  error,  but  a  secondary 
eruption  may  be  present,  and  the  glands  are  involved  early.     A  chancre  has 

a  more  inflamed  appearance  and  its  sur- 
face is  glazed,  while  the  ulcer  of  cancer 
is  sloughing  or  covered  with  the  peculiar 
granulations  of  epithelioma.  In  doubtful 
cases  a  piece  should  be  excised  for  micro- 
sco[»ic  examination. 

Treatment. — The  results  of  treat- 
ment by  operation  are  good  and  have 
been  improving,  so  that  of  the  average 
hospital  cases  one  may  hope  to  save  forty 
or  fifty  jjer  cent,  by  thorough  operation, 
while  in  cases  operated  upon  early  the 
percentage  of  cures  ought  to  be  consider- 
ably above  this.  The  operation  consists 
in  free  excision  of  the  tumor,  cutting  at 
least  half  an  inch  away  from  the  diseased 
tissue.  The  wound  can  be  brought  to- 
gether best,  if  the  tumor  is  not  too  large, 
by  making  the  incision  V-shaped.  (Fig. 
670.)  If  it  is  necessary  to  remoA'e  more 
than  one-half  of  the  lower  lij),  however, 
Malgaigne's  excellent  method  of  filling  the  gap  is  to  be  used.  This  consists 
in  making  the  excision  in  such  a  way  as  to  leave  a  square  defect  in  the  lip, 
then  making  two  horizontal  incisions  on  each  side,  the  lower  pair  beginning 
at  the  bottom  of  the  wound  and  the  upper  pair  beginning  at  the  angles  of 
the  mouth,  dividing  the  entire  thickness  of  the  cheek,  and  forming  two  rec- 
tangular flajjs,  which  are  drawn  together  to  cover  the  gap.  Along  the  upper 
edge  of  the  flaps  which  form  the  new  lip  the  mucous  membrane  is  sutured 
to  the  skin.     It  is  possible  to  remove  half  or  even  three-quarters  of  the  lower 


'.J 

Jipithelioiiia  ot  tlii'  lower  lip,  showing  lines  of 
excision  when  the  tumor  is  near  the  angle. 


DEFORMITIES  OP  THE  NOSE.  751 

lip  without  leaving  a  permanent  deformity,  for  although  the  mouth  is  much 
dra-n^u  up  immediately  after  the  operation,  in  the  course  of  from  three  to 
six  months  the  tissues  stretch  out  and  the  mouth  becomes  natural  in  appear- 
ance. The  region  under  the  chin  should  always  be  explored  by  a  transverse 
incision,  as  the  glands  will  occasionally  be  found  enlarged,  but  so  embedded 
in  the  fat  as  not  to  be  recognized  through  the  skin.  In  long-standing  or 
rapidly  growing  cases  the  submaxillary  region  should  be  thoroughly  dissected 
and  all  lymphatic  glands  removed,  even  if  not  cA'idently  diseased.  The 
necessity  for  this  precaution  is  shown  in  many  instances  where  secondary 
deposits  may  cause  the  death  of  the  patient  even  when  no  local  recurrence 
takes  place. 

Cysts. — Sebaceous  cysts  of  the  face  are  very  common,  especially  on 
the  cheek,  just  below  the  eye,  near  the  border  of  the  lower  jaw,  and  on  the 
forehead.  (For  dermoid  cysts,  see  page  270.)  Mucous  cysts  are  very  com- 
mon in  the  lips,  forming  translucent  tumors  projecting  under  the  mucous 
membrane,  which  is  greatly  thinned  and  often  adherent  over  them,  so  that 
it  is  difficult  to  dissect  it  up.  They  should  be  treated  by  excision,  or  by 
incisiou  and  a  thorough  cauterization  of  the  lining  membrane  with  a  drop 
of  carbolic  acid.  If  the  membrane  is  not  destroyed,  the  cysts  generally  form 
again.  Hypertrophy  of  the  mucous  glands  of  the  lip  may  make  a  thick 
fold  of  mucous  membrane  just  within  the  mouth,  ijroducing  the  malforma- 
tion known  as  double  lip.  It  can  be  treated,  if  the  deformity  is  great,  by 
excising  the  hypertrophied  tissues  between  ellijitical  incisions  and  by  suture 
of  the  wound.  Cysts  of  the  Meibomian  glands  are  not  uncommon  in  the 
eyelids,  and  are  usually  small.  When  inflamed  they  form  a  very  obstinate 
variety  of  "sty,"  which  requires  free  incisiou  and  extirpation  of  the  sac  to 
obtain  a  permanent  cure. 

INJUEIES   AND   SURGICAL  DISEASES   OF   THE  NOSE. 

Injuries. — Fractures  of  the  nose  are  considered  in  the  chapter  on 
Fractures.  A  severe  blow  upon  the  nose,  even  without  fracture,  may  form 
a  htematoraa  of  the  septum  which  may  block  up  the  interior  of  the  nose, 
and  if  not  promptly  absorbed  may  become  infected  and  result  in  abscess  or 
in  necrosis  of  the  bone  or  cartilage.  In  cases  of  injury  of  the  organ,  there- 
fore, the  septum  should  always  be  inspected,  and  if  a  haematoma  be  found  it 
should  be  evacuated  promptly  by  incisiou. 

Deformities. — The  rare  congenital  deformities  of  the  nose  have  already 
been  considered.  The  acquired  deformities  may  involve  either  the  bones 
or  the  soft  parts.  The  nostrils  may  be  occluded  as  a  result  of  cicatricial 
contraction  from  ulcers  due  to  tuberculosis  or  syphilis.  The  whole  organ 
may  be  driven  to  one  side  by  a  severe  blow  and  fixed  in  this  position,  or  the 
Ijridge  may  be  depressed  or  the  septum  deflected  as  the  result  of  fracture. 
Curvature  of  the  septum  may  be  caused  by  irregular  development.  Xecrosis 
is  usually  of  syphilitic  origin,  and  ma.y  result  in  the  loss  of  all  the  bony 
framework,  and  the  soft  parts  may  also  be  destroyed.  The  removal  of 
tumors  may  compel  the  i^artial  or  complete  destruction  of  the  organ. 

Treatment. — Many  of  the  deformities  of  the  nose  are  capable  of  cor- 
rection by  oj)eration,  and  when  the  soft  parts  are  intact  it  is  essential,  if 


752  EESTOKATION   OF  THE  NOSE. 

possible,  that  this  be  done  without  an  external  wound.  It  is  feasible  to 
divide  the  bones  by  means  of  small  saws  or  fine  chisels  inserted  through 
an  internal  or  a  very  small  external  wound,  and,  having  divided  them,  to 
keep  them  in  place  by  the  apparatus  described  under  fractures  of  the  nasal 
bones  until  they  become  ossified  in  their  proper  j)osition. 

Deflected  Septum. — A  badly  deformed  septum  can  be  forcibly  cor- 
rected by  strong  forceps  and  held  in  place  by  a  long,  stout  pin.  The  latter 
is  driven  into  the  frontal  bone  or  vomer,  so  that  it  lies  on  one  side  of  the 
septum.  Or  the  cartilage  can  be  cut  away  on  the  side  towards  which  it  pro- 
jects and  be  removed.  In  the  latter  operation  a  small  incision  is  made  in 
the  mucous  membrane,  the  mucous  membrane  and  the  perichondrium  are 
separated  from  the  cartilage,  and  the  latter  is  divided  with  a  strong  knife. 
A  small  elevator  is  passed  through  this  opening  and  the  jjerichondrium 
stripped  up  on  the  other  side,  when  the  cartilage  can  again  be  divided  at 
the  upper  part  of  the  incision  and  removed.  The  wound  is  limited  to  one 
side  of  the  septum,  in  order  to  avoid  the  formation  of  a  permanent  opening 
between  the  two  nostrils.  It  was  at  one  time  suggested  that  by  making  a 
permanent  opening  in  the  septum  the  air  would  pass  through  both  nostrils 
and  the  functional  effect  of  the  deformity  would  be  removed ;  but  experi- 
ence has  shown  that  the  edges  of  the  opening  are  liable  to  ulcerate,  and 
that  crusts  collect  about  it  and  produce  a  constant  irritation  which  annoys 
the  patient  more  than  the  deformity  of  the  septum.  The  cartilaginous 
septum  can  also  be  divided  by  one  or  more  incisions  crossing  the  projecting 
part,  the  cut  edges  pushed  into  place,  overlapping  each  other,  and  retained 
by  Asch's  nasal  obturator.  This  instrument  is  also  a  useful  support  in  frac- 
tures of  the  nasal  bones.  Before  operating  upon  the  bones,  particularly  in 
operations  without  external  incisions,  the  greatest  care  must  be  taken  to 
make  the  interior  of  the  nose  healthy  and  free  from  septic  material,  because 
the  bones  lie  in  such  intimate  connection  with  the  base  of  the  brain  that 
any  infection  producing  an  inflammation  of  the  veins  might  easily  extend 
backward  within  the  skull  and  result  in  a  fatal  meningitis  or  abscess. 

Restoration  of  the  Nose. — When  the  bones  of  the  nose  have  been 
lost  by  disease  or  accident  they  can  be  restored  by  various  plastic  operations, 
or  their  place  can  be  taken  by  apparatus  fitted  to  support  the  soft  parts. 
In  some  cases  of  sunken  noses  satisfactory  results  have  been  obtained  by 
inserting  an  artificial  bridge  of  celluloid  or  dental  plastic  material,  shaped 
like  a  spindle,  beneath  the  skin,  so  as  to  restore  the  external  outline  of  the 
organ.  Eecently  it  has  been  suggested  to  inject  melted  paraffin  under  the 
detached  skin,  which  sets  when  it  cools  and  acts  as  a  support.  Often  the 
soft  parts  are  also  defective  and  must  be  replaced.  Of  these  plastic  opera- 
tions the  best  known  are  as  follows  : 

A  flap  can  be  cut  from  the  forehead  with  its  pedicle  at  the  root  of  the 
nose,  and  turned  down  so  as  to  supply  the  soft  parts.  If  the  lining  of  the 
nose  is  absent,  the  flap  is  turned  over  with  its  raw  surface  external,  the 
latter  being  grafted  with  skin  later.  If  the  mucous  membrane  is  intact, 
the  flap  can  be  simply  drawn  down  so  that  the  skin  surface  is  outward  and 
the  raw  surface  is  in  contact  with  the  bone  and  mucous  membrane.  The 
flaps  can  also  be  cut  from  the  side  of  the  nose  or  the  cheek,  but  they  can  be 


RESTORATION  OF  THE  NOSE.  753 

taken  from  the  forehead  with  the  least  amount  of  disfigurement,  especially 
if  the  wound  is  grafted  with  skin. 

If  the  entire  nose  is  absent,  the  most  practical  method  of  obtaining  a 
bony  framework  is  that  suggested  by  Konig.  A  flap  of  the  usual  shape  for 
covering  the  nose  is  outlined  on  the  forehead,  the  incision  being  carried 
through  the  periosteum,  and  then  with  a  sharp  chisel  the  external  surface 
of  the  bone  is  shaved  off  in  a  thin  layer,  but  left  attached  to  the  perios- 
teum on  the  under  side  of  the  flap.  The  flap  is  then  turned  down,  and 
if  the  mucous  membrane  is  intact,  the  bone  surface  is  placed  next  to  the 
mucous  membrane  ;  but  if  there  is  no  mucous  membrane  the  flap  should  be 
turned  over,  with  the  bony  surface  directed  outward,  the  latter  being  cov- 
ered at  once  with  flaps  of  skin  taken  from  the  cheeks,  or  left  to  granulate 
and  covered  later  by  skin  grafts.  The  old  method  of  supplying  the  nose 
with  a  piece  from  the  arm  by  the  operation  of  Tagliacozzi  is  now  usually 
varied  by  using  a  finger,  after  thoroughly  removing  the  nail  and  matrix. 
The  soft  parts  on  the  j)almar  surface  of  the  finger  are  incised  in  the  middle 
line  and  turned  aside,  forming  two  lateral  flaps.  The  edges  of  the  nasal 
opening  are  freshened,  and  the  edges  of  the  flaps  on  the  sides  of  the  finger 
are  sutured  to  the  edges  of  the  aperture.  The  finger  and  hand  are  then 
securely  fixed  in  front  of  the  face  with  a  plaster-of- Paris  bandage  strength- 
ened by  wire.  After  two  weeks  have  elapsed,  one  digital  artery  is  tied, 
and  a  week  later  the  other  is  ligated,  and  finally  the  finger  is  severed  from 
the  hand.  Subsequent  small  operations  are  necessary  to  improve  the  shape 
of  the  nose.  The  bones  of  the  transplanted  finger  are  very  apt  to  atrophy, 
so  that  the  result  is  not  so  good  as  might  be  exi^ected,  and  the  necessity  for 
keeping  the  hand  in  this  one  position  during  several  weeks  is  a  serious 
drawback,  while  a  minor  trouble  is  the  difficulty  of  thoroughly  destroying 
the  matrix  of  the  nail. 

Metal  Supports. — The  difficulty  of  forming  a  suitable  bony  skeleton 
for  the  nose  has  induced  surgeons  to  try  metallic  or  other  substitutes,  the 
most  practical  of  these  being  a  platinum  tripod,  one  leg  of  the  tripod  sup- 
XJortiug  the  bridge  of  the  nose  and  the  other  two  supporting  the  alse.  The 
trij)od  is  carefully  made  to  fit  the  individual  case,  and  it  should  not  be  too 
large,  for  the  soft  parts  are  generally  scanty  and  are  likely  to  shrink.  When 
the  soft  parts  are  fairly  complete,  the  nasal  opening  may  be  exposed  to  insert 
the  support  by  Rouge's  operation.  This  consists  in  seizing  the  upper  lip 
with  sharp  retractors  and  drawing  it-upward  over  the  tip  of  the  nose,  making 
an  incision  in  the  mucous  membrane  of  the  lip  near  its  connection  with  the 
gum,  and  completely  detaching  the  upper  lip  from  the  bone.  With  the 
periosteal  elevator  the  periosteum  and  all  the  soft  parts  above  it  are  sepa- 
rated from  the  anterior  surface  of  the  upper  jaw  on  both  sides.  In  this 
way  all  the  soft  parts  of  the  nose  and  cheek  are  dissected  up,  so  that  the 
fingers  can  be  passed  upward  from  the  mouth  under  the  skin  of  the  face  as 
high  as  the  root  of  the  nose.  The  platinum  support  is  then  pushed  up 
under  the  flap,  and  its  upper  leg  fitted  into  a  small  hole  which  is  bored  in 
the  stumijs  of  the  nasal  bones  or  in  the  frontal  bone.  The  two  lower  legs  are 
fitted  into  holes  bored  in  the  superior  maxillae  at  the  lower  border  of  the 
nasal  opening.     The  soft  parts  are  then  allowed  to  fall  into  place,  the  skin 


754 


EPISTAXIS. 


of  the  nose  being  held  up  in  the  natural  position  by  the  metal  support. 
The  soft  parts  are  lightly  bandaged  down  upon  the  support  and  the  facial 
bones,  a  few  sutures  being  inserted  in  the  wound  in  the  mucous  membrane 
of  the  upper  lip.  The  metal  support  is  exposed  in  the  nose,  not  lying 
between  the  skin  and  mucous  membrane,  but  lifting  up  both  the  skin  and 
mucous  membrane  with  its  frame.  In  spite  of  the  apparent  great  extent  of 
the  wound,  the  disturbance  after  the  operation  is  slight.  This  artificial  sup- 
port has  been  worn  for  years  without  irritation,  but  occasionally  its  pressure 
develops  ulcers  and  compels  its  remoA'al.  It  will  be  remarked  that  the 
majority  of  these  plastic  operations  require  the  production  of  new  scars 
upon  the  face.  While  these  are  made  inconspicuous  by  the  modern  methods 
of  treatment,  skin-grafting,  etc.,  they  are  so  serious  a  drawback  that,  if  the 
patient  is  well-to-do,  it  is  always  a  question  whether  he  would  not  be  better 
served  by  an  artificial  nose  made  of  some  light  material  (aluminum)  covered 
with  wax  and  painted.  This  is  held  in  place  by  spectacles,  and  the  joints 
concealed  with  theatrical  paste,  producing  a  cosmetic  effect  which  is  often 
superior  to  that  of  the  best  plastic  surgery. 

Epistaxis. — Hemorrhage  from  the  nose  may  originate  from  an  injury, 
an  acute  inflammation,  or  an  ulcer,  and  in  women  it  is  occasionally  seen 
accompanying  menstruation  or  serving  as  a  substitute  for  that  function. 
The  hemorrhage  often  comes  from  a  small  artery  on  the  lower  part  of  the 
septum,  which  is  liable  to  injury  by  ulceration  or  by  the  finger-nail,  and  it 
can  often  be  arrested  by  a  small  clamp.     If  the  epistaxis  does  not  originate 

from  this  small  vessel  and 
its  source  cannot  be  found, 
it  can  sometimes  be  con- 
trolled by  snufiing  up  into 
the  nose  some  styptic  solu- 
tion, such  as  a  mixture  of 
alum  and  gallic  acid,  or 
simply  very  hot  or  very 
cold  water.  A  spray  of 
cocaine,  antij)yrin,  or  ad- 
renalin will  contract  the 
vessels  and  control  capil- 
lary oozing  from  the  mu- 
cous membrane  of  the 
nose.  If  it  does  not  yield 
to  this  treatment,  the  nose 
must  be  plugged ;   and  it 

section  of  head  showmg  Bellocq's  canu]a  (a)  in  place ;  b,  plug  .vith        . j^  ^^  answer  simply  tO 
string,  ready  to  attach  to  the  canula.  -^    ■' 

pack  the  cavity  from  the 
front :  the  ])osterior  nares  must  also  be  occluded.  A  very  ingenious  instru- 
ment is  Bellocq's  canula  (Fig.  671),  which  is  introduced  through  the  nostril, 
and  contains  a  curved  steel  spring,  which  on  being  pushed  through  the 
canula  shoots  forward  under  the  soft  palate  into  the  mouth,  carrying  a 
string,  which  is  drawn  out  and  fastened  to  the  tampon.  The  instrument 
is  then  withdrawn  and  the  tampon  pulled   into  the  posterior  naris.     A 


Fig.  671. 


FOREIGN   BODIES   IN  THE  NOSE.  755 

small  soft  catheter  cau  also  be  iised  for  this  purpose,  being  ijassed  back- 
■warcl  through  the  nostril  until  it  hangs  down  into  the  pharj'nx,  where  it 
is  picked  ujj  with  forceps  and  drawn  forward,  the  string  being  secured 
to  this  and  pulled  backward  through  the  mouth  and  the  posterior  naris 
and  forward  to  the  nostril.  It  is  an  easy  matter  to  attach  a  pad  of  cotton 
to  the  end  of  the  string  in  the  mouth,  and  under  the  guidance  of  the 
finger  push  it  backward  through  the  mouth  and  draw  it  uja  into  the  poste- 
rior naris.  This  plug  of  cotton  should  be  so  large  that  it  will  not  com- 
pletely enter  the  posterior  naris,  but  will  simply  remain  wedged  in  place. 
The  nose  is  then  packed  from  the  front,  and  the  string  attached  to  the 
posterior  pad  is  secured  to  another  ]jad,  which  rests  against  the  anterior 
nostril  and  holds  the  packing  in  place.  It  is  then  impossible  for  any 
hemorrhage  to  take  place ;  but  the  packing  must  not  be  left  too  long,  lest 
the  blood  decompose  and  septic  infection  result.  Otitis  media  has  been 
caused  by  a  neglected  nasal  tampon. 

Foreign  Bodies. — Foreign  bodies  are  not  infrequently  found  in  the 
nose,  being  introduced  by  accident  or  by  intention.  They  can  be  discovered 
by  a  ]3robe  or  by  inspection,  and  can  be  removed  easily.  Sometimes  it  is 
easier  to  push  them  back  into  the  pharynx  and  to  remove  them  thence,  but  if 
this  is  attempted  in  a  child  he  should  be  held  with  his  head  hanging  down, 
so  that  the  foreign  body  shall  not  enter  the  larynx  when  dislodged.  A  very 
good  instrument  for  the  removal  of  foreign  bodies  is  the  scoop  invented  by 
Gross,  but  a  loop  of  wire  or  an  ordinary  hair-pin  makes  a  very  efficient 
substitute.  Foreign  bodies  remaining  in  the  nose  for  some  time  become 
encrusted  with  calcareous  matter,  and  thus  form  masses  of  considerable  size, 
known  as  rhinoliths.  Insects  sometimes  become  lodged  in  the  nose,  and  flies 
may  lay  their  eggs  and  the  larviB  hatch  out  there.  The  latter  are  particu- 
larly difficult  to  dislodge,  and  a  long  course  of  cleansing  may  be  necessary 
to  rid  the  nose  of  them. 

Hypertrophy  of  the  Turbinated  Bones.— Hypertrophy  of  the 
turbinated  bones  is  not  uncommon,  and  may  require  cauterization  by  pure 
carbolic  acid  or  partial  removal  by  surgical  means.  The  i^arts  are  anaes- 
thetized with  cocaine  and  the  bone  removed  by  small  saws. 

Necrosis. — Xecrosis  of  the  bones  of  the  nose  is  not  uncommon  as  the 
result  of  inflammation,  and  the  sequestra  require  removal.  This  can  gen- 
erally be  done  from  within  under  cocaine  anaesthesia.  Necrosis  is  usually 
marked  by  a  foul  discharge,  but  a  foul  discharge  from  the  nose  does  not 
always  indicate  ulceration  and  necrosis,  for  it  is  found  in  ordinary  ozsena,  a 
condition  which  is  accompanied  by  hy^sertrophy  or  atrophy  of  the  mucous 
membrane,  the  latter  being  generally  a  second  stage  of  the  first.  The  foul- 
ness of  the  discharge  in  ozsena  is  caused  by  the  crusts  formed  by  the  dis- 
ordered secretion  and  the  retention  of  the  discharges. 

The  mucous  membrane  of  the  nose  is  liable  to  a  great  variety  of  inflam- 
mations, of  which  we  need  only  mention  diphtheria,  syphilis,  and  tuber- 
culosis. Tuberculosis  is  generally  a  superficial  affection  of  the  mucous 
membrane  only,  whereas  syi^hilis  is  very  prone  to  attack  the  bones  as  well 
as  the  membrane.  The  consideration  of  the  superficial  diseases,  however, 
belongs  more  properly  to  the  specialist. 


756 


TUMORS   OF  THE  NOSE. 


Fig.  07 


Tumors. — Tumors  of  the  nose  occur  both  within  that  organ  and  out- 
side of  it.  Outside  are  found  fibroma,  angioma,  and  epithelioma,  as  in 
other  parts  of  the  face.  Dermoids  are  very  rarely  found  at  the  root  of  the 
nose.  Polypi  are  the  most  common  internal  tumore.  The  mucous  polypi 
have  the  structure  of  the  mucous  membrane,  and  resemble  hypertrophy  of 
that  tissue.  Sometimes  the  glands  of  this  hypertrophied  mucous  membrane 
become  obstructed  and  cystic  changes  occur.  In  other  cases  the  polypi  are 
made  up  of  myxomatous,  fibrous,  or  angiomatous  tissues.  Ordinary  mucous 
polypi  originate  apparently  from  chronic  catarrh,  and  are  most  frequently 
situated  in  the  up]3er  anterior  part  of  the  nasal  cavity,  especially  at  the  end 
of  the  middle  turbinated  bone.  The  polypi  cause  obstruction  to  breathing, 
and  nasal  discharges  of  mucus,  blood,  or  pus,  and  they  may  affect  the  hear- 
ing by  obstructing  the  Eustachian  tube. 

Treatment. — Polypi  are  removed  by  grasping  the  pedicles  with  forceps 
and  twisting  them  out,  by  scraping  them  off  with  a  sharp  spoon  or  curette, 
or  by  snaring  them  with  a  cold  wire  or  a  gal vano- caustic  loop.  The  removal 
of  large  polyj)i  may  occasion  some  hemorrhage,  but  it  can  be  controlled  by 
ice-water  or  by  some  styptic  application,  such  as  alum  and  gallic  acid. 

Nasopharyngeal  Polypus. — Another  form  of  polypus  connected 
with  the  nose,  although  not  strictly  a  nasal  tumor,  is  the  so-called  naso- 
pharyngeal polypus,  a  fibrous  tumor 
which  grows  most  frequeutly  from  the 
basilar  process  at  the  base  of  the  skull. 
(Pig.  672.)  Growing  forward  from 
this  point,  it  sends  out  projections 
into  the  pharynx,  the  nose,  the  sphe- 
noidal or  frontal  sinuses,  and  the  an- 
trum of  Highmore.  These  polypi  also 
spring  from  the  margin  of  the  foramen 
lacerum  anterius,  or  the  wall  of  the 
pterygo-niaxillary  fossa,  and  then  ex- 
tend between  the  muscles  in  all  direc- 
tions, appearing  on  the  cheek  above 
and  below  the  zygoma,  and  penetrating 
the  orbit  or  the  antrum.  These  polypi 
tend  to  form  new  attachments  in  every 
direction,  and  are  sometimes  discon- 
nected from  their  original  bases.  They 
are  found  only  in  the  j'oung,  aud 
almost  invariably  in  males,  being  quite 
common  just  about  puberty.  Many 
of  these  tumors  undoubtedly  undergo 
In  structure  they  are  either  soft  or  hard  fibromata, 
often  very  vascular,  but  they  are  liable  to  return  when  removed,  and  they 
are  also  very  liable  to  degenerate  into  true  sarcoma.  These  growths  appear 
to  be  rather  rare  in  America.  Their  symptoms  are  those  of  nasal  obstruc- 
tion, distention  of  the  nose,  orbit,  and  pterygo-maxillary  space,  and  the 
ordinary  deformity  of  tumors  of  the  upper  jaw,  combined  with  severe 


Fibrous  polypus  of  the  nose.     (After  Ashhurst.) 


spontaneous  atrophy. 


DISEASES  OF  THE  NASAL  SINUSES.  757 

heniorrliages  from  the  tumor,  which  may  prove  fatal.     They  may  cause 
obstinate  neuralgia  by  pressure. 

Treatment. — Operations  upon  nasopharyngeal  polypi  are  useless  unless 
the  base  of  the  tumor  ,is  reached  and  destroyed,  and  the  operation  is  often 
very  formidable.  In  order  to  reach  the  base  some  surgeons  have  divided 
the  bones  of  the  uose  on  one  side,  and  then  broken  the  bones  opposite  and 
turned  the  whole  organ  over  as  a  flap.  Others  have  detached  the  soft  palate 
and  cut  through  the  hard  palate  for  the  same  purpose.  Still  others  have 
removed  the  upper  jaw,  that  bone  being  sacrificed  or  being  left  attached  to 
the  soft  parts  and  replaced  after  the  operation.  If  the  diagnosfs  can  be 
made  before  the  polypus  has  grown  large,  the  tumor  may  be  removed 
through  the  natural  passages  by  the  cold  wire  or  galvano-cautery  loop,  or  by 
passing  a  sharp  spoon  through  the  nose  to  the  base  of  the  polypus,  guiding 
it  by  the  finger  passed  through  the  mouth  into  the  pharynx,  and  scraping 
the  tumor  away  from  its  attachment  to  the  bone.  The  hemorrhage  during 
this  manoeuvre  may  be  severe,  and  it  is  necessary  to  operate  with  the 
patient's  head  hanging  down  over  the  end  of  the  table,  lest  he  be  suffocated 
by  the  blood,  but  it  is  easily  controlled  by  pressure  after  the  tumor  is 
removed.  Before  the  tumor  is  detached  the  mass  should  be  secured  by  a 
volsellum  or  a  thread  passed  through  it,  lest  it  fall  into  the  larynx. 

Rhinoscleroraa. — Ehinoscleroma  is  a  disease  of  the  soft  parts  of  the 
nose,  pharynx,  and  mouth.  It  appears  in  the  shape  of  hard  flat  nodules  of 
small  size  forming  in  the  skin  and  mucous  membrane,  usually  beginning 
far  back  in  the  lower  part  of  the  nose,  and  progressing  forward  to  the  nos- 
trils. The  sense  of  smell  is  not  disturbed,  and  the  only  sign  of  the  disease 
may  be  an  obstinate  catarrh  with  an  occasionally  purulent  discharge.  These 
nodules  spread  over  the  entire  pharynx,  and  sometimes  over  a  part  of  the 
tongue  and  mouth,  down  into  the  larynx.  They  appear  to  be  caused  by  a 
special  bacillus,  which  has  been  isolated.  In  the  latter  stages  the  nodules 
form  connective  tissue  and  the  mucous  membrane  contracts,  and  this  con- 
traction may  cause  such  obstruction  of  the  larynx  as  to  compel  tracheotomy. 
No  cure  is  known  for  this  disease,  but  fortunately  it  is  rare  in  this  country. 

Diseases  of  the  Nasal  Sinuses. — Frontal  Sinus. — The  frontal 
sinus  in  the  adult  occupies  the  internal  two-thirds  of  the  orbital  ridge  and 
extends  upward  about  one-half  inch  above  the  orbital  margin.  In  children 
it  is  very  small, — scarcely  larger  than  a  pea. 

Fracture. — A  fracture  of  the  superior  wall  of  the  sinus  involves  the 
base  of  the  skull,  and  there  is  great  liability  to  sepsis,  because  the  secretions 
and  blood  may  be  retained  in  the  sinus  and  may  decompose.  Even  if  the 
fissure  does  not  extend  through  the  base  of  the  skull,  intracranial  infection 
occurs  readily,  and  great  attention  must  be  paid  to  drainage.  If  a  wound 
exists,  the  sinus  should  be  drained  through  it,  and  if  there  is  no  wound,  a 
trephine  opening  must  be  made  into  the  sinus  upon  the  first  indication  of 
any  infection  extending  towards  the  brain. 

Distention  of  the  Sinus. — The  opening  into  the  frontal  sinus  (the 
infundibulum)  can  be  reached  through  the  nose  with  a  probe,  and  should  be 
sought  at  the  anterior  end  of  the  middle  turbinated  bone.  The  retention  of 
secretion  in  the  sinus  by  obstruction  of  the  infundibulum  by  a  polypus  or 

49 


758  DISEASES   OF  THE  ETHMOIDAL   SINUSES. 

by  inflammatory  swelling  causes  severe  frontal  headache,  often  limited  to 
one  side,  with  tenderness  over  the  sinus,  and  occasionally  an  intermittent 
discharge  of  mucus  or  pus,  particularly  when  the  patient  raises  his  head 
after  being  long  in  a  recumbent  position.  If  the  retention  is  complete,  and 
particularly  if  pus  forms  in  the  sinus,  causing  an  empyema,  the  sinus  is  dis- 
tended, its  wall  naturally  giving  way  where  it  is  the  thinnest,  towards  the 
orbit  and  the  nose.  This  may  result  in  diplopia,  owing  to  the  displacement 
of  the  eyeball,  and  choked  disk  may  follow.  There  may  be  an  intermittent 
discharge  of  mucus,  or  possibly  lachrymation,  and  if  the  infection  is  severe 
there  may  be  fever  and  chills,  and  meningitis  may  follow.  The  method  of 
lighting  np  parts  of  the  face  by  means  of  the  electric  light  in  a  dark  room 
may  be  employed  in  the  diagnosis,  the  lamj)  being  enclosed  in  an  opaque 
capsule  with  one  open  side  which  is  apj)]ied  to  the  forehead,  just  above  the 
sinus,  so  that  the  light  shines  through  the  bone.  The  normal  sinus  appears 
as  a  bright  spot,  but  one  containing  pus  remains  dark.  The  treatment  of 
empyema  consists  in  drainage,  and  to  establish  this  successfully  through  the 
nose  by  way  of  the  infundibulum  is  seldom  possible.  As  a  rule,  it  is  best 
to  make  a  small  incision  in  the  shaven  eyebrow,  expose  the  bone,  and 
make  a  small  trephine-opening,  or  cut  away  the  anterior  wall  of  the  sinus 
with  a  chisel.  After  the  sinus  has  been  opened  a  small  drainage-tube  may 
be  passed  through  the  infundibulum  into  the  nose.  Frequent  irrigation  is 
necessary  afterwards.  The  operation  should  be  done  as  early  as  possible, 
in  order  to  avoid  necrosis.  If  drainage  fails  to  cure,  the  lower  wall  of  the 
sinus  can  be  cut  away,  and  an  osteoplastic  flap  formed  of  the  anterior  wall, 
which  can  be  allowed  to  fall  in  so  as  to  obliterate  the  cavity  after  healing  by 
granulation  has  occurred. 

Foreign  Bodies. — Foreign  bodies  are  sometimes  deposited  in  the  sinus, 
such  as  pistol-balls,  or  fragments  of  weapons  or  missiles,  and  they  should  be 
sought  for  and  removed  when  the  sinus  is  wounded.  Insects  have  also  been 
known  to  find  their  way  up  into  the  sinus  through  the  nose,  and  their 
removal  is  exceedingly  difficult.  The  patient  should  inhale  chloroform,  in 
the  hope  that  the  vapor  may  kill  the  insect ;  but  an  empyema  is  apt  to 
follow  from  the  infection  caused  by  the  dead  insect. 

Tumors. — Tumors  may  occur  in  the  frontal  sinus,  bony,  myxomatous, 
and  fibrous,  and  also  malignant.  The  most  common  is  osteoma,  which  arises 
especially  from  the  cribriform  plate  and  grows  to  a  considerable  size,  some- 
times penetrating  to  the  orbit.  The  osteomata  are  liable  to  necrosis,  the 
small  pedicle  breaking  off  and  the  blood-supply  being  cut  off.  The  result  of 
the  necrosis  is  a  septic  coiadition  and  sometimes  meningitis,  which  explains 
the  very  high  mortality  in  operations  for  these  necrotic  tumors.  Malignant 
tumors  of  the  sinus  usually  begin  with  the  symptoms  of  an  empyema,  and  it 
is  impossible  to  make  the  diagnosis  until  an  external  swelling  appears, 
although  the  pain  which  they  occasion  is  especially  severe  and  continuous. 

The  tumors  can  be  removed  after  opening  the  sinus  as  described  above. 
Malignant  tumors  demand  very  free  removal  of  the  bone. 

Ethmoidal  Sinuses. — The  ethmoidal  sinuses,  on  account  of  their  small 
size  and  more  retired  position,  seem  to  be  less  liable  to  disease  than  the 
frontal.     Myxomatous  jwlypi  grow  in  them  and  empyema  occurs,  but  necrosis 


TUMORS   OF  THE  ETHMOIDAL  AND   SPHENOIDAL  SINUSES.         759 

of  the  bone  is  rare.  When  there  is  inflammation  of  these  sinuses  it  is 
necessary  to  drain  the  cells,  either  by  the  nose,  the  turbinated  bone  being 
removed  to  give  access  to  them,  or  by  the  orbit.  The  latter  is  the  better 
method,  for  although  any  injury  to  the  superior  oblique  muscle  would  result 
in  strabismus,  the  pulley  of  the  muscle  is  usually  displaced  by  the  swelling 
of  the  OS  planiim,  so  that  there  is  little  danger  of  its  being  injured.  The 
signs  of  disease  of  these  cells  are  headache,  nasal  obstruction,  and  occa- 
sionally exophthalmos,  diplopia,  or  "  choked  disk."  Disease  of  the  ethmoid 
may  be  suspected  if  these  symptoms  are  found,  combined  with  a  disturb- 
ance of  the  orbit  on  both  sides,  disease  of  the  frontal  sinuses  usually  being 
unilateral. 

Sphenoidal  Sinuses. — The  diagnosis  of  diseases  of  the  sphenoidal 
sinuses  is  practically  impossible,  for  the  symptoms  are  the  same  as  those 
of  the  ethmoidal.  The  sphenoidal  sinuses  can  be  reached  by  means  of  a 
probe  curved  at  the  end  and  inserted  in  the  nose  to  a  depth  of  six  and  one- 
half  centimetres  from  the  nostril,  the  probe  being  made  to  follow  the  septum 
and  then  rotated  for  a  quarter  of  a  circle,  when  its  extremity  should  enter 
the  passage  into  the  sinus.     Its  passage  will  relieve  any  retention. 

Tumors  of  the  Ethmoidal  and  Sphenoidal  Sinuses. — Osteoma, 
fibroma,  sarcoma,  and  carcinoma  occur  in  these  deep  sinuses, — the  last  two 
often  being  extensions  of  tumors  in  the  cavity  of  the  nose.  They  can  be 
removed  after  exposure  by  methods  similar  to  those  used  in  operating  on 
nasopharyngeal  polypi  (page  757).  The  malignant  tumors  are  usiially 
extensive,  but  we  have  known  of  cases  which  have  remained  well  for  some 
time  after  thorough  removal  by  the  curette. 


CHAPTER     XXX. 

SURGERY  OF  THE  TONGUE,   CHEEKS,   GUMS,  JAWS,  AND 
SOFT  AND  HARD  PALATE. 

By  Heney  E.  Whaeton,  M.D. 

Injuries   of  the   Gums,  Cheeks,  Soft  and  Hard  Palate.— 

These  may  result  from  bodies  either  thrust  through  the  cheeks  or  entering 
through  the  mouth.  Burns  and  scalds  of  these  parts  may  result  from  hot 
substances  or  hot  fluids,  or  steam,  or  caustics,  such  as  ammonia  or  strong 
acids.  The  injury  from  burns  or  scalds  is  not  usually  severe,  as  the  hot 
substance  is  quickly  ejected ;  but  those  received  from  caustic  alkalies  or 
acids  are  apt  to  be  followed  by  sloughing  of  the  mucous  membrane,  and  are 
often  marked  by  contraction  and  deformity.  Incised  and  lacerated 
wounds  of  the  cheek,  if  they  involve  the  duct  of  the  parotid  gland,  maj'  be 
followed  by  a  salivary  fistula.  Tliey  generally  result  from  falls  upon  sharp 
or  blunt  bodies,  such  as  sticks,  pencils,  or  pipe-stems,  which  enter  the 
mouth,  and  are  forcibly  driven  into  the  tissues  ;  they  may  also  result  from 
gunshot  wounds.  Perforation  of  the  soft  and  of  the  hard  palate  may  occur 
as  the  result  of  these  injuries.  Hemorrhage  following  wounds  of  these  parts 
is  usually  very  profuse  at  first,  but,  if  no  important  vessel  has  been  divided, 
soon  ceases. 

Treatment. — If  a  bleeding  vessel  is  exposed  in  the  wound,  it  should  be 
secured  by  a  ligature,  or  a  deep  suture,  and  the  wound  carefully  explored  to 
ascertain  if  a  foreign  body  is  present.  This,  if  found,  should  be  removed, 
and  after  irrigation  with  sterilized  water  or  boric  acid  solution,  the  edges  of 
the  wound  should  be  approximated  with  sutures  passed  through  the  mucous 
membrane  and  subjacent  tissues.  If  the  wound  involves  the  skin,  the 
external  wound  should  be  closed  by  a  separate  row  of  sutures.  The  patient 
should  be  given  only  liquid  nourishment,  and  instructed  to  wash  the  mouth 
constantly  with  some  weak  antiseptic  solution.  If  caustic  alkalies  or  acids 
have  been  taken  into  the  mouth,  their  action  should  be  arrested  by  the  use 
of  acid  or  alkaline  solutions,  as  the  case  may  be  ;  the  subsequent  treatment 
of  the  wound,  as  in  the  case  of  burns  and  scalds,  consists  in  keeping  the 
parts  clean  by  the  employment  of  mild  antiseptic  mouth-washes,  and  the 
prevention  of  adhesions  and  contraction  by  gauze  packing. 

Injuries  of  the  Tongue. — These  consist  of  burns,  scalds,  injuries 
from  caustic  alkalies  or  acids,  stings  of  insects,  or  incised  and  lacerated 
wounds. 

Burns  and.  Scalds  of  the  Tongue. — These  injuries  generally  result 
from  the  application  of  hot  solids  or  liquids,  and  are  usually  superficial, 
being  accompanied  by  burning  and  jiain  for  only  a  few  hours  ;  whereas  the 
injuries  following  the  application  of  caustic  alkalies  or  acids  are  deeper  and 
accompanied  by  great  pain  and  swelling,  and  are  more  likely  to  be  followed 
by  sloughing.  If  the  latter  comj)lication  occurs,  the  tongue  may  be  bound 
760 


ULCERATIVE  STOMATITIS.  761 

down  by  adhesions  aud  its  motions  seriously  interfered  with.  Bites  of 
animals  and  stings  of  insects  are  followed  by  great  swelling  of  the  organ, 
which  has  in  a  few  cases  caused  a  fatal  termination. 

Incised  and  Lacerated  Wounds  of  the  Tongue. — These  are  caused 
by  sharp  or  blunt  instruments,  or  by  the  teeth  \\\\ei\  the  tongue  is  protruded. 
The  principal  dangers  in  these  wounds  are  hemorrhage  and,  later,  septic 
infection.  Foreign  bodies  may  be  lodged  in  the  tongue,  and,  the  wound 
becoming  infected,  dangerous  secondary  hemorrhage  may  result. 

Treatment. — In  superficial  burns  or  scalds  of  the  tongue,  or  injuries 
from  caustics,  the  use  of  a  boric  acid  solution,  or  of  a  solution  of  carbolic 
acid,  gr.  ii ;  carbonate  of  sodium,  gr.  xv  ;  water,  f  Ji,  will  relieve  the  pain 
and  act  as  a  mild  antiseptic.  In  cases  of  stings  of  insects  or  bites  of  animals 
or  serpents,  the  swelling  of  the  tongue  may  be  so  great  that  respiration  will 
be  interfered  with,  in  which  case  free  incisions  should  be  made  into  the 
organ,  being  generally  followed  by  rapid  decrease  in  the  swelling.  In 
incised  and  lacerated  wounds  of  the  tongue  the  wound  should  be  carefully 
explored,  any  foreign  body  should  be  removed,  and  the  bleeding  arrested 
by  the  application  of  ligatures  to  the  bleeding  vessel,  if  possible  ;  but  if  it 
cannot  be  exposed  in  the  wound,  the  clots  should  be  removed,  and  the  edges 
of  the  wound  brought  together  by  deep  sutures  of  silk  or  catgut,  which 
serve  at  the  same  time  to  control  the  bleeding  and  to  coaptate  the  surfaces 
of  the  wound.  Antiseptic  mouth-washes  should  be  freely  used  until  the 
wound  is  healed.  Repair  is  usually  prompt,  and  the  sutures  may  be  removed 
at  the  end  of  a  week. 

DISEASES   OF  THE   MOUTH   AND   TONGUE. 

Stomatitis. — Inflammation  of  the  mucous  membrane  of  the  mouth 
presents  itself  in  a  number  of  different  forms,  but  those  which  most  concern 
the  surgeon  are  ulcerative,  syphilitic,  and  gangrenous  stomatitis. 

Ulcerative  Stomatitis. — This  condition  of  the  mucous  membrane 
results  from  wounds,  scalds  and  burns,  caustics  and  acids,  aud  the  irritation 
of  rough  or  carious  teeth  ;  ulceration  following  the  use  of  mercury  may 
also  be  included  under  this  head.  Symptoms. — The  ulceration  usually 
begins  in  the  gums  of  the  lower  jaw,  near  the  margin  of  the  teeth,  and  sub- 
sequently spreads  to  the  floor  of  the  mouth,  the  tongue,  the  lips,  and  the 
cheeks.  The  gums  are  swollen  and  congested,  and  the  surfaces  of  the  ulcers 
are  covered  with  grayish  sloughs.  The  ulcers  bleed  upon  the  slightest 
touch,  the  teeth  become  loose,  and  necrosis  of  the  alveolar  margin  of  the 
jaw  is  apt  to  occur.  Profuse  salivation  is  present,  the  breath  is  foul,  and 
the  submaxillary  glands  are  often  tender  and  swollen.  Treatment. — This 
consists  in  frequent  and  thorough  cleansing  of  the  cavity  of  the  mouth  with 
mild  antiseptic  solutions, — boric  acid,'  si  to  water  f5vi,  or  a  solution  of 
carbolic  acid,  gr.  xii ;  chlorate  of  potassium,  5i ;  water,  fsvi,  or  a  1  to  2000 
permanganate  of  potassium  solution,  and  the  ulcerated  surfaces  should  be 
touched  with  a  solution  of  nitrate  of  silver,  gr.  x  to  water  fsi.  The  patient 
should  be  placed  upon  a  liquid  diet,  and  the  use  of  tobacco  prohibited. 

Syphilitic  Stomatitis. — This  affection  is  frequently  seen  in  secondary 
syphilis,  and  is  characterized  by  the  occurrence  of  a  general  inflammation 


762 


GANGRENOUS   STOMATITIS. 


of  the  mucous  membrane  of  the  mouth  aud  fauces,  with  the  development, 
at  points,  of  whitish  patches  or  mucous  plaques,  due  to  the  thickening  and 
degeneration  of  the  epithelium.  The  diagnosis  of  this  affection  from  other 
forms  of  stomatitis  can  be  made  by  the  appearance  of  the  parts  and  the  coin- 
cident development  of  the  cutaneous  lesions  of  syphilis.  Treatment. — 
The  local  treatment  consists  in  the  use  of  a  mouth-wash  of  carbolic  acid  and 
chlorate  of  potassium,  and  the  application  of  a  ten-grain  solution  of  nitrate 
of  silver  to  the  mucous  patches ;  the  patient  should  not  be  permitted  to  use 
tobacco,  as  it  increases  the  irritation.  The  constitutional  treatment  is  most 
important,  and  consists  in  the  use  of  iodide  of  mercury  in  doses  of  one- 
quarter  to  one-half  grain,  and,  if  the  lesions  do  not  disappear  promptly,  the 
addition  of  five-  or  ten-grain  doses  of  iodide  of  potassium  may  be  followed 
by  good  results. 

Gangrenous  Stomatitis. — Noma. — This  affection,  which  is  also  de- 
scribed as  cancrmn  oris,  is  sometimes  observed  in  children  after  the  erup- 
tive fevers,  aud  is  most  frequent  after  measles.  The  subjects  in  whom  it 
develops  are  usually  poorly  fed,  or  the  inmates  of  children's  homes,  where 
the  food  and  hygienic  sui-roundings  are  poor.  A  special  organism,  the  lep- 
tothrix,  has  been  definitely  isolated  in  a  number  of  cases,  but  the  condition 
in  many  cases  j)robably  results  from  a  mixed  infection  ;  caj)illary  thrombosis 
results,  and  is  followed  by  rapidly  spreading  gangrene.  The  gangrenous 
process  soon  involves  the  soft  parts,  and  the  bones  of  the  jaws,  resulting  in 
osteomyelitis  and  extensive  necrosis,  accompanied  by  marked  constitutional 
disturbance,  high  fever,  rapid  pulse,  and  often  free  diarrhoea.  The  disease 
is  sometimes  fatal  in  a  few  days ;  if,  however,  the  patient  survives,  separa- 
tion of  the  gangrenous  tissues  occurs,  and  repair  is  followed  by  great  con- 
traction and  deformity  of  the  face. 

Symptoms. — In  a  patient  in  whom  this  affection  is  developing  the 
offensive  odor  of  the  breath  often  first  attracts  attention,  and  upon  examina- 
tion of  the  mouth  a  spot  of  ulceration  is 
usually  seen  upon  the  mucous  membrane 
of  the  cheek,  or  ujpon  the  gums.  There  is 
a  marked  rise  in  temperature,  and  the 
pulse  becomes  rapid  and  feeble.  In  a  few 
hours  a  dusky  red  indurated  spot  apjiears 
upon  the  cheek,  lip,  or  chin  over  the  seat 
of  the  ulceration  in  the  mucous  mem- 
brane, and  if  the  mouth  is  inspected,  dark 
sloughs  are  found  to  occupy  the  seat  of 
the  former  ulceration.  The  gangrenous 
process  spreads  rapidly  and  involves  the 
tissues  of  the  cheeks,  and  a  black  gan- 
grenous patch  soon  takes  the  place  of  the 
dusky  red  indurated  spot;  the  process 
soon  involves  the  gums  and  jaws,  the  teeth 
become  loose  aud  fall  out,  and  the  alveolar  process  aud  body  of  the  jaw 
become  necrosed.  (Fig.  673.)  Profuse  offensive  discharge  accompanies  this 
affection,  and  it  is  usually  fatal  in  a  few  days.     Eecovery,  however,  may 


Fig.  673. 


Gangrenous  stomatitis. 


TUMORS  OF  THE  MOUTH. 


763 


occur  in  cases  where  extensive  destruction  of  the  cheek  or  necrosis  of  the 
bone  has  taken  place.  We  have  recently  had  under  our  care  a  case  in 
which  almost  the  entire  lower  jaw  and  a  portion  of  the  ui^ijer  jaw  were 
necrosed  and  were  removed,  in  which  recovery  finally  took  place.  (Fig. 
674.)  After  the  separation  of  the  sloughs  and  dead  bone,  great  contraction 
and  deformity  often  result ;  if  the  lips  are  involved,  the  oral  aperture  may 
be  much  contracted,  or  the  lower  jaw  may 
be  so  firmly  bound  down  by  adhesions  that 
the  mouth  cannot  be  opened,  or  the  tongue* 
may  be  firmly  adherent  to  the  floor  of  the 
mouth.  Coiucidently  with  the  development 
of  gangrenous  stomatitis  in  female  children 
noma  pudendi  is  sometimes  observed. 

Treatment. — As  soon  as  it  is  evident 
that  the  gangrenous  process  has  attacked  the 
gums  or  the  cheeks,  the  patient  should  be 
anesthetized,  a  mouth-gag  inserted  to  expose 
the  oral  cavity  widely,  the  sloughing  tissues 
removed  with  forcejis  and  scissors  or  with  a 
curette,  and  the  surface  thus  exposed  cauter- 
ized with  nitric  acid  or  the  actual  cautery. 
A  mouth- wash  of  chlorate  of  potassium  and  myrrh,  or  a  weak  permanganate 
of  i^otassium  solution,  should  be  used  freely  afterwards.  The  cauterization 
should  be  repeated  in  a  few  days  if  the  disease  continues  to  si^read  or  if 
new  areas  of  gangrene  develoj).  The  patient  should  be  given  stimulants 
freely,  with  quinine  and  iron,  and  alloMed  a  most  nutritious  diet.  Under 
this  method  of  treatment  we  have  seen  the  disease  arrested,  with  moderate 
destruction  of  the  tissues,  even  in  well-advanced  cases. 


Necrosis  of  the  lower  jaw  following 
greiious  stomatitis. 


TUMORS   OF   THE   MOUTH. 

Epithelioina. — This  growth,  involving  the  floor  of  the  mouth,  is  a 
comparatively  rare  affection  as  a  primary  growth,  but  may  result  from 
extension  from  the  tongue  or  the  gums.  The  treatment  consists  in  removal 
of  the  growth  through  the  mouth  or  through  an  incision  made  below  the 
chin.  Naevus  of  the  floor  of  the  mouth  is  also  a  rare  affection,  and  its 
treatment  is  similar  to  that  employed  in  nsevus  in  other  localities. 

Ranula. — This  consists  of  a  thin-walled  cystic  tumor  springing  from 
the  floor  of  the  mouth  beneath  the  tongue,  and  containing  a  thick,  clear 
fluid.  It  may  be  unilateral  or  bilateral.  It  was  formerly  supposed  to  be 
due  to  obstruction  of  the  duct  of  Wharton,  and  in  a  few  cases  this  may  be 
the  cause ;  but  the  majority  of  ranulse  are  simply  retention-cysts  formed 
in  the  mucous  glands  in  the  mouth.  A  ranula  may  vary  in  size  from  that 
of  a  cherry  to  that  of  a  small  egg,  is  usually  unaccompanied  by  pain,  and 
attracts  the  j)atient's  attention  only  by  its  interfering  with  the  movements 
of  the  tongue  in  speech  and  in  swallowing.  When  these  cysts  attain  a  large 
size  some  fulness  may  be  noticed  in  the  submental  space. 

Treatment. — The  most  satisfactory  treatment  consists  in  grasping  the 
wall  of  the  cyst  with  toothed  forceps  and  with  curved  scissors  cutting  away 


764 


DERMOID   CYSTS   OF  THE  MOUTH. 


a  portion  of  the  cyst  wall.  If  the  openings  of  Wharton's  duct  are  seen, 
they  should  not  be  included  in  the  portion  of  the  cyst  wall  which  is  excised. 
After  emptying  the  cyst  its  walls  should  be  cauterized  with  a  solid  stick 
of  nitrate  of  silver  or  with  a  thirty-grain  solution  of  chloride  of  zinc. 
A  strip  of  iodoform  gauze  should  be  loosely  packed  into  the  cavity  and 
allowed  to  remain  for  a  few  days.  A  seton  may  also  be  employed,  but  its 
use  is  not  so  likely  to  be  followed  by  obliteration  of  the  cyst  as  is  the  oper- 
ation described. 

Acute  Ranula. — This  consists  in  a  sudden  swelling  of  the  submasillary 
gland,  which  becomes  tense  and  painful,  and  arises  from  obstruction  of  its 
duct  by  a  plug  of  mucus.  The  pain  and  swelling  develop  suddenly,  and 
are  much  aggravated  during  mastication.  Treatment. — If  the  openings 
of  the  ducts  of  the  submaxillary  gland  are  examined,  a  mass  of  inspissated 
mucus  may  be  found  in  the  orifice  of  the  duct,  or  a  mass  may  be  felt  below 
the  mucous  membrane  in  the  course  of  the  duct.  This  should  be  removed 
by  forceps,  or  the  duct  should  be  slit  open  with  a  sharp  narrow  knife  and 
the  obstructing  material  removed.  Rapid  disappearance  of  the  pain  and 
swelling  occurs  as  soon  as  the  saliva  is  allowed  to  escape. 

Dermoid  Cysts  of  the  Mouth. — These  are  sometimes  described  as 
congenital  sebaceous  cysts,  or  thyroid  dermoids,  of  the  floor  of  the  mouth, 
^      ,„^  and  are  cysts  containing  sebaceous  matter, 

hairs,  and  cholesterin,  being  true  dermoids. 
They  rarely  take  on  rapid  growth  and  pro- 
duce marked  deformity  or  discomfort  before 
the  age  of  puberty.  They  do  not  possess  the 
translucency  of  an  ordinary  ranula,  are  more 
deeply  seated,  are  covered  by  the  mucous 
membrane  and  muscles,  are  most  frequently 
situated  in  the  median  line,  and  are  often 
attached  to  the  hyoid  bone.  The  cyst  may 
present  an  elastic  fluctuating  swelling  j)ro- 
jecting  into  the  mouth,  and  may  also  cause 
marked  swelling  beneath  the  chin.  (Fig. 
675.)  They  are  rarely  painful,  but  cause  diffi- 
culty in  speech  and  swallowing  by  pushing 
the  tongue  upward  and  interfering  with  its 
motions.  They  often  attain  the  size  of  a  hen's  egg  or  of  a  small  orange.  If 
infection  occurs,  the  abscess  points  beneath  the  chin. 

Treatment. — Complete  extirpation  of  the  cyst  is  the  only  satisfactory 
method  of  treatment.  This  can  be  accomplished  through  the  mouth,  or  by 
making  an  incision  through  the  skin  below  the  chin.  The  latter  operation 
is  to  be  preferred,  as  it  is  then  possible  to  keep  the  wound  aseptic,  but 
removal  through  the  mouth  is  a  satisfactory  operation.  In  the  latter  method 
the  mouth  should  be  held  widely  open  with  a  gag,  and  the  tongue  held 
upward  with  a  retractor ;  an  incision  is  then  made  through  the  mucous 
membrane  over  the  cyst,  the  muscles  are  separated  with  a  director,  and  the 
cyst  is  exposed  ;  this  is  seized  with  toothed  forceps,  and  as  it  is  drawn  out 
its  walls  are  separated  from  the  surrounding  tissues  with  the  finger  or  a 


Dermoid  cyst  of  the  floor  of  the  mouth 
projecting  beneath  the  chin. 


MACEOGLOSSIA.  765 

blunt  director,  the  use  of  the  knife  or  the  scissors  rarely  being  required. 
When  the  cyst  has  been  removed,  a  strip  of  iodoform  gauze  is  passed  to  the 
depth  of  the  wound ;  this  is  allowed  to  remain  in  place  for  a  few  days, 
and  an  antiseptic  mouth-wash  is  used  frequently  imtil  the  wound  is  healed. 
If  incision  below  the  chin  is  resorted  to,  the  cyst  is  removed  by  a  careful 
dissection,  the  wound  is  drained  by  a  strip  of  iodoform  gauze,  the  external 
wound  is  closed  by  sutures,  and  a  gauze  dressing  is  applied. 

For  Salivary  Calculus,  see  under  Diseases  of  the  Salivary  Glands. 

DISEASES  OF  THE  TONGUE. 

Tongue-Tie. — This  is  a  comparatively  rare  affection,  and  consists  in 
an  abnormal  shortness  of  the  frenum  linguje  or  of  its  attachment  too  far 
forward  towards  the  tip  of  the  tongue,  which  prevents  the  protrusion  of  the 
organ  beyond  the  line  of  the  incisor  teeth.  Any  child  who  is  not  precocious 
in  talking  is  apt  to  be  credited  with  this  affection.  We  have  seen  very  few 
cases  of  marked  tongue-tie  in  the  service  of  a  large  children's  hospital.  If 
this  condition  is  present  the  child  may  experience  difficulty  in  taking  the 
breast,  and  later  impairment  of  speech  may  be  marked.  A  very  aggravated 
form  of  tongue-tie  sometimes  results  from  the  tongue  being  bound  down 
by  cicatricial  adhesions  after  ulceration  of  the  organ  and  of  the  Hoor  of  the 
mouth.  Treatment. — This  consists  in  placing  a  retractor  or  the  flat  end 
of  a  director  under  the  free  portion  of  the  tongue  and  lifting  the  organ 
towards  the  roof  of  the  mouth,  thus  rendering  the  frenum  tense.  The 
frenum  should  then  be  divided  for  a  short  distance  with  scissors,  care  being 
taken  to  cut  away  from  the  tongue  so  as  to  avoid  the  ranine  vessels.  After 
the  frenum  has  been  incised  it  can  easily  be  torn  back  for  a  short  distance 
with  the  finger.  In  cases  of  cicatricial  adhesion  of  the  tongue  to  the  floor 
of  the  mouth,  a  plastic  operation  is  required  to  correct  the  deformity  and 
secure  mobility  of  the  organ. 

Elongation  of  the  Frenum. — Oases  are  occasionally  observed  in 
which,  from  elongation  or  relaxation  of  the  frenum  linguEe,  the  tongue  falls 
backward  when  the  patient  assumes  the  recumbent  posture,  and  occludes 
the  orifice  of  the  larynx,  constituting  the  affection  known  as  tongue- swallow- 
ing. Death  has  resulted  from  this  condition.  It  has  been  observed  after  a 
too  free  division  of  the  frenum,  and  after  operations  upon  the  floor  of  the 
mouth,  or  excision  of  the  central  portion  of  the  lower  jaw,  which  interferes 
with  the  attachment  of  the  muscles  of  the  tongue.  Treatment. — This  con- 
sists in  excising  a  portion  of  the  frenum  and  suturing  the  edges  together,  or, 
if  the  condition  develops  after  operations  upon  the  mouth  or  the  jaw,  the 
tip  of  the  tongue  should  be  transfixed  with  a  ligature,  and  drawn  forward 
and  secured  until  adhesions  have  formed. 

Macroglossia. — Hypertrophy  of  the  tongue,  or  macroglossia,  is  a  con- 
dition which  is  characterized  by  a  great  increase  in  size  of  the  tongue,  the 
organ  being  so  much  enlarged  that  it  cannot  be  contained  within  the  oral 
cavity.  The  affection  is  usually  congenital,  but  does  not  ordinarily  attract 
attention  until  the  end  of  the  first  or  the  second  year  ;  we  have,  however, 
seen  a  marked  case  of  this  affection  in  an  infant  of  five  months.  The  dis- 
ease, which  is  closely  allied  to  elephantiasis,  may  be  classified  as  a  lymphan- 


766 


ACUTE  GLOSSITIS. 


gioma  cavernosum,  and  presents  marked  increase  and  dilatation  of  the 
lymphatic  vessels,  with  increase  of  the  blood-vessels  and  hy]3erplasia  of  the 
connective  tissue.  The  anterior  j)ortion  of  the  tongue  is  usually  affected, 
the  base  of  the  organ  remaining  normal  in  size.  In  marked  cases  a  large 
mass  of  the  tongue  is  prolapsed,  and  cannot  be  retracted  within  the  mouth  ; 
the  shape  of  the  dental  arch  may  be  changed  by  the  pressure  and  weight  of 
the  organ,  and  the  latter  may  be  furj-owed  where  it  rests  upon  the  teeth ; 
the  portion  of  the  organ  which  is  permanently  prolapsed  becomes  dry  and 
brown.     (Fig.  676. )     If  the  hypertrophy  of  the  organ  is  moderate  it  causes 

little  inconvenience,  but  when 
Fig-  676.  it  fing  the  cavity  of  the  mouth, 

or  is  prolapsed,  it  gives  the 
patient  discomfort  and  interferes 
very  seriously  with  taking  food. 
Treatment. — The  patient 
having  been  anaesthetized  and 
a  gag  introduced  between  the 
jaws,  the  tongue  should  be 
grasped  with  forceps  and  drawn 
forward,  a  strong  ligature  being 
introduced  through  each  side  of 
the  tongue  to  enable  the  operator 
to  draw  it  forward  and  retain 
control  of  the  stump  after  the 
removal  of  the  anterior  jjortion 
of  the  organ.  A  Y-shaped  piece 
of  the  tongue,  with  its  apex 
directed  backward,  should  then 
be  excised,  and  the  edges  of 
the  wound  brought  together  by 
sutures  passed  through  the  thickness  of  the  flaps.  Hemorrhage  is  not  usu- 
ally free,  but  bleeding  vessels  should  be  grasped  with  haemostatic  forceps 
and  ligated  ;  the  deep  sutures  generally  control  the  bleeding  perfectly.  If 
the  tissue  removed  has  been  sufScient,  after  the  flaps  have  been  sutured 
the  stump  is  retained  in  the  mouth,  and  it  continues  to  shrink  for  some 
time  after  the  operation.     The  sutures  should  be  removed  in  ten  days. 

Acute  Glossitis. — This  condition,  which  consists  in  a  parenchymatous 
inflammation  of  the  tongue,  is  a  rare  affection,  which  occurs  more  frequently 
in  adults  than  in  children.  It  may  involve  one-half  of  the  tongue,  consti- 
tuting hemifflossitis,  or  may  involve  the  whole  organ.  It  may  result  from 
bites  of  insects,  cuts,  burns,  exposure  to  cold,  or  septic  conditions.  Symp- 
toms.— The  tongue  rapidly  increases  in  size,  and  may  fill  the  cavity  of  the 
mouth  so  that  breathing  is  interfered  with ;  the  organ  becomes  red  and 
covered  with  a  muco-puruleut  discharge  ;  salivation  is  profuse,  and  speech 
and  swallowing  are  difficult  and  painful.  There  is  at  the  same  time  marked 
constitutional  disturbance,  as  shown  by  the  elevation  of  the  temperature  and 
the  rapidity  of  the  pulse.  Treatment.— Although  the  sj-mptoms  are  most 
distressing  and  often  alarming  they  usually  subside  promptly  under  treat- 


Macroglossia. 


CHRONIC  SUPERFICIAL   GLOSSITIS. 


767 


nient.  lo  cases  in  which  the  affection  is  only  moderately  developed  the 
patient  should  be  given  an  active  purgative,  should  suck  pieces  of  ice,  and 
use  an  antiseptic  mouth-wash  ;  under  this  treatment  the  pain  and  swelling 
usually  quickly  subside.  If,  however,  the  swelling  is  great  and  increasing, 
and  is  accompanied  by  the  symptoms  previously  mentioned,  free  longitudinal 
incisions  should  be  made  into  the  dorsum  of  the  organ,  deep  enough  to  expose 
its  muscular  substance.  These  incisions  are  followed  by  the  escape  of  blood- 
stained serum,  and  often  free  bleeding,  but  the  latter  subsides  in  a  short  time. 
After  incision  the  swelling  diminishes  rai)idly,  and  the  patient  often  in  a 
few  minutes  experiences  great  relief.  An  antiseptic  mouth-wash  should  be 
employed  until  the  incisions  are  healed. 

Abscess  of  the  Tongue.— This  is  an  extremely  rare  affection,  and 
may  result  from  acute  glossitis,  from  exposure  to  cold  or  heat,  or  from  foreign 
bodies  embedded  in  the  tongue.  The  abscess  may  involve  the  central  por- 
tion or  the  lateral  aspects  of  the  organ,  and  may  form  slowly  and  give  rise 
to  little  pain,  or  may  develop  rapidly  and  be  accompanied  bj^  the  symptoms 
of  acute  glossitis.  Symptoms. — These  are  largely  those  of  acute  glossitis ; 
the  tongue  becomes  swollen  and  may  be  protruded  from  the  mouth,  swal- 
lowing and  speech  are  difficult  and  painful,  salivation  is  profuse,  and  the 
l^atient  sits  with  the  head  bent  forward,  to  allow  the  saliva  to  escape  from  the 
mouth  and  prevent  painful  efforts  at  swallowing.  Sleei)  in  the  recumbent  posi- 
tion is  impossible  on  account  of  the  saliva  running  back  and  causing  efforts 
at  swallowing.  Upon  examination  of  the  tongue  a  sense  of  fluctuation  upon 
palpation  can  generally  be  felt  at  some  point.  Treatment. — Early  incision 
is  indicated  in  these  cases,  even  if 

fluctuation    cannot    be    distinctly    'ig.(ui. 

made  out.  A  free  incision  should  ; 
be  made,  and  if  pns  does  not  escape,  : 
a  director  should  be  introduced 
into  the  incision  and  x^ushed  in  dif- 
erent  directions  through  the  tissues, 
which  will  usually  be  followed  by 
the  escape  of  pus.  The  relief  of 
distressing  symptoms  is  generally 
very  prompt  after  the  abscess  is 
opened.  An  antiseptic  mouth- wash 
should  afterwards  be  employed. 

Chronic  Superficial  Glos- 
sitis.— This  condition,  also  de- 
scribed as  leucoplakia,  psoriasis,  and 
ichthyosis  linguce,  is  an  affection  of 
the  tongue  which  is  occasionally 
seen,  and  which  results  fi'om 
chronic  inflammation  of  the  mucous 
membrane,  with  localized  thicken- 
ing of  the  epithelium.  It  arises  from  excessive  smoking,  from  the  constant 
introduction  of  irritating  substances  into  the  mouth,  from  the  use  of  undi- 
luted alcoholic  beverages,  and  from  syphilis.     (Fig.  677. )     It  is  of  interest 


m 


\ 


\ 


Chronic  superficial  glossitis.     (Museum  of  the  German 
Hospital  of  Philadelphia. ) 


768  ULCERATION  OF  THE  TONGUE. 

to  the  surgeon  from  the  fact  that  if  the  condition  is  not  relieved  and  the 
irritating  causes  are  not  removed  there  often  develops  persistent  ulcera- 
tion, which  may  give  rise  to  epithelioma.  Treatment. — This  consists  in 
removing  the  causes  of  irritation,  and  in  syphilitic  cases  employing  mercurj'^ 
and  iodide  of  potassium,  with  mild  antiseptic  mouth-washes.  The  diet 
should  be  regulated,  and  smoking  and  the  use  of  alcohol  interdicted.  The 
use  of  a  one  per  cent,  solution  of  chromic  or  salicylic  acid  is  often  followed 
by  good  results. 

Ulceration  of  the  Tongue. — This  may  result  from  wound^,  burns, 
or  scalds  of  the  tongue,  or  from  the  sharp  edges  of  carious  or  broken  teeth, 
and  also  from  disturbance  of  the  digestive  system.  The  latter  ulceration  is 
often  multiiile,  may  occupy  large  surfaces  of  the  organ,  and  is  most  fre- 
quently seen  in  children.  Ulceration  of  the  under  surface  of  the  tongue, 
involving  the  frenum,  is  very  common  in  children  suffering  from  whooping- 
cough,  and  is  caused  by  the  tongue  being  violently  forced  against  the  lower 
teeth.  Ulceration  arising  from  the  irritation  of  sharp  or  irregular  teeth  is 
situated  at  the  lateral  mai'gins  or  the  tip  of  the  organ.  A  traumatic  ulcer, 
if  it  has  existed  for  some  time,  is  apt  to  be  surrounded  by  marked  indura- 
tion, which  may  render  its  diagnosis  from  eijithelioma  and  syphilis  difficult. 
Symptoms. — Pain  at  first  is  not  a  marked  symptom  unless  irritating  sub- 
stances come  in  contact  with  the  ulcer  ;  but  if  the  ulcer  becomes  inflamed, 
or  has  existed  for  some  time,  it  may  cause  pain  upon  movements  of  the 
tongue,  and  may  render  the  taking  of  food  difficult.  More  or  less  discharge 
is  apt  to  occur  from  the  ulcerated  surface  and  causes  the  mouth  to  become 
foul.  Treatment. — Ulceration  due  to  sharp  or  rough  teeth  should  be 
treated  by  filing  the  edges  of  the  offending  teeth,  or  by  their  removal,  and 
the  application  of  a  ten-grain  solution  of  nitrate  of  silver  and  the  use  of  a 
mild  antiseptic  mouth- wash.  The  treatment  of  ulceration  dependent  upon 
digestive  disturbance  consists  in  the  regulation  of  the  diet  and  the  use  of 
remedies  to  improve  the  digestion,  with  the  local  use  of  a  weak  solution  of 
nitrate  of  silver  and  a  mouth-wash.  In  all  cases  of  ulceration  of  the  tongue 
the  diet  should  consist  of  bland  articles, — a  liquid  diet  is  best, — and  the 
patient  should  be  forbidden  to  use  tobacco. 

Lupus. — Lupus  of  the  tongue  usually  exists  in  connection  with  a  similar 
affection  of  the  nose,  face,  and  lips,  and  is  rarely  observed  as  an  independent 
affection  of  this  organ.  Treatment. — This  consists  in  thoroughly  scraping 
the  ulcer  with  a  curette  and  in  the  application  of  Paquelin's  cautery,  at  the 
same  time  antituberculous  remedies,  such  as  cod-liver  oil  and  iodide  of  iron, 
and  tonics  being  administered. 

Tuberculous  Ulceration  of  the  Tongue.— Primary  tuberculosis 
of  the  tongue  is  a  rare  affection,  but  tuberculous  ulceration  of  this  organ  in 
connection  with  pulmonary  or  laryngeal  tuberculosis,  or  general  tuberculo- 
sis, is  not  infrequently  observed.  It  is  rarely  seen  in  children,  being  most 
apt  to  develop  after  puberty.  (Fig.  678.)  The  prognosis  in  tuberculous 
ulceration  of  the  tongue  is  always  grave,  as  it  is  usually  secondary  to 
tuberculous  affections  of  other  parts  of  the  body  ;  its  development  generally 
hastens  the  fatal  termination,  as  the  pain  and  difficulty  in  taking  food 
cause  the  patient  to  lose  strength  rapidly. 


SYPHILIS  OF  THE  TONGUE. 


769 


Tuberculous  ulceration  of  the  tongue.    (Museum  of 
the  German  Hospital  of  Philadelphia.) 


Symptoms. — The  disease  manifests  itself  by  the  development  of  a 
nodule,  usually  near  the  tip  of  the  tongue,  which  breaks  down,  leaving  a 
deep  ulcer  with  clean-cut  edges  and  little  surrounding  induration.  The 
ulcer  at  first  causes  little  discomfoi't, 

but  after  a  time  becomes  very  jiain-       ''°'  "  ' 

ful.  The  presence  of  tuberculous 
lesions  in  other  parts  of  the  body 
serves  to  differentiate  this  alfectiou 
from  gummatous  and  cancerous  ul- 
cerations. 

Treatment. — The  use  of  the  cu- 
rette and  cautery,  with  the  applica- 
tion of  iodoform,  appears  to  arrest 
the  progress  of  the  ulceration,  but 
is  seldom  followed  by  healing  of  the 
ulcer.  In  many  cases  no  operative 
treatment  is  indicated  ;  here  a  nutri- 
tious and  unirritating  diet  should  be 
given,  the  ulcer  dusted  with  iodo- 
form, and  mild  antiseptic  mouth- 
washes employed.  As  pain  is  usually 
a  prominent  symptom,  it  may  be 
relieved  by  the  local  application  of  a  two  per  cent,  solution  of  cocaine  or 
campho-phenique ;  if  the  patient  cannot  be  rendered  comfortable  by  these 
applications,  excision  of  a  portion  of  the  lingual  nerves  may  be  resorted  to. 

Primary  Syphilis  of  the  Tongue. — Chancre  of  the  tongue  is  occa- 
sionally seen,  and  appears  as  a  small  papule,  which  breaks  down  and 
ulcerates  and  presents  marked  induration,  and  is  accompanied  by  enlarge- 
ment of  the  submaxillary  glands.  Owing  to  the  rarity  of  its  occurrence  in 
this  situation,  its  specific  character  is  often  overlooked.  The  true  nature  of 
the  affection  is,  however,  soon  demonstrated  by  the  appearance  of  the  sec- 
ondary lesions  of  syphilis.  Treatment. — This  ulcer  heals  rapidly,  and  the 
irritation  disappears  under  the  internal  use  of  mercurj' ;  at  the  same  time 
an  antiseptic  mouth-wash  should  be  employed. 

Secondary  Syphilis  of  the  Tongue. — This  affection  may  manifest 
itself  either  in  tlie  form  of  mucous  patches  or  plaques  or  in  superficial  ulcer- 
ation. Mucous  patches  are  observed  in  acquired  or  inherited  syphilis,  and 
consist  of  slightly  elevated,  isolated,  grayish  patches  composed  of  thickened 
epithelium,  which  rests  upon  the  inflamed  and  swollen  papillte.  They 
usually  occupy  the  dorsum,  tip,  and  lateral  aspects  of  the  tongne,  but  are 
occasionally  seen  upon  its  under  surface,  and  generally  coexist  with  similar 
patches  upon  the  lips,  cheeks,  and  palate.  Superficial  ulceration  of  the 
tongue  is  also  common  in  secondary  syphilis.  The  ulcers  are  multiple, 
present  sharply  cut  edges  and  a  grayish  base,  and  are  painful.  The  ulcera- 
tion usually  is  situated  uj)on  the  tip  and  edges  of  the  tongue,  and  coexists 
with  similar  lesions  of  the  mucous  membrane  of  the  angles  of  the  mouth, 
lips,  cheeks,  and  palate.  Treatment. — This  consists  in  the  administration 
of  iodide  of  mercury,  in  doses  of  one-quarter  to  one-half  grain,  three  or  four 


770 


SYPHILIS  OF.  THE  TONGUE. 


times  a  day,  and  the  use  of  a  mouth-wash  of  1  to  4000  corrosive  sublimate 
solution,  or  a  solution  of  carbolic  acid  and  chlorate  of  potassium,  or  the 
patches  or  ulcers  may  be  painted  with  a  1  to  200  solution  of  corrosive  sub- 
limate. Under  this  treatment  the  lesions  usually  disappear  rapidly.  In 
cases,  however,  where  the  improvement  is  slow,  the  administration  of  iodide 
of  potassium,  from  five  to  ten  grains,  combined  with  biniodide  of  mercury, 
one-twenty-fourth  of  a  grain,  will  be  followed  by  the  most  satisfactory 
results.  Healing  in  these  cases  is  often  delayed  by  the  ii-ritation  produced 
by  the  use  of  tobacco,  which  should  be  avoided. 

Tertiary  Syphilis  of  the  Tongue. — The  lesions  of  tertiary  syphilis 
often  appear  many  years  after  the  primary  infection,  and  consist  of  a  round- 
cell  infiltration  which  may  result  in  the  development  of  fibrous  tissue, 
causing  a  sclerosed  and  deeply  fissured  condition  of  the  tongue,  or  a  local- 
ized accumulation  may  occui'  at  some  portion  of  the  organ,  giving  rise  to  a 
gumma.  The  sclerotic  process  may  involve  the  mucous  membrane  or  the 
whole  organ.  In  the  early  stage  of  the  affection  the  tongue  may  be  increased 
considerably  in  size,  and  in  the  later  stage  it  becomes  hard  and  marked  by 
deep  longitudinal  fissures  which  extend  from  the  tip,  which  is  often  serrated, 
over  the  dorsum  of  the  organ.  The  appearance  presented  is  very  character- 
istic.    (Fig.  679.) 

Gummata  of  the  Tongue. — These  growths  arise  from  a  localized 
round-cell   infiltration,    and   are   common   in   acquired   syphilis,    but   are 

extremely  rare  in  the  inherited 
_       disease.    Gummata  may  be  super- 


FiG.  679. 


Syphilitic  Assures  of  the  tongue.    (Museum  of  the 
German  Hospital  of  Philadelphia.) 


Ulcerated  gumma  of  the  tongue. 


ficial,  occurring  in  the  deeper  layers  of  the  mucous  membrane  or  in  the  sub- 
mucosa,  or  they  may  be  deep,  being  situated  in  the  muscular  substance  of 
the  tongue.  Deep  gummata  are  usually  situated  in  the  median  line  of  the 
tongue,  and  can  be  best  felt  from  the  dorsum.  They  are  likely  to  break 
down  and  form  an  ulcer.  (Fig.  680. )  This,  if  it  persists  for  a  long  time 
and    is    subjected    to    frequent   irritation,    may  become   epitheliomatous. 


TUMORS  OF  THE  TONGUE.  771 

Treatment. — This  consists  in  the  employment  of  iodide  of  potassium  in 
doses  of  from  ten  to  thirty  grains  three  times  a  day,  and  in  some  cases  the 
addition  of  biniodide  of  mercury,  one-twenty-fourth  of  a  grain,  will  be  of 
marked  benefit.  In  sclerosis  of  the  tongue  in  the  early  stages,  or  where  the 
parts  are  inflamed,  the  application  of  a  lotion  of  chromic  acid,  gr.  x,  water, 
f§  i,  or  of  a  solution  of  nitrate  of  silver  of  the  same  strength,  will  be  followed 
by  great  improvement.  Under  the  constitutional  treatment  gummata  may 
disappear  and  gummatous  ulcers  heal  promptly  without  much  deformity 
resulting  ;  but  in  well-marked  cases  of  deep  sclerosis,  although  the  inflam- 
matory symptoms  may  quickly  subside  under  treatment,  the  fissured  and 
indurated  condition  of  the  part  remains  as  a  permanent  deformity. 

Actinomycosis  of  the  Tongue. — This  affection  of  the  tongue  is  an 
extremely  rare  one,  and  arises  from  direct  infection  by  the  fungus.  Micro- 
scojjic  examination  will  reveal  the  nature  of  the  trouble,  and  the  treatment 
consists  in  thorough  curretting,  followed  by  the  application  of  the  actual 
cautery  to  the  surface. 

TUMOKS  OP  THE  TONGUE. 

Naevus  of  the  Tongue. — This  form  of  vascular  growth  occurring  in 
the  tongue  is  generally  a  venous  angioma,  and  is  usually  congenital,  except 
where  it  extends  to  the  tongue  from  the  floor  of  the  mouth.  It  usually 
presents  a  tumor  of  limited  extent.  Nfevus  of  the  tongue  presents  the 
peculiarity  that  it  may  remain  stationary  for  a  long  time,  seeming  to  have 
much  less  tendency  to  increase  in  size  than  ntevus  in  other  locations. 
Treatment. — This  consists  in  excision  of  the  growth  if  possible,  or  the  use 
of  the  actual  cautery  or  galvano-cautery.  The  patient  should  be  anaes- 
thetized, the  point  of  the  cautery  iron  introduced  into  the  tumor  at  a  dull- 
red  heat,  and  the  mass  of  the  tumor  thoroughly  cauterized.  Little  reaction 
follows,  and  one  application  is  usually  followed  by  a  cure. 

Papillomata  of  the  Tongue. — These  tumors,  which  may  be  met  with 
at  all  iieriods  of  life,  arise  from  an  overgrowth  of  the  ei^ithelium  and  con- 
nective-tissue basis  of  the  papillfe  of  the  tongue,  and  usually  present  a 
pedunculated  growth  without  surrounding  induration.  Papilloma  of  the 
tongue  occurring  during  and  after  middle  life, 
particularly  if  surrounded  by  induration,  should  ^^'^-  ^S^- 

be  looked  upon  with  suspicion  as  probably  epi- 
theliomatous.  Treatment. — This  consists  in 
cocainizing  the  base  of  the  tumor  and  cutting  it 
off  with  scissors  or  the  knife.  If  bleeding  is 
free,  the  bleeding  surface  should  be  touched 
with  a  cautery  iron. 

Lymphangiomata,  fibromata,   Upomata,    adeno- 
mata, and  cysts  of  the  tongue  are  occasionally        ,    ^^,^■hT^ZZ'^^,^„^^^^ 

T  ^  o  J  C\  it  ot  the  tongue     (Agnew ) 

met  with,  and  may  be  congenital.     (Fig.  681.) 

They  may  exist  for  years  without  producing  any  inconvenience,  but  if  they 
cause  deformity  or  inconvenience  they  should  be  excised.  In  the  case  of  a 
cyst,  it  should  be  dissected  out  or  opened,  its  contents  evacuated,  and  its 
inner  surface  cauterized  with  nitrate  of  silver. 


772 


CARCINOMA   OF  THE  TONGUE. 


Sarcoma  of  the  Tongue. — This  is  an  extremely  rare  affection,  very 
few  cases  having  been  reported.  The  growth  originates  in  the  body  of  the 
tongue,  and  appears  as  a  hard,  painless  mass  covered  by  the  mucous  mem- 
brane.    The  treatment  consists  in  early  and  free  excision  of  the  growth. 

Carcinoma  of  the  Tongue. — This  affection  of  the  tongue  usually 
commences  as  a  fissure,  nodule,  or  ulcer  upon  the  margin  or  tip  of  the 
tongue,  but  may  originate  at  any  part  of  the  organ.  (Pig.  682.)  It  is  one 
of  the  most  distressing  and  painful  forms  of  cancer,  and  usually  proves  fatal 
within  two  years,  but  may  run  a  more  rapid  course.     It  is  more  common  in 

males  than  in  females,  and  is  most  fre- 
quently seen  between  the  ages  of  forty- 
five  and  fifty-five.  In  the  majority  of 
cases  some  form  of  local  irritation  is  the 
exciting  cause  of  the  disease.  Smoking, 
the  local  irritation  of  the  organ  caused 
by  alcoholic  drinks,  the  irritation  pro- 
duced by  the  stem  of  a  tobacco-pipe  or  a 
sharf)  or  rough  tooth,  scars  resulting  from 
wounds,  badly  fitting  tooth-plates,  in  fact, 
any  local  cause  of  irritation  of  the  tongue, 
may  be  followed  by  the  development  of 
cancer  of  this  organ.  Benign  growths  of 
the  tongue,  if  they  have  existed  for  some 
time,  may  become  epitheliomatous ;  the 
development  of  epithelioma  in  a  certain 
number  of  cases  of  leucoplakia  and  psoria- 
sis linguae  has  been  observed.  Chronic 
ulceration  of  the  organ  arising  from  wounds  or  from  broken-down  gummata 
may  also  be  an  exciting  cause  of  carcinoma  of  the  tongue.  The  continuous 
use  of  caustics  applied  to  ulcerated  surfaces  uj)on  the  tongue  often  converts 
a  benign  ulcer  into  a  malignant  one. 

Symptoms. — The  ulcer  is  usually  a  deep  one,  with  irregular  nodular 
edges,  and  is  surrounded  by  an  area  of  induration,  but  may  occasionally 
present  a  fungous  appearance.  As  soon  as  the  ulceration  is  well  developed 
there  is  an  excessive  flow  of  saliva  and  foul  blood-stained  discharge ;  pain 
is  also  a  prominent  symptom,  and  is  felt  in  the  tongue  and  the  ear ;  the 
lymphatic  glands  in  the  submaxillary  region  are  soon  involved,  and  later 
those  of  the  neck.  The  growth  often  extends  from  the  tongue  and  involves 
the  floor  of  the  mouth.  Infiltration  and  binding  down  of  the  tongue  inter- 
fere with  its  mobility,  so  that  speech  and  swallowing  soon  become  difficult. 
Death  results  from  a  slow  septic  poisoning,  from  exhaustion  following  the 
constant  i^aiu,  or  from  profuse  hemorrhage  if  the  lingual  vessels  are  opened  ■ 
by  ulceration,  or  septic  pneumonia  may  cause  a  fatal  termination. 

Diagnosis. — All  ulcerations  of  the  tongue  in  patients  over  forty  yeai'S  of 
age  should  be  looked  upon  with  suspicion  and  be  carefully  studied.  Chancre 
and  tuberculous  and  syphilitic  ulcerations  are  most  frequently  confounded 
with  carcinoma  of  the  tongue.  Chancre  of  the  tongue  is  apt  to  be  met  with 
in  younger  subjects  than  those  in  whom  carcinoma  is  likely  to  occur,  and  is 


Carcinoma  of  the  tongue.     (Museum  of  the 
German  Hospital  of  Philadelphia.) 


TREATMENT  OF  CARCINOMA   OF  THE  TONGUE.  773 

soon  followed  by  enlargement  of  the  glands  and  the  development  of  symp- 
toms of  syphilis.  Syphilitic  ulceration  and  gummata  generally  improve 
rapidly  under  the  use  of  full  doses  of  iodide  of  potassium,  but  constitutional 
syphilis  does  not  preclude  the  possibility  of  the  development  of  cancer  in  a 
patient  having  such  a  history,  and  it  is  a  well-recognized  fact  that  the  disease 
sometimes  develops  in  broken-down  gummata. 

Tuberculosis  of  the  tongue  is  extremely  rare  as  a  primary  affection,  and 
a  tuberculous  ulcer  is  usually  accompanied  by  tubercular  lesions  in  other 
parts  of  the  body.  In  cases  where  doubt  exists  as  to  the  nature  of  the 
ulceration,  a  microscopical  examination  of  a  portion  of  the  ulcer  will  reveal 
its  true  nature.  Fixation  and  induration  of  the  tongue  are  the  most  reliable 
diagnostic  symptoms  of  cancer,  but  they  occur  late  in  the  disease. 

Treatment. — As  carcinoma  of  the  tongue  is  invariably  fatal  if  untreated, 
operative  treatment  should  be  undertaken  as  soon  as  the  diagnosis  is  made. 
The  operations  which  are  practised  upon  the  tongue  in  cases  of  carcinoma 
are  either  partial  or  complete  excisions  of  the  organ.  Complete  excision  of 
the  tongue  is  an  operation  attended  with  considerable  danger  and  with  a 
mortality  of  from  ten  to  fifteen  per  cent.  Death  after  this  operation  results 
from  hemorrhage,  shock,  or  septic  pneumonia.  In  addition  to  the  extir- 
pation of  the  tongue,  all  enlarged  and  indurated  lymphatic  glands  in  the 
region  of  the  tongue  should  be  removed.  The  submaxillary  lymphatic 
glands  are  usually  involved  and  should  be  removed,  and  at  the  same  time, 
as  the  submaxillary  salivary  glands  are  often  involved,  they  should  be  extir- 
pated ;  their  removal  has  also  been  recommended,  to  prevent  the  devel- 
opment of  ranula  from  obstruction  of  their  ducts. 

ComiDlete  excision  of  the  tongue  with  removal  of  the  affected  glands  is 
sometimes  followed  by  a  permanent  cure  of  the  affection,  and  even  if  it  fails 
to  accomiDlish  this  end,  renders  the  patient's  condition  more  comfortable 
and  prolongs  life,  and  death  from  recurrent  disease  in  the  glands  of  the  neck 
and  elsewhere  is  not  attended  with  as  much  suffering  as  the  primary  affec- 
tion. Appreciation  of  this  fact  will  justify  the  surgeon  in  recommending 
the  operation  as  a  possible  means  of  prolonging  life  and  of  diminishing  pain 
and  discomfort. 

Cases  of  carcinoma  of  the  tongue  which  present  the  following  conditions, 
extensive  involvement  of  the  floor  of  the  mouth,  with  adhesion  of  the  tongue 
to  it  and  to  the  jaws,  involvement  of  the  soft  palate,  and  enlargement  and 
induration  of  the  submaxillary  lymphatic  glands  and  the  glands  situated 
under  the  sterno-cleido-mastoid,  are  manifestly  inoperable.  Operation  may 
also  be  contraindicated  by  the  condition  of  the  patient,  as  well  as  by  the 
extensive  development  of  the  disease.  A  patient  exhausted  by  constant 
suffering,  and  who  has  not  been  able  to  take  sufficient  food,  or  one  in 
advanced  age,  will  not  bear  the  shock  of  so  severe  an  oj)eration  as  excision 
of  the  tongue.  In  inoperable  cases  the  pain  and  discomfort  may  be  relieved 
in  a  measure  by  painting  the  ulcerated  surface  with  a  two  per  cent,  solution 
of  cocaine,  or  by  the  local  use  of  campho-ph6nique  and  a  mild  antiseptic 
mouth-wash  ;  moj'phine  in  increasing  doses  is  sooner  or  later  required,  and 
may  be  given  by  the  mouth  or  by  hyi^odermic  injection.  Exposure  of  the 
growth  to  the  X-rays  in  inoperable  cases  may  be  followed  by  benefit. 

50 


774  EXCISION  OF  THE  TONGUE. 

Excision  of  a  portion  of  the  lingual  nerve  has  been  employed  with  good 
results  for  the  relief  of  pain. 

Partial  Excision  of  the  Tongue. — In  cases  where  the  growth  is  small 
and  is  situated  upon  the  tip  or  edge  of  the  anterior  half  of  the  tongue,  and 
the  submaxillary  glands  are  not  enlarged,  partial  excision  may  be  practised. 
After  partial  excision,  if  a  considerable  portion  of  the  organ  is  removed,  the 
tongue  is  apt  to  be  bound  down  by  adhesions,  and  swallowing  and  speech 
are  more  or  less  affected  ;  and  although  recurrence  of  the  growth  is  no  more 
likely  to  occur  in  the  remaining  portion  of  the  tongue  than  in  the  glands  or 
the  floor  of  the  mouth,  the  operation  is  not,  on  the  whole,  very  satisfactory. 
Before  extensive  operations  upon  the  tongue  the  patient  should  be  taught 
to  feed  himself  with  an  oesophageal  tube.  Before  the  operation  the  tongue 
and  the  mouth  should  be  sterilized  as  completely  as  possible  by  the  fre- 
quent use  of  antiseptic  mouth- washes.  In  excising  a  portion  of  the  tongue, 
the  jaws  should  be  separated  with  a  gag  after  the  patient  has  been  anaes- 
thetized, and  two  ligatm-es  passed  through  the  tongue  near  the  tip,  one  on 
each  side  of  the  median  line ;  by  traction  upon  these  the  tongue  is  drawn 
out,  when  it  is  split  down  the  centre  with  a  knife  and  freed  from  its  attach- 
ments to  the  floor  of  the  mouth  with  scissors,  and  the  diseased  portion 
removed  by  cutting  through  the  sound  tissue  well  beyond  the  seat  of  the 
disease.  The  bleeding,  which  is  free,  is  controlled  by  grasping  the  vessels 
with  haemostatic  forceps,  and  subsequently  securing  them  by  ligatures  ;  deep 
sutures  or  the  actual  cautery  may  also  be  employed  to  control  the  bleeding. 

Complete  Excision  of  the  Tongue. — The  immediate  danger  in  this 
operation  arises  from  hemorrhage,  the  blood  escaping  from  the  mouth  or 
passing  into  the  air  passages.  Preliminary  ligation  of  the  lingual  arteries 
in  the  neck  renders  the  operation  a  coaiparatively  bloodless  one,  and  the 
incisions  through  which  the  arteries  have  been  tied  may  be  utilized  to 
expose  and  remove  the  submaxillary  lymphatic  and  salivary  glands.  To 
prevent  the  escape  of  blood  into  the  air-passages  a  preliminary  tracheotomy 
may  be  done,  and  the  larynx  packed  with  gauze.  The  operations  which 
are  now  most  frequently  resorted  to  for  the  removal  of  the  tongue  are 
Whitehead's  and  Kocher's. 

Whitehead's  Operation. — The  ijatient  is  anesthetized,  and  the  jaws 
are  widely  separated  with  a  gag  ;  a  strong  ligature  is  passed  through  the  tijD 
of  the  tongue,  which  is  drawn  forward,  and  the  muscular  attachments  of 
the  organ  are  divided  rapidly  with  scissors.  If  the  lingual  arteries  have  not 
been  primarily  ligated  in  the  neck,  thej'  are  tied  as  soon  as  they  are  cut, 
or  before  they  are  divided,  if  possible ;  the  tongue  should  then  be  removed 
as  near  the  epiglottis  as  possible.  A  strong  silk  ligature  should  be  passed 
through  the  glosso-epiglottidean  fold  and  its  ends  brought  out  of  the  mouth  ; 
this  is  to  be  kept  in  place  for  a  few  days,  to  enable  the  surgeon  to  draw  the 
epiglottis  and  floor  of  the  mouth  forward  in  case  of  bleeding.  The  surface 
of  the  wound  should  then  be  dusted  with  iodoform,  or  an  ethereal  solution 
of  iodoform,  or  compound  tincture  of  benzoin,  may  be  painted  over  it. 
Where  it  is  possible,  the  mucous  membrane  should  be  sutured  over  the 
stump  of  the  tongue.  The  glands  must  be  removed  by  a  submaxillary 
incision. 


DISEASES  OF  THE  JAWS.  775 

Kocher's  Operation. — This  operation  is  the  most  satisfactory  one  when 
the  floor  of  the  mouth  or  the  jaw  is  involved  in  the  growth.  A  preliminary 
tracheotomy  is  sometimes  performed,  and  the  pharynx  plugged  with  a  steril- 
ized sponge,  but  this  is  not  necessary  and  adds  to  the  gravity  of  the  opera- 
tion. An  incision  is  then  made  from  a  point  just  below  the  mastoid  process, 
and  is  carried  down  the  anterior  edge  of  the  sterno-cleido-mastoid  muscle 
to  its  middle  ;  at  this  point  it  is  carried  across  the  neck 
to  the  hyoid  bone,  and  from  the  middle  of  this  bone  Fig.  G8.3. 

to  the  chin.  (Fig.  683.)  The  flap  marked  out  by  this 
incision  is  then  carefully  dissected  up  and  turned 
upward  on  the  cheek.  The  lingual  and  facial  arteries 
and  any  large  veins  are  ligated  ;  the  lymphatic  glands 
and  submaxillary  and  sublingual  salivary  glands  are 
removed.  The  lingual  artery  upon  the  opposite  side 
is  tied  through  a  separate  incision.  The  mucous  mem- 
brane along  the  iaw  and  the  mylo-hyoid  muscle  are 

"■^  1  j_iiT      Incision  for  Kocher  s  opera- 

next  divided,  and  the  tongue  is  drawn  out  through  tion. 

the  incision  and  removed  with  scissors  close  to  the 
epiglottis.     After  securing  bleeding  vessels,  the  cavity  is  packed  with  iodo- 
form gauze,  and  the  wound  is  not  closed  by  sutures,  but  is  allowed  to  heal 
by  granulation.     The  most  perfect  drainage  is  secured  by  this  method,  and 
the  risk  of  septic  pneumonia  is  averted. 

The  after-treatment  consists  in  feeding  the  patient  for  some  days  by  means 
of  an  cesophageal  tube.  The  wound  should  be  frequently  irrigated  with  an 
antiseptic  solution  and  loosely  packed  with  iodoform  gauze,  which  should 
be  changed  daily. 

Results  of  Excision  of  the  Tongue.— The  mortality  after  this  operation  is 
from  ten  to  fifteen  per  cent. ,  but,  although  recurrence  of  the  disease  within 
a  year  in  the  stump,  the  fauces,  or  the  glands  of  the  neck  is  common,  a 
number  of  actual  cures  have  been  reported.  The  patient's  life  is  con- 
siderably prolonged  by  the  operation  in  the  majority  of  cases,  and  he  is 
generally  relieved  from  the  pain  and  distress  which  are  always  present  in 
those  not  subjected  to  operative  treatment. 

DISEASES  OF  THE  JAWS. 
Hypertrophy  of  the  Gums.— The  muco-periosteum  which  is  attached 
to  the  alveolar  processes  of  the  jaws  may  increase  so  much  in  extent  as  to 
almost  or  quite  cover  tlie  teeth,  or  the  ihucous  membrane  may  be  so  much 
increased  that  it  forms  folds.  This  condition  may  be  relieved  by  cocain- 
izing the  parts  and  applying  Paquelin's  cautery  at  a  number  of  points,  and 
where  there  are  pendulous  folds  the.se  should  be  excised. 

Spongy  Gums. — The  gums  may  be  congested,  swollen,  and  painful, 
and  bleed  upon  very  slight  irritation.  This  condition  is  often  observed 
in  stomatitis,  in  alveolar  abscess,  in  scurvy  and  syphilis,  and  as  the  result 
of  the  prolonged  use  of  mercury.  The  presence  of  this  affection  renders 
the  mastication  of  solid  food  painful.  Treatment.— This  consists  in  the 
use  of  astringent  and  antiseptic  mouth-washes  composed  of  chlorate  of 
potassium  or  boric  acid.     The  cause  of  the  affection  should  be  sought 


776  ABSCESS  OF  THE  ANTRUM. 

for  and  removed,  and  the  general  health  should  be  improved  by  the  use  of 
tonics. 

Alveolar  Abscess. — This  originates  in  the  alveolar  socket,  and  results 
from  septic  changes  in  the  pulp  of  a  carious,  or  dead  tooth.  Alveolar 
abscess  may  be  superficial,  and  consist  of  a  collection  of  pus  immediately 
beneath  the  gum,  when  it  is  commonly  known  as  a  "gum-boil,"  or  the  pus 
may  collect  around  the  root  of  the  tooth  and  find  an  exit  by  following  the 
line  of  the  tooth,  appearing  at  its  insertion  into  the  gum,  or  by  perforating 
the  thin  shell  of  the  alveolus  and  burrowing  under  the  muco-periosteum, 
appearing  at  various  points,  often  some  distance  from  its  origin.  If  the 
abscess  originates  in  the  upper  jaw,  it  may  point  in  the  roof  of  the  mouth 
or  in  the  soft  palate,  in  the  floor  of  the  nasal  fossa,  or  in  the  antrum,  while 
in  abscess  originating  in  the  lower  jaw  it  is  apt  to  j)oint  on  the  gum  or  on 
the  mucous  membrane  between  the  cheek  and  the  gum,  on  the  cheek,  or  in 
the  submaxillary  region.  Symptoms. — These  consist  of  pain  of  a  severe 
and  throbbing  character,  and  of  swelling  of  the  mucous  membrane  in  the 
region  of  the  abscess  and  of  the  cheek  ;  in  alveolar  abscess  of  the  upper  jaw 
the  eyelid  may  be  swollen  and  cedematous.  The  lymphatic  glands  may  be 
enlarged  and  tender  ;  at  the  same  time  febrile  symijtoms  appear,  the  tongue 
is  coated,  and  the  breath  becomes  very  foul.  Treatment. — As  soOn  as  the 
presence  of  suppuration  is  detected  an  incision  should  be  made  to  give  exit 
to  the  pus,  and  this  is  usually  followed  by  marked  relief,  but  a  sinus  often 
persists  for  some  time,  unless  the  diseased  or  dead  tooth  or  the  necrosed 
portion  of  the  alveolus  is  removed.  The  incision  should,  if  j)ossible,  be 
made  in  the  mouth,  to  avoid  scars  and  persistent  sinuses  upon  the  face. 
After  oijening  the  abscess  an  antiseptic  mouth-wash  should  be  employed 
for  a  few  days.  If  the  abscess  opens  spontaneously  uj^on  the  cheek  or  neck, 
a  troublesome  sinus  is  apt  to  remain.  In  cases  where  the  jius  is  confined  to 
the  alveolar  socket,  drilling  of  the  alveolar  wall  and  the  root  of  the  tooth 
may  be  followed  by  relief.  It  is  not  always  necessary  to  remove  the  dis- 
eased tooth  if  it  is  treated  by  a  competent  dentist. 

Abscess  of  the  Antrum. — Empyema  of  the  antrum  consists  of  a 
collection  of  pus  in  the  antrum  of  Highmore,  which  results  from  suppura- 
tion in  connection  with  the  teeth  of  the  upper  jaw,  injury  or  disease  of  the 
walls  of  the  cavity,  or  extension  of  inflammation  from  neighboring  cavities. 

Symptoras. — These  are  dull,  aching  pain,  tenderness,  and  swelling  of 
the  gum  below  the  antrum,  with  the  development  of  febrile  symptoms,  and 
occasionally  oedema  and  redness  of  the  overlying  skin,  with  obstruction  of 
the  tear-duct  and  escape  of  tears  over  the  cheek.  The  occasional  discharge 
of  pus  from  the  nose  in  connection  with  the  above  symptoms  is  very  signifl- 
cant.  Tumors  of  the  nasopharynx,  or  those  growing  from  the  inner  wall 
of  the  antrum  before  they  have  caused  deformity  by  expanding  its  walls, 
often  present  symptoms  similar  to  those  of  antral  abscess,  and  have  some- 
times been  confounded  with  this  affection.  The  most  important  diagnostic 
symptoms  are  the  periodical  escape  of  pus  from  the  nose  and  the  presence 
of  diseased  upper  bicuspid  and  molar  teeth  on  the  same  side  of  the  jaw. 
Transillumination  has  recently  been  employed  to  demonstrate  the  pres- 
ence of  pus  in  the  antrum  ;  this  is  accomplished  by  placing  a  small  electric 


NECROSIS  OF  THE  JAW.  777 

lamp  in  the  inoutli  and  closing  the  jaws,  when  if  the  antrum  is  in  a  healthy 
condition  a  translucent  curved  band  of  light  appears  beneath  each  lower 
eyelid,  which  band  does  not  appear  if  the  antrum  contains  pus ;  a  tumor  of 
the  antrum  will  also  interfere  with  the  development  of  the  band  of  light,  so 
that  this  method  is  not  absolutely  reliable. 

Treatment. — If  a  dead  tooth  or  stump  is  present  in  the  region  of  the 
antrum,  its  removal  will  often  be  followed  by  the  escape  of  pus,  and  drainage 
may  be  accomplished  in  this  way.  If  the  teeth  are  not  diseased,  the  antrum 
should  be  perforated  with  a  bone-drill  through  the  canine  fossa,  and  when 
pus  escapes  the  wound  should  be  enlarged  and  the  cavity  freely  irrigated. 
At  the  time  the  antrum  is  opened  its  cavity  should  be  explored  for  the  pres- 
ence of  necrosed  bone  or  a  foreign  body.  The  symptoms  usually  disappear 
rapidly  after  free  drainage  has  been  secured. 

Periostitis  of  the  Jaw. — This  affection  may  result  from  injury  or  may 
have  its  origin  in  an  alveolar  abscess,  and  is  frequently  followed  by  the 
formation  of  an  abscess  and  necrosis  of  the  underlying  bone.  A  periosteal 
abscess,  if  allowed  to  run  its  course,  will  discharge  sooner  or  later,  but  in 
the  mean  time  causes  miich  suffering,  and  necrosis  is  apt  to  occur.  The 
symptoms  of  this  affection  are  local  swelling,  pain,  and  febrile  disturbance. 
Treatment. — This  consists  in  one  or  more  free  incisions  through  the 
swollen  tissues,  which  should  be  deep  enough  to  expose  the  underlying 
bone  fi'eely,  and  should,  if  possible,  be  made  through  the  mucous  membrane 
of  the  mouth,  to  avoid  external  scars.  If  the  incisions  are  made  promptly, 
the  pain  and  swelling  rapidly  disappear,  and  necrosis  of  the  bone  and  per- 
sistent sinuses  may  be  avoided.  If  necrosis  has  already  occurred,  antiseptic 
mouth-washes  should  be  employed,  and  later  the  necrosed  bone  removed. 

Necrosis  of  the  Jaw. — This  is  frequently  observed  after  compound 
fractures  of  the  jaws,  as  the  result  of  periostitis  or  osteomyelitis,  from 
exposiu'e  to  the  fumes  of  phosphorus  or  from  mercury,  and  is  occasionally 
seen  as  a  sequel  of  measles,  scarlet  fever,  typhoid  fever,  or  gangrenous 
stomatitis ;  as  a  result  of  the  latter  affection  necrosis  of  a  large  portion  of 
the  jaws  may  occur.  liTecrosis  follow- 
ing alveolar  abscess  and  compound 
fractures  is  generally  limited  in  extent, 
and  in  the  foi'mer  affection  a  thin  shell 
of  bone  only  is  involved. 

Phosphorus  Necrosis. — This  form 
of  necrosis  of  the  jaw  results  from  ex- 
posure to  the  fumes  of  phosphoi-us, 
which  gain  access  to  the  bone  by  the 
exposed  pulps  of  the  teeth,  and  is  usu- 
ally observed  in  operatives  in  match-    ,-  .^  ,      ,  >         % 

■'I  ^  Neurosis  ol  the  jaw  trom  phosphorus.     (.AgUKW.) 

factories.      (Fig.    684.)     It    has   been 

found  that  persons  with  sound  teeth  can  be  exposed  to  the  fumes  of  phos- 
phorus without  the  development  of  the  affection.  Symptoms. — These  may 
not  be  marked  at  first,  but  swelling  of  the  tissues  over  the  jaws  soon  appears, 
and  as  a  portion  of  the  bone  becomes  necrosed  a  shell  of  bone  develops  from 
the  periosteum.     Extensive  necrosis  is  the  rule  in  these  cases.     There  is 


778  TUMORS  OF  THE  JAW. 

great  fetor  of  the  breatli,  wliicli  is  often  the  first  symptom  which  calls 
attentiou  to  the  condition. 

Treatment. — In  cases  of  necrosis  of  the  jaw  it  is  well  to  wait  until  the 
dead  bone  has  been  separated  from  the  living  bone  before  its  removal  is 
undertaken.  The  patient  during  this  time  should  use  fi-eely  antiseptic 
mouth- washes  of  boric  acid,  tincture  of  myrrh,  or  j)ermanganate  of  potassium, 
and  care  should  be  taken  to  provide  for  the  free  discharge  of  pus.  When 
the  necrosed  portion  of  the  bone  is  loose  it  should  be  removed,  but  if  possible 
the  removal  should  be  delayed  until  new  bone  has  formed  to  preserve  the 
shape  of  the  jaw  ;  this  should  be  done  through  the  mouth  if  possible,  the  gum 
being  ini^ised  as  freely  as  is  necessary,  and  the  bone  being  removed  by  the  use 
of  an  elevator  and  forceps.  Almost  the  entire  lower  jaw  may  be  removed 
through'  the  mouth  in  this  manner  without  making  an  external  incision.  If 
it  is  thought  advisable,  the  dead  bone  may  be  divided  by  bone-cutting 
forceps  and  removed  in  sections.  After  the  removal  of  the  bone  antiseptic 
mouth-washes  should  be  employed.  More  or  less  reproduction  of  bone 
occurs  from  the  periosteum  after  the  removal  of  the  dead  bone,  and  serves 
to  retain  the  shape  and  ultimate  function  of  the  jaw  ;  reproduction  of  bone 
is  much  more  marked  in  the  lower  than  in  the  upper  jaw. 

Actinomycosis  of  the  Jaw. — This  affection  is  occasionally  seen  in 
the  jaws  ;  the  fungus  reaches  the  jaw  through  a  carious  tooth,  and  sets  up 
inflammation,  causing  marked  swelling,  with  implication  of  the  surrounding 
tissues  and  the  skin,  being  followed  by  the  formation  of  sinuses  and  the  dis- 
charge of  serous  or  purulent  fluid.  An  examination  of  the  discharge  in  a 
case  of  this  nature  will  reveal  small  yellow  bodies  which  contain  clusters  of 
actinomyces.  The  lymphatic  glands  become  enlarged,  and  if  the  disease  is 
not  arrested  by  prompt  treatment  secondary  foci  may  develop  in  the  lungs 
or  the  intestine.  Treatment. — This  consists  in  exposing  the  diseased  bone 
and  removing  it  freely  with  the  gouge  or  curette,  the 
Fig.  685.  surfaces    being    subsequently  touched  with   the    actual 

cautery. 

TUMORS  OF  THE  JAW. 

Tumors  of  the  Gum.s. — These  are  fibromata,  sar- 
comata, epitheliomata,  or  x^apillomata. 

Fibroma. — Epulis. — This  tumor  originates  from  the 
root  of  a  carious  or  broken  tooth,  consists  of  fibrous  tissue 
covered  with  mucous  membrane,  and  is  most  frecxuently 
met  with  in  the  lower  jaw.  It  is  usually  of  moderate 
^^'"'(AiterAgnr.V''"'  ^ize,  but  Occasionally  may  attain  the  dimensions  of  an 
egg  and  cause  marked  deformity.  (Fig.  685.)  The  repu- 
tation for  malignancy  which  these  tumors  have  obtained  is  probably  due  to 
the  fact  that  in  the  early  stage  it  is  impossible  clinically  to  distinguish  them 
from  sarcomata. 

Sarcoma. — This  growth  may  occur  at  any  age,  and  has  even  been 
observed  in  infants.  It  originates  from  the  muco-periosteum,  and  is  usu- 
ally of  the  round-cell  or  the  spindle-cell  variety.  It  may  occur  in  either 
the  upper  or  the  lower  gums,  and  project  into  the  space  between  the  cheeks 
and  the  teeth,  or  towards  the  palate,  grows  rapidlj',  producing  displace- 


TUBIOES  OF  THE  JAW.  779 

ment  of  the  teeth  and  marked  change  in  the  shape  of  the  alveolar  process 
of  the  jaw,  and,  if  of  considerable  size,  may  protrude  from  the  mouth. 

Epithelioma. — This  growth  originates  in  the  mucous  membrane  cover- 
ing, the  alveolar  processes  of  the  jaws,  and  is  more  frequent  in  the  lower 
than  in  the  upper  jaw.  The  disease  may  also  start  in  a  leucoplakic  patch, 
and  infiltrate  the  gum  and  extend  to  the  floor  of  the  mouth  or  cheeks,  when 
the  underlying  bone  soon  becomes  eroded.  The  lymphatic  glands  of  the 
neck  are  involved  early  in  the  disease.  This  affection  runs  a  rapid  course 
unless  arrested  by  surgical  treatment ;  death  results  from  sejitic  pneumonia, 
or  from  exhaustion  consequent  upon  pain,  hemorrhage,  and  difficulty  in 
taking  sufficient  food. 

Papilloma. — This  affection  is  not  a  serious  one ;  the  papillary  growth 
originating  from  the  gums  presents  the  characteristic  appearance  of  papil- 
loma in  other  parts,  and  the  affection  is  of  especial  interest  only  from  the 
fact  that  it  may  be  confounded  with  epithelioma.  The  slow  growth,  absence 
of  induration  and  x)ain,  and  the  lack  of  glandular  involvement  serve  to  dis- 
tinguish it  from  the  latter  affection. 

Treatment. — The  treatment  of  fibroma  of  the  gums,  or  epulis,  consists 
in  free  removal  of  the  growth  and  of  the  root  of  the  diseased  tooth,  together 
with  a  portion  of  the  bone  to  which  it  is  attached.  This  is  best  accom- 
plished by  extracting  one  or  more  teeth  and  then  excising  a  jjortion  of  the 
alveolar  process  of  the  jaw  in  conjunction  with  the  tumor.  Eemoval  in  this 
manner  is  seldom  followed  by  a  recurrence  of  the  affection.  In  cases  of 
sarcoma  or  epithelioma  of  the  gums  the  diseased  structures  should  be  freely 
excised,  together  with  a  portion  of  the  underlying  bone,  and,  if  the  growths 
have  not  attained  too  large  a  size,  the  operation  can  be  done  within  the 
mouth.  The  removal  of  these  growths  is,  however,  usually  soon  followed 
by  recurrence,  which,  if  it  involves  the  jaw,  may  call  for  a  still  more  exten- 
sive operation.  The  more  promptly  they  are  removed,  the  better  is  the 
chance  of  delaying  recurrence  of  the  disease  and  giving  the  patient  a  con- 
siderable period  of  relief  from  suffering.  Papillary  growths  of  the  gums  in 
persons  beyond  middle  life  should  not  be  treated  by  cauterization,  but 
should  be  excised  as  early  as  jjossible,  as  such  growths  by  constant  irri- 
tation may  become  epitheliomatous. 

Osteoma  of  the  Jaw. — This  tumor  consists  of  a  localized  outgrowth 
of  bone,  and  is  more  common  in  connection  with  the  lower  than  with  the 
upper  jaw ;  it  may  originate  in  the  alveolar  process,  the  body,  or  the  nasal 
processes  of  the  uj)per  jaw.  It  may  cause  more  or  less  pain,  but  is  princi- 
pally marked  by  the  deformity  and  loss  of  function  which  its  presence  occa- 
sions. Treatment. — This  consists  in  exposing  the  growth  by  an  incision, 
and  its  removal  by  a  saw  or  a  chisel. 

Carcinoma  of  the  Jaw. — Carcinoma  may  affect  the  jaws,  and  is 
more  common  in  the  upjjer  than  in  the  lower  jaw.  The  disease  first  appears 
in  the  gums,  and  rajjidly  involves  the  bone.  The  lymphatic  glands  are 
affected  early  in  the  disease,  and  as  the  growth  increases  in  size  great 
deformity  of  the  face  results.  (Fig.  6StJ.)  Treatment. — The  removal  of 
the  growth  should  be  promptly  accomi^lished,  the  soft  parts  as  well  as  the 
diseased  bone  being  freely  removed.     Excision  of  one-half  of  the  upper  jaw 


780 


SARCOMA   OF  THE  JAW. 


Fig.  686. 


is  often  demanded  iu  these  cases.     In  spite  of  free  removal  of  the  growth, 
reciu-rence  is  often  rapid. 

Sarcoma  of  the  Jaw. — These  growths  originate  in  the  periosteum  or 
the  bone,  may  occur  at  any  period  of  life,  and  ai'e  not  uncommon  in  chil- 
dren. They  grow  rapidly,  causing  great 
deformity  of  the  face,  and  recur  quickly  after 
removal.  When  originating  in  the  body  of 
the  lower  jaw  (Pig.  687),  they  expand  the 
inner  and  outer  plates  of  the  bone ;  in  the 
uijper  jaw  they  usually  originate  in  the  alve- 
olar and  nasal  processes.  (Fig.  688.)  They 
are  of  the  spindle-  and  round-cell  varieties. 
The  former  often  contain  tracts  of  hyaline 
cartilage,  which  have  caused  them  to  be 
classed  with  cartilaginous  tumors. 

Treatment. — This  consists  in  the  re- 
moval of  the  growth  with  the  bone  fi-om 
which  it  springs.  To  obtain  the  best  results 
the  tumor  should  be  removed  as  early  as 
possible,  and,  if  it  is  found  that  it  is  impos- 
sible to  remove  the  growth  completely,  no 
operation  should  be  undertaken.  A  large 
portion  of  the  upper  or  lower  jaw  may  be  involved  and  require  removal, 
and  the  operation,  if  the  growth  is  extensive,  may  be  attended  with  great 
risk.  Many  cases  when  they  come  under  the  care  of  the  surgeon  are  inop- 
erable by  reason  of  their  great  extent.     If  both  sides  of  the  upper  or  the 


Carcinoma  of  the  upper  j;i 


Fig.  688. 


Fig.  687. 


Sarcoma  of  the  lower  jaw.    (Deaver.) 


Sarcoma  of  the  upper  jaw.    (Willard.) 


entire  lower  jaw  is  involved,  so  that  the  complete  removal  of  either  would 
be  required,  the  operation  is  not  a  justifiable  one,  on  account  of  the  risk  of 
the  operation  itself  and  the  subseqiient  dif&culty  in  taking  nourishment ; 
but  if  the  removal  of  a  portion  only  of  the  jaw  is  required,  the  operation  is 
not  attended  with  great  danger,  and  the  patient  may  have  a  considerable 
period  of  comfort  before  recurrence  takes  place.     The  operation  is  described 


TUMORS   OF  THE  ANTRUM. 


781 


under  Excision  of  the  Jaw.  In  inoperable  cases  tlie  nse  of  the  X-rays 
should  be  considered,  as  recent  experience  has  given  some  remarkable 
results  in  these  cases. 

Odontomata. — These  tumors  have  been  described  in  the  article  upon 
Tumors  (page  275),  and  the  greatest  interest  is  attached  to  their  presence  from 
the  fact  that  they  have  often  been  confounded  with  malignant  growths  of 
the  jaw,  and  as  a  result  of  this  error  extensive  and  unnecessarily  severe 
operations  have  been  undertaken  for  their  removal.  The  diagnosis  is  made 
from  malignant  tumors  of  the  jaw  by  their  occurrence  in  connection  with 
the  absence  of  certain  teeth  in  young  subjects,  and  the  painlessness  and 
slowness  of  their  growth.  Treatment. — As  these  tumors  are  usually  encap- 
sulated, they  should  be  exj)osed,  and  enucleated  if  j^ossible  ;  if  this  cannot 
be  done  the  bony  wall  of  the  tumor  may  be  cut  away,  and  the  cavity  packed 
with  gaiize  and  allowed  to  heal  by  granulation.  In  cases  where  the  diagnosis 
cannot  be  satisfactorily  made,  it  is  wise  to  make  an  exploratory  incision  to 
ascertain  the  nature  of  the  growth,  and  avoid  the  unnecessary  removal  of  a 
large  portion  of  the  jaw. 

Tumors  of  the  Antrum.— The  antrum  may  be  the  seat  of  myxoma- 
tous, sarcomatous,  and  epitheliomatous  growths.  Myxoma. — These  tumors 
are  often  associated  with  similar  growths  in  the  nasal  cavities,  and  when 
large  cause  expansion  of  the  bone  and  result  in  great  deformity.  Sarcoma. 
— Sarcoma  of  the  antrum  may  be  of  the  spindle-  or  round-cell  variety,  and 
originates  in  the  muco-periosteum.  As  the 
growth  increases  in  size  it  may  extend  into 
the  nasal  cavities ;  it  may  also  extend  down- 
ward, displacing  the  alveolar  j^rocesses  and 
the  teeth,  or  upward,  disijlacing  the  orbital 
plate.  (Fig.  689.)  The  growth  may  per- 
forate the  anterior  wall  of  the  antrum  and 
involve  the  cheek  or  the  posterior  wall  and 
find  its  way  into  the  spheno-maxillary  or 
temporal  fossa.  Epithelioma. — This  affec- 
tion of  the  antrum,  which  occurs  in  patients 
past  middle  life,  usually  starts  from  the 
upper  jaw,  and  is  accompanied  by  pain, 
oedema  of  the  eyelid,  and  infiltration  of  the 
skin  over  the  antrum,  which  is  finally  perfo- 
rated, after  which  a  fungous  growth  appears 
upon  the  cheek.  Extensive  involvement  of 
the  subcutaneous  tissue  occurs  at  the  same 
time.     In  the  early  stages  of  sarcoma  or 

epithelioma  of  the  antrum  the  symptoms  presented  are  very  similar  to  those 
of  abscess  of  the  antrum,  and  there  may  be  doubt  as  to  the  nature  of  the 
affection  unless  a  discharge  of  pus  from  the  nose  occurs. 

Treatment. — If  doubt  exists  as  to  the  nature  of  the  swelling,  an  explor- 
atory punctui-e  should  be  made  through  the  canine  fossa  before  undertaking 
any  radical  treatment.  In  cases  of  sarcoma,  excision  of  one-half  of  the 
upper  jaw  is  the  operation  which  gives  the  best  results.    In  epithelioma  the 


Sarcoma  of  the  antrum. 


782  DEFOEMITIES   OF  THE  JAWS. 

anterior  surface  of  the  antrum  should  be  exposed  by  turning  up  a  flap  from 
the  cheek,  when  the  diseased  bone  and  soft  parts  should  be  thoroughly 
removed,  with  any  infiltrated  skin  which  overlies  the  bone  ;  if  the  tissues  of 
the  orbit  or  eyeball  are  involved,  they  should  also  be  removed.  A  large, 
gaping  wound  results,  which  is  packed  and  allowed  to  heal  by  granulation. 
The  results  of  operation  in  cases  of  sarcoma  are  better  than  those  in  epithe- 
lioma ;  in  both  cases,  however,  recurrence  is  likely  to  take  place  sooner  or 
later,  but  the  patient's  life  is  often  prolonged  by  the  operation. 

Deformities  of  the  Jaws. — Congenital  deformities  of  the  jaws  in 
connection  with  harelip,  and  median  fissure  of  the  lower  jaw  have  already 
been  considered  (page  743).  There  is  also  occasionally  observed  defective 
development  of  the  lower  jaw,  which  causes  the  patient  to  present  a  peculiar 
appearance,  and  is  associated  with  fixation  of  the  jaw,  rendering  the  use  of 
solid  food  almost  impossible.  Acquired  deformities  of  the  jaws  are  not 
uncommon,  and  may  result  from  injuries  or  from  the  contraction  of  the  soft 
parts  following  burns  or  sloughing.  The  habit  of  thumb-sucking  in  infants 
and  children  may  cause  a  change  in  the  shape  of  the  jaws,  as  well  as  in  the 
direction  of  the  teeth.  In  hypertroi^hy  of  the  tongue  the  pressure  of  the 
enlarged  organ  may  cause  a  change  in  the  shape  of  the  jaws.  Treatment. 
— In  cases  of  acquired  deformities  little  can  be  done  in  the  way  of  treatment, 
aside  from  removing  the  cause  of  the  deformity,  to  prevent  further  distor- 
tion. In  congenital  deformities  associated  with  fixation  of  the  jaw,  excision 
of  the  condyles  or  division  of  the  neck  of  the  condyles  has  been  followed  by 
an  improvement  in  motion. 

Diseases  of  the  Temporo-Maxillary  Articulation. — The  tem- 
poro-maxillary  articulation  may  be  the  seat  of  acute  arthritis  or  of  osteo- 
arthritis. 

Acute  Arthritis. — This  may  result  from  injuries,  but  most  frequently 
follows  the  exanthemata,  and  is  therefore  most  common  in  children.  The 
symptoms  are  pain,  swelling,  and  redness  over  the  articulation,  and  if  sup- 
puration occurs  the  pus  may  come  to  the  surface  over  the  joint  or  may 
escape  into  the  external  auditory  meatus.  In  such  cases  necrosis  of  the 
condyle  and  ramus  of  the  jaw  may  occur.  Ankylosis,  either  fibrous  or 
osseous,  of  the  affected  joint  may  occur  as  a  result  of  sujipuration  in  this 
articulation.  Treatment. — This  consists  in  obtaining  rest  of  the  articula- 
tion by  securing  the  lower  jaw  firmly  to  the  upper  by  means  of  a  Barton's 
bandage,  and  at  the  same  time  counterirritation  should  be  made  over  the 
articulation,  followed  by  the  use  of  warm  fomentations  or  of  belladonna  and 
mercurial  ointment.  The  patient  should  not  be  allowed  to  chew  or  talk, 
and  should  be  nourished  by  liquid  food.  If  supxjuration  occurs,  an  incision 
should  be  made  to  evacuate  the  pus.  If  necrosis  of  the  condyle  of  the  jaw 
develops,  the  diseased  bone  will  require  removal. 

Osteoarthritis. — This  affection  of  the  maxillary  articulation  is  also 
described  as  rheumatoid  arthritis,  and  is  often  associated  with  a  similar 
affection  in  other  joints  of  the  body.  The  interarticular  fibrocartilage  and 
articular  cartilages  gradually  disappear,  and  these  changes  are  accomijauied 
by  outgrowths  of  bone.  The  patient  complains  of  pain  and  crepitation 
upon  movements  of  the  jaw,  and  a  partial  dislocation  of  the  condyles  may 


CLEFT  PALATE.  783 

occur,  producing  prominence  of  the  chin,  and  more  or  less  loss  of  function 
soon  results.  Treatment. — This,  as  in  the  case  of  osteoarthritis  of  other 
joints,  is  extremely  unsatisfactory,  but  mild  counterirritation  is  often  fol- 
lowed by  relief  of  the  pain. 

Ankylosis  of  the  Jaw. — This  condition  usually  results  from  supx:>irra- 
tive  arthritis  of  the  temporo-maxillary  joint,  may  involve  one  or  both 
joints,  and  may  be  fibrous  or  bony  in  character.  The  symptoms  are  inabil- 
ity to  oj)en  the  mouth  or  to  masticate  solid  food,  so  tliat  the  patient  has  to 
subsist  upon  a  liquid  diet.  Treatment. — Various  operations  have  been 
employed,  such  as  division  of  the  neck  of  the  condyles,  excision  of  the  con- 
dyle, and  Esmarch's  operation,  which  consists  in  removing  a  wedge-shaped 
piece  of  bone  from  the  jaw  by  an  incision  just  in  front  of  the  masseter 
miiscle,  with  its  apex  at  the  alveolar  border.  If  muscular  fibres  or  fascia 
can  be  fastened  between  the  ends  of  the  bone,  the  formation  of  a  false  joint 
is  more  likely  to  be  secured.  The  object  of  these  operations  is  to  establish 
a  false  joint  at  the  seat  of  operation.  The  operations  which  are  followed  by 
the  best  results  are  excision  of  the  condyle  and  Esmarch's  operation. 

Closure  of  the  Jaws. — This  may  be  a  temporary  spasmodic  affection, 
due  to  irritation  of  the  fifth  cranial  nerve,  causing  reflex  irritation  of  the 
muscles  of  mastication,  or  to  the  failure  of  the  eruption  of  the  wisdom 
tooth.  .  Permanent  closure  of  the  jaws  may  result  from  ankylosis  or  from 
cicatricial  contraction  following  ulceration  or  sloughing  of  the  mouth  and 
cheeks,  and  this  condition  not  infrequently  follows  extensive  lacerated 
wounds  of  those  parts  and  gangrenous  stomatitis.  Inability  to  open  the 
mouth  and  to  masticate  solid  food  are  the  prominent  symptoms  of  this  affec- 
tion. Treatment. — In  cases  of  closure  of  the  jaws  which  have  not  been 
preceded  by  inflammatory  symj)toms  it  will  generally  be  found  that  the 
condition  is  due  to  the  non-eruption  of  a  wisdom-tooth,  and  if  an  exami- 
nation shows  that  this  has  not  appeared,  an  incision  should  be  made  and  it 
should  be  sought  for  and  removed ;  the  second  molar  should  be  removed 
if  the  wisdom-tooth  cannot  be  located.  This  procedure  will  often  be  fol- 
lowed by  the  relief  of  the  symjitoms. 

In  cases  of  closure  of  the  jaws  due  to  cicatricial  contraction  the  division 
of  the  band  of  tissue,  or  plastic  operations  uiaon  the  soft  parts,  is  usu- 
ally followed  by  no  i)ermanent  improvement ;  Esmarch's  operation,  or 
excision  of  the  condyle,  which  has  been  previously  described,  are  the  pro- 
cedures which  are  likely  to  be  followed  by  satisfactory  results. 

Cleft  Palate. — This  is  a  congenital  malformation  resulting  from  partial 
or  total  failure  of  union  between  the  maxillary  processes  and  the  parietal 
segments.  A  bifid  uvula  is  the  mildest  form  of  this  malformation.  In  other 
cases  the  soft  palate  may  be  fissured,  or  both  the  soft  and  the  hard  palate 
may  be  separated  for  a  certain  distance,  and  in  the  most  marked  cases  the 
separation  may  involve  the  whole  of  the  soft  and  the  hard  j)alate  and  extend 
forward  between  the  intermaxillary  bones  and  the  superior  maxilla. 

Symptoms. — Clefts  of  the  hard  palate  result  in  free  communication 
between  the  cavity  of  the  mouth  and  the  nasal  cavities,  so  that  in  swallowing, 
food  and  liquids  pass  into  the  latter  cavities  and  often  escape  from  the 
anterior  nares.     The  voice  in  cases  of  cleft  palate  is  indistinct,  nasal,  and 


784  CLEFT  PAXATE. 

unpleasant  in  character.  Infants  suffering  with  cleft  palate  cannot  take  the 
breast,  and  have  to  be  fed  with  a  spoon  or  a  dropper,  which  allows  the 
milk  to  run  down  into  the  pharynx  without  suction  on  the  part  of  the  child. 
Owing  to  the  difficulty  in  taking  food,  many  of  these  cases  die  of  mal- 
nutrition within  the  first  few  months. 

Treatraent. — The  treatment  of  this  condition  consists  in  performing  a 
plastic  operation,  by  which  the  edges  of  the  cleft  are  freshened  and  brought 
together  by  sutures,  so  that  the  abnormal  communication  of  the  mouth  with 
the  nasal  cavities  is  shut  off.  The  same  object  may  be  attained,  but  we 
think  in  a  much  less  satisfactory  manner,  by  the  fitting  of  a  metal  or  a 
rubber  obturator.  This  method  of  treatment  is  generally  recommended  by 
dental  surgeons,  but  possesses  the  disadvantage  that  the  obturator  has  to  be 
frequently  renewed,  ■  and  unless  it  is  removed  and  kept  clean  it  is  apt  to 
become  offensive.  Operative  treatment  has  been  practised  in  infants,  but 
we  do  not  think  it  a  wise  procedure,  for  there  is  necessarily  a  considerable 
loss  of  blood,  which  is  not  well  borne  by  these  subjects,  and  the  flaps  are 
often  thin  and  poorly  nourished,  so  that  failure  of  union  is  not  uncommon. 
We  therefore  think  operative  treatment  should  be  postponed  until  the 
patient  is  three  or  four  years  of  age.  The  results  of  the  operation  as  regards 
union  of  the  flaps  are  always  uncertain  ;  a  portion  of  the  flaps  may  unite, 
or  union  may  fail  in  the  whole  line  from  vomiting,  from  coughing,  or  from 
the  poorly  nourished  condition  of  the  flaps.  Gases  with  wide  separation 
with  small  horizontally  projecting  palatal  processes  are  unfavorable  ones 
for  operation.  Several  operations,  therefore,  may  be  required  before  union 
is  obtained  in  the  whole  line  of  the  cleft.  If  after  repeated  operations,  as 
sometimes  haiipens,  no  union  is  obtained,  the  patient  should  be  fitted  with 
an  obturator.  The  results  in  successful  cases,  as  regards  improvement  in 
swallowing  and  relief  of  regurgitation  are  generally  good,  but  the  tone  of 
the  voice  and  the  defective  articulation  are  not  often  much  changed ;  the 
latter,  after  closure  of  the  cleft,  may  be  much  improved  by  systematic  train- 
ing. The  operation  is  not  devoid  of  risk,  patients  occasionally  dying  from 
shock^  hemorrhage,  or  septic  pneumonia. 

The  plastic  operations  which  are  practised  to  remedy  this  defect  are 
staphylorrhaphy,  which  consists  in  fi-eshening  and  uniting  the  edges  of  the 
fissure  of  the  soft  palate,  and  uranoplasty,  which  consists  in  a  plastic  opera- 
tion for  the  closure  of  the  cleft  in  the  hard  palate.  In  complete  clefts  of 
the  hard  and  of  the  soft  iialate  these  operations  are  combined. 

Staphylorrhaphy. — The  patient  should  be  anaesthetized,  and  the  shoul- 
ders raised  by  a  pillow  so  that  the  head  falls  far  back  ;  a  gag  should  be  intro- 
duced to  hold  the  jaws  widely  apart.  The  lower  edge  of  the  soft  palate  is 
grasped  on  one  side  with  long  toothed  forceps,  a  narrow-bladed  knife  intro- 
duced into  the  tissues  at  the  edge  of  the  gap,  and  a  thin  strip  of  tissue 
removed.  The  same  i^rocedure  is  repeated  uxjon  the  opposite  side.  Sutures 
of  silk,  silver  wire,  or  silkworm-gut  (the  latter  material  is  best)  are  next 
introduced  through  the  edges  of  the  flaps  of  the  soft  palate,  with  curved 
needles  fixed  in  long  handles  and  having  an  eye  near  the  point.  (Fig.  690.) 
After  the  needle  has  been  passed  through  the  tissues  on  one  side  it  is 
threaded  and  withdrawn,  and  the  needle  for  the  other  side  is  passed  through 


URANOPLASTY. 


785 


the  tissues  and  is  threaded  with  the  other  end  of  the  suture  and  withdrawn. 
Sutures  are  applied  in  this  way  until  a  sufficient  number  have  been  intro- 

FiG.  690. 


Staphylorrhaphy  needles. 

duced  to  approximate  the  edges  of  the  gap,  when  each  suture  is  tightened  and 
clamped  with  a  perforated  shot.  Incisions  are  next  made  in  the  soft  palate 
with  a  tenotome,  to  divide  the  palatal  muscles ;  the 
knife  should  be  entered  internal  to  the  hamular  pro- 
cess, and  made  to  cut  upward  until  the  muscles  have 
been  divided  and  the  wounds  gape.  After  the  oper- 
ation the  patient  should  be  given  only  licxuid  nour- 
ishment and  not  allowed  to  talk,  and  the  mouth  be 
washed  out  after  taking  food  with  a  mild  antiseptic 
solution.  At  the  end  of  ten  days  the  sutures  should 
be  removed. 

Fig.  692. 


a,  Incision  for  freshening  Periosteal  elevators. 

edges  of  the  gap ;  b,  Incisions 
in  the  hard  palate. 

Uranoplasty. — For  this  operation  the  patient  should  be  anaesthetized 
and  placed  in  the  same  position  as  for  staphylorrha^jhy,  and  the  edges  of  the 
hard  and  the  soft  palate  fi-eshened  by  removing  strips 
of  mucous  membrane  (Fig.  691,  a)  ;  curved  incisions 
are  next  made  through  the  hard  palate  down  to  the 
bone  on  each  side  (Fig.  691,  b),  about  one-fom-th  of 
an  inch  inside  of  the  alveolar  process.  A  periosteal 
elevator,  curved  on  the  fiat  or  straight  (Fig.  692),  is 
next  introduced  into  the  incisions,  and  a  muco-peri- 
osteal  flap  is  dissected  up  ;  or  an  osteotome  may  be 
introduced  into  the  incisions  and  the  bone  freely 
divided,  so  that  the  detached  poi'tions  with  their 
muco-periosteal  covering  may  be  readily  approximated 
in  the  line  of  the  cleft.  Sutures  are  next  passed 
through  the  freshened  edges  of  the  hard  and  the  soft 
palate  as  previously  described,  and  drawn  up  and 
clamped  with  shot.  (Fig.  693.)  Free  hemorrhage  pro^imttlfJa  shottdsu- 
often  occurs  in  both  of  these  operations,  which  is  tuxes-,  sho^vlng  gaping  of 
usually  easily  controlled  by  pressure,   but  if  it  is 

severe  it  may  be  necessary  to  pack  the  incisions  with  gauze.   "Wolff's  method, 
which  consists  in  making  incisions  near  the  alveolar  border  of  the  gums, 


786  ULCERATION   OF  THE  PALATE. 

detaching  muco-periosteal  flaps,  packiDg  the  wounds  with  gauze  for  a  few 
days,  and  subsequently  freshening  the  edges  of  the  palate  and  uniting  them 
with  sutures,  may  be  practised. 

The  after-treatment  in  this  operation  is  similar  to  that  after  staphylor- 
rhaphy, but,  as  a  rule,  the  sutures  should  be  allowed  to  remain  for  two  weeks. 
If  union  occurs  in  a  part  of  the  cleft  only,  a  subsequent  operation  may  be 
necessary  to  obtain  a  complete  closure. 

Abscess  of  the  Palate.— This  may  be  situated  in  either  the  hard  or 
the  soft  palate.  Abscess  of  the  hard  palate  may  result  from  dental  caries, 
and  is  usually  situated  just  within  the  alveolar  arch ;  it  may  also  occur  in 
connection  with  syphilitic  or  tuberculous  disease  of  the  underlying  bone. 
The  most  marked  symptoms  of  this  affection  are  pain  and  swelling ;  the  pain 
is  often  very  severe  ;  the  swelling  is  at  first  firm,  but  soon  softens.  Necrosis 
of  the  underlying  bone  is  common  in  this  affection.  Abscess  of  the  soft 
palate  may  follow  acute  tonsillitis.  Treatment. — This  consists  in  making 
a  free  incision  to  evacuate  the  pus,  after  which  the  cavity  should  be  irri- 
gated with  jperoxide  of  hydrogen  until  the  sinus  is  healed.  If  the  abscess 
arises  from  a  diseased  tooth,  this  should  receive  treatment. 

Syphilitic  Affections  of  the  Palate. — These  are  common  in  the 
secondary  and  tertiary  stages  of  the  disease.  The  lesions  observed  in 
secondary  syphilis  are  mucous  patches  and  superficial  ulcerations.  The 
chief  lesions  of  the  hard  palate  in  tertiary  syphilis  are  gummata,  which 
originate  either  in  the  periosteum  of  the  palate  or  in  the  floor  of  the  nose, 
and  perforate  the  bony  roof  of  the  palate,  causing  a  marked  change  in  the 
character  of  the  voice,  and  permitting  food  and  fluids  to  pass  into  the  nasal 
cavities.  Gummata  are  apt  to  be  situated  in  the  median  line  of  the  palate, 
and  if  they  break  down  or  are  opened,  more  or  less  caries  and  necrosis  of  the 
bony  roof  of  the  palate  occur.  Gummata  of  the  soft  palate  originate  in  the 
submucosa,  and  often  result  in  perforation.  Treatment. — This  consists  in 
the  use  of  mercury,  and  the  local  application  to  the  mucous  patches  or 
ulcerations  of  a  solution  of  nitrate  of  silver,  gr.  x  to  water  fgi,  or  of  a  1  to 
400  bichloride  solution.  The  use  of  a  mouth- wash  of  carbolic  acid  and 
chlorate  of  potassium  is  also  followed  by  good  results.  In  gumma  of  the 
palate,  iodide  of  potassium  in  doses  of  from  ten  to  fifteen  grains  may  be  fol- 
lowed by  the  rapid  disappearance  of  the  tumor.  If  the  gumma  has  broken 
down,  the  same  internal  treatment  should  be  employed,  and  the  ulcer  treated 
by  the  use  of  mild  antiseptic  washes  and  the  application  of  a  solution  of 
nitrate  of  silver. 

Ulceration  of  the  Palate.— This  may  involve  either  the  hard  or  the 
soft  palate,  and  results  sometimes  from  operative  or  accidental  wounds,  but 
most  commonly  from  syphilis.  Tuberculous  ulceration  of  the  palate  is  also 
seen.  The  treatment  depends  upon  its  cause.  In  traumatic  cases  the  use  of 
an  antiseijtic  wash  and  the  application  of  nitrate  of  silver  are  usually 
followed  by  good  results.  Syphilitic  ulceration  should  be  treated  by  iodide 
of  potassium  in  full  doses  in  addition  to  the  local  treatment ;  and  in  tubercu- 
lous ulceration,  antituberculous  remedies  should  be  employed. 

Necrosis  and  caries  of  the  palate  may  result  from  wounds,  but  are  most 
frequently  the  results  of  syphilis.     In  this  affection  the  exfoliation  of  the 


TUMORS   OF  THE  PALATE.  787 

bone  is  very  slow,  and  if  perforation  of  the  roof  of  the  mouth  occurs,  an 
obturator  should  be  worn,  or  the  opening  may  be  closed  by  a  plastic  opera- 
tion, a  flap  being  slid  from  the  palate  to  close  the  gap.  No  operative 
treatment  should  be  undertaken  until  the  dead  bone  has  separated  and  a 
healthy  granulating  surface  is  present. 

Tuberculosis  of  the  Palate. — This,  as  a  primary  affection,  is  ex- 
tremely rare,  but  it  may  be  tissociated  with  tuberculosis  of  the  lungs, 
tongue,  or  pharynx,  or  with  lu]3us  of  the  nose,  and  may  involve  either  the 
soft  or  the  hard  palate.  When  the  soft  palate  is  involved,  disseminated 
tubercular  nodules  develoj),  which  break  down  and  form  ulcers.  lu  the 
hard  palate  the  bone  may  be  primarily  affected,  and  ulceration  of  the  palate 
and  perforation  of  the  roof  of  the  mouth  may  occur.  In  tuberculosis  of  the 
palate  the  neighboring  lymphatic  glands  are  usually  involved.  The  disease, 
if  primary,  under  treatment  may  terminate  favorably,  but  in  the  majority 
of  cases,  as  it  is  associated  with  tuberculosis  of  other  parts,  the  i^rognosis  is 
unfavorable.  Treatment. — This  consists  in  the  use  of  anti-tubercular 
remedies,  tonics,  fresh  air,  and  a  change  of  climate.  The  local  treatment 
consists  in  the  use  of  mild  antiseptic  washes,  and,  if  the  disease  is  localized, 
curetting  the  ulcerated  surface  and  j)ainting  it  frequently  with  an  ethereal 
solution  of  iodoform  may  be  followed  by  healing. 

Tumors  of  the  Palate. — Sarcoma  of  the  Palate. — This  form  of 
growth  is  more  common  in  the  palate  than  epithelioma,  and  its  treatment 
should  be  early  removal,  but,  unfortunately,  recurrence  usually  takes  place 
rapidly.  Epithelioma  of  the  palate  may  also  occur  as  a  primary  growth, 
but  generally  results  from  extension  of  the  growth  from  the  mouth  and 
tongue.  The  lymphatic  glands  are  involved  early  in  the  disease.  The 
treatment  consists  in  early  and  free  removal  of  the  growth.  Adenomata  of 
the  Palate. — Various  forms  of  adenomata,  adeno-fibromata,  adeno-myxo- 
mata,  or  adeno-chondromata  may  be  observed  in  the  palate.  The  growths 
usually  increase  slowly  in  size,  and  are  more  common  in  the  soft  than  in  the 
hard  palate ;  they  are  usually  enclosed  in  a  distinct  capsule,  so  that  after 
being  exposed  by  incision  they  can  be  turned  out  withotit  much  difficulty. 
They  should  be  removed  early,  and  have  no  tendency  to  recur. 

Mucous,  dermoid,  and  sebaceous  cysts  may  also  occuj)y  the  palate, 
simple  mucous  cysts  being  those  most  frequently  met  with.  The  treatment 
of  cysts  of  the  palate  should  be  conducted  upon  the  same  general  principles 
as  for  similar  lesions  in  other  parts  of  the  body. 

Lipomata,  fibromata,  and  meningoceles  (the  latter  occupy  the 
median  line  of  the  palate)  are  occasionally  observed  in  this  location. 

Naevi  of  the  venous  variety  are  not  uncommon  in  the  hard  palate,  and 
the  most  satisfactory  treatment  of  these  growths  consists  in  the  employment  of 
the  galvano-cautery,  punctures  being  made  with  the  point  at  a  dull  red  heat. 

Aneurism  of  the  posterior  palatine  artery  sometimes  occurs  as  the  result 
of  an  injury  ;  the  possible  presence  of  this  lesion  should  cause  the  surgeon 
to  examine  every  tumor  of  the  palate  carefully  before  making  an  incision 
into  it.  Treatment. — If  the  aneurism  be  small,  it  should  be  excised,  if  lai'ge, 
electrolysis  should  be  employed,  and  if  this  fails  to  cure  the  affection,  liga- 
tion of  the  external  carotid  arteiy  may  be  required. 


CHAPTER    XXXI. 

SURGERY  OF  THE  NECK. 
By  B.  Faeqtjhae.  Curtis,  M.D. 

Injuries. — A  simple  contusion  of  the  neck  may  be  very  serious,  for  a 
severe  blow  may  compress  some  of  the  important  nerves  against  the  spinal 
column  and  produce  a  sudden  stoppage  of  the  heart  and  death  without  any 
visible  injury.  The  brachial  plexus  may  be  lacerated  or  entirely  destroyed. 
Hsematoma  of  the  sterno-mastoid  muscle  is  frequently  seen  in  the  new-born 
infant,  forming  a  fusiform  swelling  and  causing  torticollis.  It  usually 
I'esolves,  but  a  permanent  contraction  and  deformity  may  result.  The  hyoid 
bone  may  be  fractured  by  a  blow  or  by  an  attempt  at  strangulation.  Great 
pain  on  swallowing  and  crepitus  may  be  present  in  such  cases.  Union  does 
not  take  place  for  six  or  eight  weeks,  and  the  suffering  may  be  considerable. 
Twists  or  sprains  of  the  neck  cause  pain  and  stiffness,  which  may  be  so  severe 
as  to  resemble  dislocation  or  fracture,  but  the  symptoms  of  the  latter  are 
marked  from  the  beginning,  while  in  the  case  of  a  sprain  the  symptoms  are 
worse  after  a  few  hours  than  at  first. 

Cutthroat  Wounds. — Incised  wounds  of  the  neck  are  not  common, 
except  the  extensive  injuries  caused  by  attempts  at  suicide  by  cutting  the 
throat,  in  which  cases  the  wound  is  usually  uxdou  the  left  side  of  the  neck,  • 
the  knife  being  held  in  the  right  hand.  Cutthroat  wounds  are  seldom  fatal, 
for  the  great  vessels  generally  escape  division  owing  to  their  deep  situation 
in  the  angle  between  the  trachea  and  the  spine,  but  the  hemorrhage  from 
the  superficial  veins  is  very  serious,  and  the  patients  present  a  horrible 
appearance  from  the  simultaneous  opening  of  the  air-j)assages.  The  wounds 
are  generally  in  the  neighborhood  of  the  hyoid  bone,  and  instances  have 
been  known  in  which  the  latter  has  been  separated  from  the  base  of  the 
tongue,  the  pharynx  being  opened  so  that  three  or  four  fingers  could  be 
passed  in.  "Wounds  of  the  veins  in  the  neck  are  especially  liable  to  the 
complication  of  aspiration  of  air,  producing  sudden  death. 

Treatment. — The  treatment  in  these  cases  consists  in  the  arrest  of  hem- 
orrhage, the  thorough  cleansing  of  the  parts,  the  insertion  of  a  tracheotomy 
tube  if  the  trachea  has  been  opened,  and  the  closing  of  the  wound  by  a  few 
stitches.  If  the  pharynx  has  been  opened  it  may  be  sutured,  but  the 
external  wound  should  be  left  open  in  such  cases  to  allow  perfectly  free 
drainage  in  case  of  leaking  from  the  deeper  wound.  The  large  nerves  are 
injured  even  less  frequently  than  the  main  vessels.  The  patients  are  often 
insane  and  need  watching  afterwards. 

Stab  Wounds. — Stab  wounds  of  the  neck  may  be  as  dangerous  as  the 
wide  cutthroat  wounds,  for  single  nerves  may  be  divided  or  small  punctures 
made  in  the  vessels,  resulting  in  the  production  of  arteriovenous  aneurisms. 
The  pneumogastrie  nerve  has  been  divided  in  these  wounds,  and  also  the 
thoracic  duct. 


INFLAMMATIONS   OF  THE  NECK.  789 

Treatment. — A.  wound  of  this  character  which  jiresents  any  serious 
symptoms  should  be  enlarged  and  explored,  to  enable  the  surgeon  to  dis- 
cover the  nature  of  the  injury  and  apply  the  proper  remedy.  If  possible, 
the  divided  ner\-es  should  be  sutured,  and  the  thoracic  duct  likewise. 

Gunshot  Wounds. — Gunshot  wounds  resemble  stab  wounds,  but  pre- 
sent contusion  and  laceration  of  the  parts  as  well.  They  are  very  frequently 
fatal  on  account  of  injury  of  the  great  vessels,  and  in  stab  wounds  and  gun- 
shot injuries  secondary  hemorrhage  is  frequent.  Extensive  wounds  may 
divide  the  brachial  or  the  cervical  plexus,  producing  paralysis.  The  nerves 
are  to  be  sutured  immediately  in  such  cases,  with  due  care  to  unite  the 
corresponding  ends. 

Inflaramations. — The  superficial  inflammations  of  the  neck  do  not 
differ  from  those  of  other  parts.  Carbuncle  is  very  frequently  found  on 
the  back  of  the  neck,  and  furuncles  are  exceedingly  common.  Cellulitis 
is  quite  frequent,  and  is  very  liable  to  interfere  with  respiration  by  direct 
pressure  or  by  causing  oedema  of  the  larynx.  The  infectious  process  may 
also  extend  down  into  the  mediastinum  and  cause  fatal  complications.  It 
very  often  takes  its  origin  in  a  lymph-gland,  which  forms  an  abscess  and 
infects  the  cellular  tissue  around  it.  In  the  form  of  cellulitis  known  as 
Ludwig's  angina,  which  is  found  in  the  floor  of  the  mouth,  the  cellular 
tissue  between  the  mucous  membrane  and  the  mylo-hyoid  muscle  becomes 
acutely  inflamed,  generally  as  a  consequence  of  infection  of  the  lymph-node 
over  the  submaxillary  gland.  This  inflammation  tends  to  sloughing  rather 
than  to  the  formation  of  pus,  and  requires  very  free  and  early  incisions, 
because  it  often  produces  oedema  of  the  larynx,  and  may  result  in  death. 
The  tongue  is  lifted  ujd  against  the  roof  of  the  mouth,  the  mouth  cannot  be 
opened  fully,  and  the  patient  expieriences  great  difficulty  in  swallowing,  and 
may  also  present  marked  dyspnoea. 

Treatment. — The  best  incision  for  cellulitis  of  the  floor  of  the  mouth 
is  one  passing  downward  from  the  chin  near  the  middle  line  to  the  hyoid 
bone,  then  curving  upward  towards  the  angle  of  the  jaw.  A  semilunar  flap 
is  formed  and  the  submaxillary  gland  exjiosed,  which  is  pushed  aside  and 
the  mylo-hyoid  perforated  with  a  blunt  instrument,  such  as  an  artery  for- 
ceps. If  no  abscess  is  found,  but  merely  a  dense  general  oedema  of  the 
parts,  the  tissues  should  be  broken  down  in  all  directions  by  the  finger,  one 
finger  of  the  other  hand  being  placed  in  the  mouth,  and  the  two  being- 
brought  together  until  only  the  mucous  membrane  remains  between  them, 
in  order  to  make  sure  that  every  part  of  the  diseased  tissue  has  been  reached. 
The  process  is  frequently  bilateral,  and  the  finger  can  be  easily  pushed  across 
the  median  muscles  to  the  other  side,  which  should  also  be  drained  by  a  small 
incision.  When  general  antesthesia  is  emxjloyed  in  these  cases  preparations 
are  to  be  made  for  tracheotomy,  for  these  patients  bear  an  antesthetic  very 
badly,  as  even  when  conscious  they  can  hardly  swallow  or  eject  mucus  or 
saliva  from  the  back  of  the  mouth.  This  form  of  cellulitis  can  sometimes 
be  aborted  by  very  early  operation,  the  affected  area  being  exposed  by 
proper  incisions,  and  the  peculiar  waxy  indurated  tissues  being  broken 
down  with  a  blunt  instrument  or  with  the  finger.  Occasionally  a  large 
indurated  swelling  contains  only  a  few  drops  of  pus. 

51 


790  EETEOPHARYNGEAL  ABSCESS. 

Abscesses. — Abscesses  in  tlie  neck  are  most  likely  to  form  in  the  follow- 
ing lymphatic  or  cellular  spaces :  (1)  between  the  larynx  and  trachea  and 
the  muscles  overlying  them  ;  (2)  around  the  great  vessels  ;  (3)  at  the  lower 
end  of  the  sterno-mastoid  ;  (4)  about  the  submaxillary  gland  ;  and  (5)  between 
the  pharynx  and  the  vertebrse. 

Treatment. — These  abscesses  should  be  incised  early.  Deep-seated  pus 
can  be  reached  by  free  incisions  made  by  dissection  so  as  to  recognize  the 
various  structures  ;  or  else,  after  division  of  the  skin  and  fascia,  a  dressing 
forceps  can  be  pushed  gently  between  the  tissues  until  the  pus  escapes,  and 
the  opening  can  then  be  enlarged  by  opening  the  blades.  The  opening 
should  be  made  if  possible  at  the  most  dependent  part  of  the  cavity. 

Retropharyngeal  Abscess. — The  last-mentioned,  or  retropharyngeal 
abscesses,  may  be  acute  from  septic  infection  originating  in  a  tonsillar 
abscess.  They  may  also  be  chronic  or  tuberculous,  being  secondary  to 
osteitis  of  the  spine  or  to  tubercular  disease  of  the  glands  or  tissues  between 
the  pharynx  and  the  spinal  column.  They  are  rarely  seen  in  adults,  but  are 
frequent  in  children,  especially  during  the  first  two  years  of  life.  These 
abscesses  project  into  the  pharynx,  and  sometimes  find  their  way  down 
along  the  oesophagus  even  to  the  mediastinum.  They  may  develop  very 
rapidly.  A  child  who  has  apparently  been  in  good  health  may  be  suddenly 
seized  with  great  difficulty  in  breathing,  and  examination  reveals  bulging  of 
the  posterior  pharyngeal  wall,  almost  entirely  occluding  the  passage.  The 
greatest  respiratory  difficulty,  however,  occurs  when  the  abscess  extends 
downward  and  compresses  the  trachea. 

Treatment. — The  older  method  of  treatment  consisted  in  opening  the 
abscess  freely  in  the  pharynx,  but  this  is  objectionable,  because  the  pus  may 
enter  the  air  passages  and  cause  pneumonia  or  even  suffocation.  The  cavity, 
moreover,  then  communicates  with  the  pharynx,  and  is  very  likely  to 
undergo  septic  infection.  It  is,  therefore,  far  better  to  open  the  abscess 
externally,  and  careful  examination  should  be  made  for  a  tumor  near  the 
larynx  or  up  under  the  angle  of  the  jaw.  If  iiuctuation  can  be  felt  here, 
the  abscess  should  be  cut  down  upon  and  opened ;  and  even  if  the  abscess 
cannot  be  detected  externally,  an  incision  should  be  made  on  the  side  of  the 
neck  parallel  with  the  sterno-mastoid,  either  near  the  angle  of  the  jaw  or  on 
a  level  with  the  larynx,  and  a  careful  blunt  dissection  made  just  internal  to 
the  carotid.  The  abscess  can  usually  be  recognized  by  palpation  with  one 
finger  in  the  month  and  the  other  finger  in  the  wound,  and  when  it  is  found 
a  pair  of  dressing-forceps  is  forced  into  it  and  the  opening  enlarged  by  sepa- 
rating the  blades.  A  drainage-tube  is  then  inserted,  and  recovery  usually 
takes  place  in  the  course  of  a  few  weeks,  unless  bone-disease  is  present.  In 
cases  of  emergency  the  abscess  may  be  opened  in  the  pharynx,  the  child 
being  held  with  its  head  hanging  down,  to  avoid  the  danger  of  aspiration 
of  i>us  into  the  latynx. 

Affections  of  the  Lymphatic  Glands. — The  lymphatic  glands  of 
the  neck  are  peculiarly  liable  to  inflammation,  being  exposed  to  infection 
from  the  skin  or  from  the  mouth,  nose,  and  ear.  This  infection  may  be 
acute  from  any  of  the  ordinary  pyogenic  iDrocesses,  or  it  may  be  chronic, 
either  tubercular  or  syphilitic.     Pediculi  capitis  are  a  frequent  cause  of 


TUBERCULOUS  ADENITIS.  791 

enlarged  glands  in  the  neck,  probably  because  of  the  opportunities  afforded 
for  infection  by  the  constant  scratching  of  the  scalp  with  the  finger-nails. 

Tuberculous  Adenitis. — The  neck  is  a  favorite  situation  for  tubercu- 
lous glands,  and  they  form  the  most  common  tumors  of  this  region.  A 
single  gland  may  be  involved,  but  more  commonly  all  of  a  certain  group  are 
affected.  The  infection  may  enter  through  any  tuberculous  lesion  on  the 
head,  and  chronic  affections  which  are  not  tuberculous,  such  as  chronic 
eczema,  catarrh,  or  decayed  teeth,  may  result  in  tuberculous  infection  of  the 
glands,  the  infection  in  these  cases  passing  through  the  local  lesion  and 
reaching  the  glands  but  dying  out  in  the  local  lesion.  The  involvement 
of  the  glands  may  also  be  secondary  to  distant  foci  in  the  lung  or  else- 
where. Tuberculous  glands  are  found  at  all  ages,  but  are  most  common 
about  puberty  or  soon  after.  (Fig.  694.)  When 
several  glands  are  affected,  usually  one  or  two 
will  be  larger  than  the  rest.  They  vary  from 
a  pea  to  a  walnut,  and  even  to  a  hen's  egg,  in 
size,  but  large  masses  are  exceptional,  unless 
two  or  three  glands  have  been  fused  into  one. 
There  is  very  commonly  a  periadenitis  or  in- 
flammation of  the  cellular  tissue,  which  renders 
the  gland  adherent  to  the  neighboring  parts, 
and  if  the  node  lies  just  under  the  skin  the 
latter  also  becomes  involved.  The  glands  may 
resolve  or  remain  stationary,  or  they  may  form 
an  abscess.     The  adherent  skin  may  become  '  , 

thin   and  of  a   deep    purple   or  blue   color,  and  Tubercular  ceivital  adenitis. 

when  the  abscess  has  discharged  a  sinus  is  very 

apt  to  persist.  If  the  primary  lesion  is  in  the  mouth,  the  submaxillary 
glands  will  be  invaded.  Lesions  of  the  face,  the  conjunctiva,  the  temple, 
or  the  skin  in  front  of  the  ear  affect  the  group  of  glands  anterior  to  the 
sterno-mastoid  ;  while  lesions  of  the  ear  itself  affect  those  posterior  to  the 
sterno-mastoid  as  far  back  as  the  occiput,  and  lesions  of  the  scalp  affect  the 
posterior  gron^js  of  glands. 

Diagnosis. — In  the  diagnosis  of  tuberculosis,  syphilis  should  be 
excluded.  Syphilitic  enlargement  of  the  glands  of  the  neck  is  not  common 
unless  there  is  a  general  adenopathy.  Syphilitic  glands  are  hard  and  less 
likely  to  suppurate,  and  are  more  uniform  in  size.  In  elderly  persons 
enlarged  glands  in  the  neck  should  excite  suspicions  of  concealed  malignant 
disease,  and  lead  to  a  careful  examination  of  the  nose,  throat,  and  mouth. 

Treatment. ^ — The  treatment  of  tuberculous  glands  of  the  neck  calls  for 
much  judgment.  If  the  glands  are  small  and  freely  movable,  they  need  not 
be  touched,  but  attention  should  be  paid  to  the  general  health  and  to 
removing  the  cause  of  the  infection.  Iodine  is  usually  applied  to  the  skin 
in  these  cases,  but  its  utility  in  promoting  resolution  of  the  glands  is  doubt- 
ful. If  a  gland  is  visibly  enlarging,  or  if  a  small  gland  tends  to  break  down 
and  form  an  abscess,  it  should  be  excised  before  this  occurs.  If  a  very  large 
number  of  glands  are  involved,  the  question  of  operation  will  depend  upon 
the  condition  of  the  patient.      Advanced  phthisis  contraindicates  opera- 


792 


TUMORS   OF  THE  NECK. 


tion  ;  but  if  there  are  slight  signs  of  tuberculosis  in  the  lung,  large  masses 
of  glands  should  be  removed,  in  order  to  relieve  the  j)atient  of  the  tubercu- 
lous material.  The  incisions  chosen  in  the  operation  should  be  such  as  will 
leave  the  least  evident  scars.  The  submaxillary  region  may  be  opened  by 
raising  a  flap  by  an  incision  beginning  at  the  middle  line  under  the  chin, 
curving  downward  to  the  hyoid  bone  and  then  upward  towards  the  angle  of 
the  jaw.  The  glands  anterior  to  the  stern o- mastoid  are  removed  by  an 
incision  along  the  anterior  border  of  that  muscle,  and  those  posterior  to  it 
are  best  reached  by  an  incision  from  the  mastoid  process  downward  towards 
the  acromion  along  the  anterior  border  of  the  trapezius.  Two  or  more  of 
these  regions  will  often  require  operation  at  the  same  time.  Very  careful  dis- 
section is  frequently  necessary  in  separating  the  glands  from  the  vessels  and 
nerves.  Every  gland  should  be  removed,  as  any  that  are  left  will  enlarge 
later,  and  glands  will  appear  even  when  the  extirpation  has  seemed  com- 
plete. A  permanent  cui-e  can  be  obtained  in  from  one-half  to  three-quarters 
of  the  cases. 

If  the  glands  are  too  soft  to  be  extirpated  entire  by  the  knife  and  scis- 
sors they  should  be  thoroughly  scraped  out  with  a  sharp  curette.  If  a  cold 
abscess  has  formed,  it  can  often  be  cured  by  aspiration  and  injection  of  the 
sac  with  iodoform  glycerin ;  but  this  should  not  be  attempted  until  the 
entii-e  gland  has  broken  down,  leaving  only  the  capsule  as  a  sac.  The 
treatment  of  the  sinuses  left  by  tuberculous  glandular  abscesses  is  very 
unsatisfactory.  A  thorough  application  of  tincture  of  iodine  or  pure  car- 
bolic acid  will  occasionally  cure  them.  If  this  fails  the  sinus  should  be 
scraped  out  with  a  sharp  spoon  or  comj)letely  excised,  the  last  method  being 

generally   necessary  if  any  remains  of 
glandular  tissue  exist  about  it. 

Tumors  of  the  Neck.— The  tu- 
mors of  the  neck  are  of  great  interest 
on  account  of  the  relations  which  they 
sustain  to  important  vessels  and  nerves. 
Sebaceous  cysts   are  very  common, 
especially  upon  the  nape  of  the  neck. 
Lipoma  is  frequent,  especially  in  the 
diffuse  form,  and  angioma  also.    Malig- 
nant disease  of  the  skin  of  the  neck  is  a 
rarity  ;  but  sarcoma  is  quite  common, 
originating  from  the  fascia  or  the  glands, 
,^      and  secondary  carcinoma  of  thelym- 
\'     phatic  glands  is  ^'ery  common.      (Fig. 
095.)     The  congenital  tumors  of  the 
/    'V^  neck  have  already  been  sufficiently  de- 

•  scribed  in  the  account  of  dermoid  and 

branchial  cysts.  Solid  tumors  may  also 
develop  from  these  foetal  remains,  especially  from  the  so-called  carotid  gland, 
— a  mass  of  lymphatic  tissue  in  the  fork  of  the  carotids.  In  making  the 
diagnosis  of  the  various  tumors  of  the  neck,  due  account  must  be  taken  of 
the  rapidity  of  their  development,  the  age  of  the  patient,  the  various  symp- 


FiG.  (ilCr 


SALIVARY  FISTULA.  793 

toms  produced  by  their  pressure  upon  the  nerves  and  vessels  or  by  their 
mechanical  interference  with  respiration  or  swallowing,  the  shape  and  con-' 
sistency  of  the  tumor,  and  the  extent  to  which  the  skin  and  the  lymph- 
glands  are  involved.  The  diagnosis  must  depend  chiefly  upon  the  particular 
organ  or  tissue  in  which  the  tumor  has  its  origin.  The  lymphatic  glands, 
if  we  include  simple  hypertrophy,  will  be  found  to  furnish  the  greatest 
number  of  tumors. 

The  bursae  which  normally  exist  between  thehyoid  bone  and  the  thyroid 
cartilage,  or  above  the  hyoid  bone  between  the  muscles  of  the  tongue,  are 
liable  to  inflammation.  A  diagnosis  between  these  bursal  swellings  and  the 
cysts  which  originate  from  the  thyroglossal  tract  may  be  impossible.  Sacs 
containing  air  are  found  in  the  neighborhood  of  the  larynx  in  rare  cases, 
being  produced  by  a  sort  of  hernial  protrusion  of  the  mucous  membrane, 
generally  originating  in  the  ventricles  between  the  true  and  false  cords. 
These  sacs  sometimes  reach  the  size  of  a  man's  fist  on  forcible  expiration, 
and  can  be  emptied  by  compression.  Their  distention  can  be  prevented  by 
compressive  bandages,  but  once  formed  they  can  be  cured  only  by  completely 
dissecting  out  the  wall  of  the  sac  and  ligating  the  pedicle  which  communi- 
cates with  the  larynx. 

Congenital  Sinuses. — Congenital  sinuses  are  not  infrequent  in  the 
neck,  occurring  in  the  lines  of  the  branchial  clefts  (page  272).  Median 
sinuses  may  originate  from  the  thyroglossal  tract.  The  lateral  sinuses  may 
be  complete,  or  may  have  only  one  orifice,  either  external  or  internal,  the 
latter  usually  opening  near  the  posterior  pillars  of  the  fauces.  They  cause 
no  symptoms  except  a  slight  mucous  discharge.  The  orifices  become  closed 
occasionally,  and  the  retained  secretions  decompose,  inflammation  is  set  up, 
and  the  sinus  forms  a  chronic  abscess.  They  can  be  cured  by  destroying  the 
epithelial  lining  thoroughly  by  cauterization,  but  this  is  rarely  successful. 
Their  extirpation  may  be  very  diiScult  on  account  of  their  intimate  relation 
with  the  great  vessels  and  nerves,  but  it  is  sometimes  justifiable. 

Cervical  Rib. — A  supernumerary  rib  is  occasionally  found  attached  to 
the  seventh  cervical  vertebra.  It  lies  in  close  relations  with  the  subclavian 
artery  and  the  brachial  plexus,  and  may  cause  lesions  of  the  artery  and 
neuralgia.  In  about  a  dozen  cases  removal  of  the  rib  has  been  necessary. 
It  must  also  be  considered  in  the  diagnosis  of  tumors. 

THE   SALIVARY  GLANDS. 

Injuries. — Contusions  and  wounds  of  these  glands  are  not  iraijortant, 
for  they  heal  readily  and  with  only  a  temporary  discharge  of  saliva. 

Salivary  Fistvila. — Division  of  Steno's  duct  may  result  in  a  perma- 
nent salivary  fistula  opening  on  the  surface  of  the  skin,  which  is  irritated 
by  the  discharge,  or  in  a  stricture  of  the  duct.  The  injury  to  the  duct  is 
proved  by  the  discharge  of  saliva  from  the  wound  or  by  the  passage  of  a 
probe  into  the  wound  from  the  orifice  of  the  duct  in  the  mouth.  The  fistula 
is  very  difficult  to  cure,  especially  if  the  passage  of  the  duct  to  the  mouth 
is  entirely  closed. 

Treatment. — An  opening  into  the  mouth  is  formed  by  passing  a  stout 
silk  suture  with  a  needle  at  each  end  from  the  fistula  into  the  mouth,  trans- 


794 


INFLAMMATION   OF  THE  SALIVARY   GLANDS. 


Fig.  696. 


Treatment  of  salivary  fistula,  showing 
ends  of  deep  ligature  in  the  mouth. 


fixing  the  entire  thickness  of  the  cheek  and  tying  the  two  ends  of  the  liga- 
ture tightly  within  the  mouth.  (Fig.  696.)  The  thread  slowly  cuts  its  way 
through,  and  the  epithelium  follows  in  the 
track  of  the  ligature  and  renders  the  ojjening 
permanent.  When  this  canal  has  been  estab- 
lished the  fistula  will  frecxuently  close  of  itself, 
but  if  it  should  fail  to  do  so  a  small  flap  should 
be  cut,  turned  into  the  gap,  and  secured  by 
sutures,  the  surrounding  skin  being  brought 
together  over  the  outside  raw  surface  of  the 
flap.  More  than  one  attempt  to  close  the  open- 
ing will  often  be  necessary.  In  some  cases  the 
divided  ends  of  the  duct  have  been  found  and 
reunited  with  sutm-es,  or  a  new  canal  has  been 
formed  from  the  mucous  membrane  of  the  cheek 
with  success. 

Inflamination. — "  Mumps." — The  most 
common  inflammation  of  the  salivary  glands  is 
the  contagious  disease  known  as  "mumj)s," 
which  almost  invariably  attacks  the  parotid, 
although  the  submaxillary  is  also  occasionally 
inflamed.  The  testicles,  and  rarely  the  mammae,  are  also  liable  to  a  "meta- 
static" inflammation  at  the  same  time  as  the  salivary  glands,  and  orchitis 
may  exist  alone.  Mumps  generally  runs  a  course  of  a  week  or  ten  days, 
with  slight  fever  and  a  rather  painful  swelling,  frequently  on  both  sides, 
although  one  side  is  often  more  affected  than  the  other.  The  process  usually 
ends  in  resolution,  and  suj)puration  is  rare.  Abscesses. — Abscesses  are 
most  common  in  the  parotid.  Direct  infection  of  the  glands  may  take  place 
from  the  mouth  through  the  ducts,  or  indirect  infection  from  some  neighbor- 
ing wound  through  the  lymphatics.  Metastatic  abscesses  may  follow  some 
distant  process,  such  as  osteomyelitis,  jsuerperal  endometritis,  or  tyj)hoid 
fever.  They  have  also  been  observed  not  infrequently  as  the  result  of  gon- 
orrhoea ;  but  such  cases  may  be  due  to  dii'ect  infection  of  the  duct  by  the 
gonococcus.  Abscesses  of  the  parotid  are  slow  in  healing,  on  account  of 
the  tough  stroma  and  capsule.  They  are  apt  to  cause  septicaemia  or  menin- 
gitis or  cerebral  abscess.  Treatment. — This  consists  in  thorough  drainage 
by  very  free  and  early  incisions,  which  must  be  made  in  horizontal  lines 
parallel  with  the  fibres  of  the  facial  nerve,  so  as  not  to  injure  the  latter. 
The  pterygo-maxillary  space  will  sometimes  need  draining  by  an  incision 
below  the  angle  of  the  jaw. 

Chronic  Inflammation. — Chronic  parotitis  is  sometimes  seen.  The 
saliva  becomes  ropy  and  viscid  and  blocks  the  duct  and  causes  painful  dis- 
tention of  the  gland.  The  gland  then  presents  a  flat,  board-like  swelling  in 
the  cheek,  and  may  threaten  to  suppurate.  Iodide  of  potassium  in  full 
doses  and  the  passage  of  a  probe  through  the  duct  may  result  in  a  cure,  but 
the  affection  is  often  very  obstinate.  A  chronic  inflammation  of  the  stroma 
with  marked  enlargement  of  the  gland  has  been  observed  in  the  submaxil- 
lary gland.     It  resembles  a  sarcoma  and  should  be  treated  by  extirpation. 


TUMORS  OF  THE  SALIVARY  GLANDS.  795 

Calculi. — Concretions  may  form  in  tlie  salivary  ducts,  and  they  are 
most  frequent  in  Steuo's  duct,  forming  behind  a  stricture.  They  often  have 
a  small  foreign  body  as  a  nucleus.  The  calculi  are  rough  calcareous  or  j^hos- 
phatic  deposits,  usually  small,  but  occasionally  of  the  size  of  a  hen's  egg. 
They  cause  hard  smooth  swellings,  with  very  few  symptoms,  the  principal 
of  which  is  that  strong  pressure  upon  them  is  painful.  The  calculi  should 
be  removed  by  incision  through  the  mucous  membrane  of  the  cheek  as  soon 
as  their  presence  is  recognized. 

Ttlinors. — Retention  cysts  of  the  lingual  and  submaxillary  glands  are 
known  as  Ranulae,  and  are  considered  under  Diseases  of  the  Mouth. 

Mixed  Tumors. — The  most  common  neoplasm  of  the  salivary  glands 
is  the  so-called  mixed  tumor,  which  consists  of  fibrous  tissue,  fat,  cartilage, 
and  adenomatous  tissue.  It  arises  from  the  remains  of  the  congenital  bran- 
chial tissues,  but  is  seldom  apparent  before  puberty.  These  tumors  are 
most  common  in  the  i^arotid,  and  grow  slowly  until  they  reach  the  size  of  an 
English  walnut  or  a  hen's  egg,  when  they  are  apt  to  become  stationary. 
They  form  hard  rounded  masses,  often  lobulated,  sometimes  almost  pedun- 
culated, standing  out  abruptly  from  the  side  of  the  face.  If  cysts  develoj) 
in  them  they  become  elastic  and  grow  more  rapidly.  The  skin  over  them 
usually  remains  unaltered  and  not  adherent.  They  may  reach  the  size  of  a 
man's  head,  and  when  large  they  generally  cause  facial  paralj^sis  by  pressure 
upon  the  facial  nerve.  In  a  certain  number  of  cases  they  degenerate  into 
sarcoma,  and  therefore  they  should  be  removed  while  they  are  small,  if  it 
can  be  done  without  injury  to  the  facial  nerve.  They  are  well  encapsulated 
and  it  is  not  necessary  to  remove  the  surrounding  tissues. 

Malignant  Tumors. — Malignant  tumors  appear  in  the  salivary  glands, 
especially  in  the  parotid,  but  the  sublingual  is  almost  exempt.  Sarcoma 
generally  develops  by  the  degeneration  of  one  of  the  mixed  tumors,  and 
therefore  the  tumor  is  of  rather  long  duration,  growing  very  slowly  at  first. 
Carcinoma  appears  after  middle  life,  and  forms  rather  flat  tumors,  infil- 
trating the  entire  substance  of  the  gland  and  lifting  the  lobe  of  the  auricle. 
They  often  occasion  severe  pain  in  the  ear.  The  majority  are  rather  slow  in 
growth,  but  some  develop  rapidly.  Before  they  are  recognized  they  have 
generally  involved  the  deepest  parts  of  the  gland,  and  they  recur  even  after 
apparently  thorough  extirpation. 

Treatment. — Extirpation  is  the  only  possible  treatment,  and  in  remov- 
ing the  parotid  gland  for  malignant  disease  the  facial  nerve  must  be  entirely 
disregarded,  for  every  j)ortion  of  the  gland  must  be  removed,  including  the 
lobe  which  winds  around  the  ramus  of  the  jaw.  In  order  to  make  a  com- 
plete removal  of  this  portion  of  the  gland  and  to  control  the  dissection 
properly,  it  will  generally  be  found  necessary  to  cut  away  about  half  an 
inch  of  the  posterior  border  of  the  ramus  and  of  the  angle  of  the  jaw  with 
the  rongeur,  after  the  superficial  part  of  the  gland  has  been  dissected  up  and 
turned  backward  so  as  to  uncover  that  ijortiou  of  the  bone. 

THE   TONSILS. 

Inflaminations. — The  tonsils  are  liable  to  many  superficial  infiamma- 
tory  conditions,  such  as  follicular  tonsillitis  and  diphtheria.     Secondary 


796  HYPERTROPHY   OF  THE  TONSILS. 

syphilitic  ulcers  are  also  frequent,  and  in  the  tertiary  stage  gummata  may 
form  large  tumors. 

Abscess. — Suppurative  inflammation  of  the  tonsil  resulting  in  abscess, 
however,  most  frequently  comes  under  the  care  of  the  surgeon.  While  the 
abscess  occasionally  forms  in  the  substance  of  the  tonsil,  it  generally  lies 
in  the  cellular  tissue  external  to  the  gland.  The  swelling  is  sometimes  so 
great  that  the  tonsil  projects  across  the  middle  line  of  the  pharynx,  and  the 
soft  palate  bulges  forward.  The  pain  may  be  severe,  and  the  patient  may 
have  great  difficulty  in  swallowing  and  be  unable  to  open  his  mouth.  Some- 
times the  condition  is  bilateral,  adding  to  the  suffering.  Tonsillitis  is  most 
Irequent  in  young  adults,  apparently  having  some  connection  with  rheuma- 
tism, and  the  administi-ation  of  bicarbonate  of  sodiiim  or  of  the  salicylates 
may  abort  the  inflammation  and  prevent  suppuration. 

Treatment. — The  abscess  usually  points  just  external  to  the  anterior 
pillar  of  the  fauces,  and  the  pus  should  be  evacuated  in  that  situation 
with  a  bistoury  wound  with  plaster  nearly  to  the  point,  which  should  be 
directed  straight  backward  in  order  to  avoid  the  internal  carotid  artery, 
which  lies  just  at  the  outer  side.  The  incision  should  be  free,  and  cocaine 
may  be  employed  if  necessary.  The  abscess  may  point  posterior  to  the 
tonsil,  where  it  is  difficult  to  reach  the  pus.  Sometimes  it  is  possible  to 
evacuate  the  pus  by  passing  a  director  into  one  of  the  lacunse  of  the  tonsil. 

Hypertrophy. — Hypertrophy  of  the  tonsils  is  a  common  affection. in 
children,  generally  as  the  result  of  repeated  attacks  of  inflammation.  The 
tonsils  are  sometimes  so  large  that  they  meet  in  the  middle  line  and  cause  a 
fulness  in  the  neck  at  the  angle  of  the  jaw.  The  child  may  be  forced  to 
bi'eathe  through  the  mouth,  for  the  tonsils  obstruct  the  nasopharynx  and 
the  third  tonsil  is  usually  enlarged  at  the  same  time,  and  the  child  may 
acquire  a  peculiar  idiotic  appearance.  The  affection  is  most  common  in  the 
so-called  strumous  or  scrofulous  diathesis,  in  which  there  is  a  tendency  to 
enlargement  of  all  the  lymphatic  glands.  The  hypertrophied  tonsil  may  be 
normal  in  structure,  but  the  fibrous  stroma  is  usually  more  abundant. 

Treatment. — Hypertrophied  tonsils  require  removal,  which  may  be 
accomplished  by  catching  the  tonsil  with  long  toothed  forceps  and  drawing 
it  well  out  towards  the  median  line  and  then  slicing  it  off  with  a  sharp, 
probe-pointed  curved  bistoury.  A  tonsillotome  renders  the  operation  easier, 
and  the  simplest  form  of  instrument  is  the  best.  Ifo  ansesthetic  is  required. 
The  hemorrhage  is  sometimes  excessive,  but  is  readily  controlled  by  ice  or 
by  pressure.  Pressure  may  be  applied  by  a  pair  of  forceps  the  ends  of 
which  are  long  enough  to  reach  from  the  angle  of  the  lips  back  to  the 
tonsil,  one  branch  being  inserted  in  the  mouth  and  the  other  resting  on  the 
cheek,  both  being  supplied  with  broad  ends  and  thick  pads. 

Small  calculi  occasionally  form  in  the  crypts  of  the  tonsil,  but  seldom 
reach  a  size  large  enough  to  require  an  operation  for  their  removal. 

Tumors. — K'eoplasms  of  the  tonsil  are  not  common,  and  benign  growths 
are  especially  rare.  Sarcoma  forms  tumors  of  considerable  size  growing 
rapidly  with  a  tendency  to  spread  into  the  adjacent  soft  parts.  Epithe- 
lioma develops  in  the  tonsil,  and  can  be  recognized  by  the  induration, 
ulceration,  and  brittle  granulations  with  a  tendency  to  bleed.     The  tumors 


INFLAMMATIONS   OF  THE  PHARYNX.  797 

are  usually  not  observed  until  it  is  too  late  to  operate  ;  but  if  the  diagnosis 

can  be  made  suf&ciently  early,  and  the  tonsil  thoroughly  I'emoved  before  the 

surrounding  parts  ai-e  involved,  a  cure  can  undoubtedly  be  eifected. 

Treatment. — The  tonsil  can  be  removed  by  Mikulicz's  operation  of 

pharyngotomy  (page  798),  or  by  splitting  the  cheek  backward  to  the  ramus 

of  the  jaw  in  the  line  of  the  mouth.    These  operations  are  to  be  preferred  to 

the  mutilating  methods  of  dividing  or  sacrificing  large  portions  of  the  lower 

jaw.     Large  tumors  should  be  left  untouched,  as  it  is  impossible  to  obtain  a 

cure. 

THE  PHARYNX. 

Injuries. — In  cases  of  cutthroat  wounds  the  knife  may  open  the  pharynx 
at  the  base  of  the  tongue,  sometimes  making  an  opening  into  which  several 
fingers  can  be  passed.  The  pharynx  may  be  severely  burned  by  swallowing 
caustics  or  inhaling  steam  or  flame.  Demulcent  sprays  are  to  be  used, 
and  strictui-e  avoided  by  faithful  use  of  bougies.  Malformations  of  the 
pharynx  may  produce  diverticula  and  fistulte,  the  latter  passing  outward  in 
the  line  of  the  branchial  clefts  as  already  described.  The  diverticula 
resemble  those  of  the  oesophagus. 

Inflammations. — The  pharynx  is  subject  to  superficial  inflammations 
of  a  catarrhal,  diphtheritic,  or  rheumatic  nature,  which  are  of  no  particular 
interest  to  the  surgeon  ;  tubercular  ulceration,  however,  is  found,  and  syphi- 
litic ulceration  is  exceedingly  common.  Extensive  tubercular  ulceration 
seldom  heals.  Deep  ulceration  of  the  pharynx  may  expose  the  bone  at  the 
base  of  the  skull  and  open  the  sphenoidal  sinuses.  The  mucous  membrane 
of  the  pharynx  is  provided  with  numerous  deep  follicles,  and  if  a  suppura- 
tive inflammation  is  set  up  an  abscess  may  form  external  to  the  mucous  mem- 
brane. An  incision  should  be  made  as  soon  as  the  abscess  can  be  detected. 
Among  the  syphilitic  inflammations  should  be  mentioned  gumma,  which 
may  form  tumors  of  considerable  size  in  the  wall  of  the  pharynx. 

Foreign  Bodies. — Foreign  bodies  may  become  imj)acted  in  the  pharynx, 
but  they  are  easily  removed,  as  a  rule,  by  the  finger  or  by  forceps,  and  may  be 
dislodged  in  a  child  by  holding  it  head  downward  and  shaking  it  vigorously. 

Stricture. — Burns  of  the  pharynx  may  cause  strictures  of  that  passage 
by  the  contraction  of  the  scars  left  when  they  heal.  Extensive  tubercular 
or  syphilitic  ulceration  may  produce  great  narrowing  of  the  pharynx  when 
the  ulcers  cicatrize.  The  soft  palate  is  di-awn  backward  and  becomes 
adherent  to  the  posterior  wall  of  the  pharynx,  and  the  passage  from  the 
nose  to  the  mouth  may  be  entirely  closed.  This  is  most  frequently  seen  in 
the  infantile  and  hereditary  forms  of  syphilis.  Deglutition  and  resijiration 
may  be  interfered  with  by  strictures  of  the  lower  pharynx.  Treatment. — 
These  deformities  will  sometimes  yield  to  patient  stretching  with  bougies, 
assisted  by  division  of  the  most  prominent  bands.  Rubber  ligatures  can  be 
passed  through  the  bands,  tied,  and  allowed  to  cut  through.  In  one  des- 
perate case  we  obtained  a  cure  by  cutting  a  flap  from  the  skin  of  the  neck, 
opening  the  pharynx  above  the  hyoid  bone  at  the  base  of  the  tongue, 
cutting  the  cicatricial  bands,  and  turning  the  flaj)  into  the  wound  so  that 
the  skin  was  secured  in  the  gap  made  by  dividing  the  stricture.  The  base 
of  the  flap  was  divided  and  the  pharyngotomy  wound  closed  later. 


798  PHAEYNGOTOMY. 

Adenoids.— At  the  apex  of  the  pharynx  is  a  collectiou  of  lymphoid 
tissue  in  the  niucons  membrane  which  sometimes  forms  a  considerable  mass 
and  is  known  as  the  third  or  ijharyngeal  tonsil.  When  this  is  of  large  size 
it  may  cause  considerable  obstruction  to  breathing.  Small  multiple  tumors 
of  adenoid  tissue,  known  as  vegetations,  are  sometimes  found  blocking 
up  the  vault  of  the  pharynx.  Both  of  these  growths  may  be  removed 
with  a  strong  curette,  and  the  soft  varietj'  can  be  scraped  off  with  the 
finger-nail. 

Tumors. — The  nasopharyngeal  fibrous  polypi  have  been  described 
in  the  section  on  the  nose.  Mucous  polypi  are  found  in  the  pharynx, 
formed  of  myxomatous  tissue  and  sometimes  covered  with  normal  mucous 
membrane.  They  are  benign  growths,  and  do  not  return  after  thorough 
removal  by  avulsion.  Congenital  polypi,  in  which  the  surface  is  covered 
by  hairy  mucous  membrane  or  skin,  occur,  and  the  tumor  may  project  from 
the  mouth,  as  has  been  mentioned  undei'  the  head  of  teratoma.  Malignant 
disease  of  the  pharynx  is  not  uncommon.  Sarcoma  develops  in  the 
deeper  parts  of  the  mucous  membrane  and  grows  both  externally  and  into 
the  pharynx,  forming  tumors  of  considerable  size,  which  may  fill  the  ptery- 
goid fossa.  These  tumors  ulcerate  quite  early,  and  then  run  a  rapid  course 
with  an  inevitably  fatal  issue.  The  diagnosis  can  seldom  be  made  in  time 
to  admit  of  successful  extirpation.  Epithelioma  is  of  slower  growth,  and 
forms  a  superficial,  ulcerating,  indurated  patch  upon  the  mucous  membrane, 
which  extends  slowly  in  different  directions.  It  generally  attacks  the  vault 
of  the  pharynx,  and  as  it  gives  few  symptoms  it  is  not  noticed  by  the 
patient  until  it  is  too  late  for  treatment. 

Pharyngotomy. — The  operation  of  opening  the  pharynx  is  called 
pharyngotomy.  The  upper  part  is  best  reached  by  the  method  of  Miku- 
licz, who  makes  an  oblique  incision  parallel  to  the  anterior  border  of  the 
steruo-mastoid,  beginning  at  the  ear  and  extending  half-way  down  the  neck, 
from  the  centre  of  which  an  incision  is  carried  forward,  dividing  the  skin 
only.  The  angle  of  the  jaw  is  exposed  in  the  anterior  branch  of  the  incision, 
the  ijeriosteum  is  stripped  from  the  bone,  and  the  latter  is  divided  obliquely, 
just  above  the  angle,  with  a  saw,  after  which  the  periosteum  is  dissected  up 
and  the  ramus  is  seized  with  strong  forceps  and  twisted  out.  The  important 
vessels  and  nerves  in  the  pterygo-maxillary  fossa  are  pushed  to  one  side 
and  the  mucous  membrane  of  the  pharynx  exposed.  If  there  has  been 
considerable  hemorrhage  or  shock,  the  wound  may  be  packed  and  the 
pharynx  not  opened  for  several  •  days.  The  operation  wound  is  covered 
with  granulations  by  that  time,  and  the  danger  of  infection  is  reduced. 
The  pharynx  having  been  opened,  tumors  of  the  pharyngeal  wall  or  of  the 
tonsil  can  be  removed  with  comj)arative  ease,  especially  if  one  finger  be 
placed  in  the  mouth.  The  deformity  resulting  from  the  loss  of  bone  is 
slight,  and  we  have  found  that  the  lateral  displacement  of  the  jaw  is  less 
than  the  width  of  one  tooth.  The  lower  j)art  of  the  pharynx  is  opened  by 
subhyoid  pharyngotomy,  the  incision  being  just  below  and  parallel  with 
the  hyoid  bone.  The  wound  is  deepened  by  careful  dissection  until  the 
mucous  membrane  of  the  pharynx  is  reached,  and  the  latter  is  incised  on  a 
line  with  the  epiglottis,  just  above  the  larynx.     This  incision  gives  access 


CICATRICIAL  STRICTURE  OF  THE  (ESOPHAGUS.  799 

to  the  upper  part  of  the  larynx  or  oesophagus,  as  well  as  to  the  lower  part 
of  the  pharynx.  The  same  region  can  be  exijosed  by  a  transverse  incision 
above  the  hyoid  bone,  either  median  or  slightly  to  one  side.  After  the 
operation  is  concluded  the  edges  of  the  mucous  membrane  may  be  sutured 
and  the  external  wound  lightly  packed,  or  the  entire  wound  may  be  left 
open  and  the  patient  fed  by  a  stomach-tube.  After  operations  upon  the 
pharynx  the  patient  should  be  fed  for  two  or  three  days  by  the  rectum,  by 
the  introduction  of  a  tube  through  the  nose,  or  even  by  leaving  a  tube 
permanently  in  place  in  the  wound.  The  last  method  is  objectionable 
because  of  the  unusual  secretion  of  saliva  and  mucus  excited  by  the  tube 
and  the  increased  danger  of  infection. 

THE    (ESOPHAGUS. 

Injuries. — Injuries  of  the  oesophagus,  except  burns  or  scalds,  are  rare. 
Wounds  are  seldom  seen,  except  the  severe  cutthroat  and  gunshot  wounds, 
which  generally  result  fatally  from  injury  to  other  parts.  Spontaneous 
rupture  of  the  oesophagus  has  beea  known  to  occur,  the  contents  escaping 
into  the  mediastinum.  Burns  by  hot  licxuids  or  caustic  substances,  the 
most  common  being  lye,  are  quite  frequent,  especially  in  children.  The 
treatment  consists  in  the  administration  of  alkalies,  vegetable  acids  (vine- 
gar), and  white  of  egg  to  neutralize  the  caustic.  Eectal  alimentation 
should  be  resorted  to,  and  demulcents,  of  which  milk  is  the  best,  given  by 
the  mouth.  After  the  acute  inflammation  has  subsided,  the  daily  use  of 
bougies  is  instituted,  to  i^revent  the  formation  of  stricture. 

Cicatricial  Stricture. — Cicatricial  narrowing  of  the  oesophagus  may 
follow  the  healing  of  tuberculous  or  syphilitic  ulcers,  or  injury  by  burns 
(hot  liquids  or  caustics,  especially  lye),  or  by  the  lodging  of  a  foreign  body 
in  the  tube.  It  maj^  be  annular  or  involve  a  considerable  length  of  the  tube, 
and  it  occurs  most  frequently  near  the  larynx  or  the  stomach.  A  stricture 
causes  gradually  increasing  difficulty  in  swallowing  until  regurgitation 
finally  results.  The  oesophagus  above  the  stricture  may  become  dilated  and 
food  may  be  retained  for  some  time  before  it  is  reje<;ted,  being  j)artly 
digested  by  the  saliva  in  the  mean  time.  The  diagnosis  from  hysterical 
spasm  or  obstruction  by  a  tumor  or  an  aneurism  may  occasion  some  difficulty, 
but  the  history  of  a  previous  injury  or  of  syphilitic  disease  is  in  favor  of  the 
presence  of  a  cicatrix.  Careful  examination  should  always  be  made  for 
signs  of  aneurism.  The  situation  of  a  stricture  can  sometimes  be  determined 
by  auscultation  over  the  back  while  the  patient  swallows  some  water,  a 
peculiar  gurgle  being  heard  instead  of  the  gentle  sound  normally  produced 
by  the  descending  fluid.  The  stricture  may  be  examined  by  instruments 
similar  to  those  employed  in  the  urethra, — flexible  bulbous  and  cylindrical 
bougies  of  proper  length.  The  distance  in  the  adult  from  the  incisor  teeth 
to  the  entrance  of  the  oesophagus  is  about  six  inches,  and  to  the  cardiac 
orifice  about  sixteen  inches.  To  pass  the  bougies  the  patient  should  be 
seated  facing  the  surgeon,  the  head  slightly  bent  backward,  and  a  gag 
between  the  teeth.  The  surgeon  depresses  the  base  of  the  tongue  gently 
with  the  finger,  along  which  he  passes  the  bougie  after  di2:)j)ing  it  in  warm 
water.    The  bougies  should  have  blunt  points,  and  must  be  used  with  great 


800  FOREIGN  BODIES  IN  THE  CESOPHAGUS. 

gentleness,  for  the  oesophagus  has  frequently  been  perforated  and  the  i^leura 
-wounded  by  these  instruments. 

Treatment. — Cicatrical  strictures  of  the  oesophagus  may  be  treated  by 
dilatation  with  bougies  in  the  majority  of  cases.  A  rubber  tube  can  be 
stretched  over  a  moderately  stiff  bougie,  passed  into  the  stricture,  disengaged 
from  the  bougie,  and  the  latter  withdrawn,  allowing  the  tube  to  regain  its 
normal  caliber  as  it  lies  in  the  stricture,  and  thus  dilate  the  latter.  (Von 
Hacker.)  "When  the  stricture  has  become  impassible  it  is  necessary  to  make 
an  opening  in  the  stomach  in  order  to  feed  the  patient  or  as  a  temporary 
procedure  to  get  a  bougie  through  the  stricture,  for  it  is  sometimes  possible 
to  pass  a  bougie  upward  from  the  stomach  when  none  will  go  through  from 
the  mouth.  If  a  fine  bougie  can  be  passed  and  a  silk  thread  drawn  through 
the  stricture,  the  latter  may  be  nicked  by  drawing  the  thread  to  and  fro,  as 
suggested  by  Abbe,  and  a  larger  bougie  can  then  be  passed.  A  stretched 
out  rubber  tube  can  be  drawn  into  the  stricture  by  the  thread,  and  left  there 
to  exert  elastic  dilatation.  When  the  stricture  has  become  fairly  patent  to 
bougies,  the  gastric  fistula  may  be  closed.  If  a  valular  opening  is  made 
(Stamm's  method)  it  will  close  spontaneously.  Cicatricial  strictures  have 
occasionally  been  divided  with  instruments  internally,  as  in  internal  ure- 
throtomy, but  the  oj)eration  is  dangerous  and  has  fallen  into  disuse.  They 
may  also  be  treated  by  permanent  tubage.     (See  page  803. ) 

Hysterical  Spasm. — Spasmodic  strictui-e  of  the  cesophagus  most  fre- 
quently occurs  in  women  about  the  age  of  thirty  or  thirty-five,  and  is  usually 
associated  with  other  symptoms  of  hysteria,  although  it  may  be  the  sole  sign 
of  that  condition.  The  spasm  is  sometimes  caused  by  a  reflex  irritation  due 
t»  the  presence  of  wax  in  the  ear  or  to  some  irritation  of  the  nose  or  throat, 
and  can  then  be  remedied  by  correcting  these  conditions.  In  other  cases 
no  cause  can  be  found,  and  a  comi^lete  cure  is  difficult  to  obtain,  although 
improvement  generally  follows  systematic  dilatation.  A  characteristic 
feature  of  this  spasm,  like  that  of  the  urethra,  is  that  it  yields  more  readily 
to  a  full-sized  bougie  with  a  blunt  end  than  to  a  very  fine  and  pointed  one. 
Eelapses  are  very  frequently  seen  in  this  condition.  Besides  the  inability 
to  swallow,  there  is  occasionally  a  feeling  of  pain  or  constriction  in  the 
neck.  The  symptoms  may  begin  suddenly  or  gradually.  A  sudden  begin- 
ning, the  presence  of  pain,  the  absence  of  an  overflow  of  saliva  from  the 
mouth,  and  the  coexistence  of  other  hysterical  symptoms,  enable  a  diag- 
nosis to  be  made.  Cicatricial  and  cancerous  strictures  begin  slowly,  saliva 
collects  above  and  troubles  the  patient  by  its  quantity,  and  there  is  usually 
no  pain. 

Foreign  Bodies. — Foreign  bodies  often  lodge  in  the  oesophagus,  being 
swallowed  accidentally  or  in  jest  or  by  the  insane.  The  most  common  are 
coins,  buttons,  pieces  of  bone,  or  artificial  teeth.  Foreign  bodies  generally 
lodge  in  the  narowest  parts  of  the  oesophagus,  just  behind  the  larynx,  and 
near  the  cardiac  orifice.  The  symptoms  of  the  presence  of  a  foreign  body 
are  difficulty  in  swallowing,  local  pain,  and  sometimes  a  symptomatic  cough, 
produced  by  the  pressure  of  the  foreign  body  uj)on  the  recurrent  laryngeal 
nerve  back  of  the  larynx,  resembling  that  heard  in  aneurism.  The  presence 
of  a  foreign  body  and  its  location  can  be  detected  by  passing  a  bougie  and 


CESOPHAGOTOMY. 


801 


feeling  a  metallic  click  or  a  rough  object.  The  pharynx  should  always  be 
explored  with  the  finger.  The  location  of  the  foreign  body  can  sometimes 
be  determined  by  auscultation,  as  in  stricture.  The  X-ray  pictures  aftbrd  an 
excellent  means  of  locating  metallic  or  bony  objects.  An  especially  danger- 
ous location  is  at  a  depth  of  nine  inches  from  the  teeth,  as  the  aorta  crosses 
at  that  point,  and  may  be  injured  by  ulceration. 

Treatment. — In  children  the  removal  of  foreign  bodies  is  sometimes 
possible  by  inverting  the  child  and  making  it  inhale  ammonia  to  excite 
strong  expiratory  efforts,  meanwhile  shaking  the  patient.  Sometimes  the 
passage  of  a  plain  bougie  down  to  the  foreign  body  or  past  it  will  dislodge  it 
so  that  it  will  follow  the  instrument  on  withdrawal.  Various  instruments 
have  been  invented  for  the  purpose  of  removing  foreign  bodies  from  the 
cesox)hagus,  the  safest  of  which  is  the  horse-hair  probang,  which  may  be  made 
to  pass  by  the  foreign  body,  and  when  withdrawn  the  horse-hair  opens  into  a 


Horse-hair  probani 


large  disk.  (Fig.  697.)  The  so-called  coin-catcher  (Fig.  698),  which  has  a 
double  shield-shaped  point  pivoted  upon  the  end  of  the  bougie,  is  not  so  safe, 
for  sometimes  it  cannot  be  detached  from  the  foreign  body,  and  there  may 
be  difficulty  in  removing  the  instrument  unless  the  foreign  body  is  forcibly 

Fig.  698. 


Coin-catcher. 

dragged  up  with  it.  Forceps  can  be  used  only  when  the  foreign  body  is  very 
high  up.  If  the  foreign  body  is  round,  so  that  it  is  not  likely  to  injure  the 
surrounding  parts,  it  may  be  forced  downward  into  the  stomach  by  a  blunt, 
stout  bougie,  but  'this  should  never  be  done  with  a  sharp-pointed  object. 
When  the  foreign  body  has  been  in'jplace  for  some  'days,  attempts  at  instaru- 
mental  removal  become  very  dangerous,  because  ulceration  may  have  already 
begun,  as  in  a  case  in  which  we  performed  oesophagotomy  one  week  after  a 
brass  coin  had  been  swallowed  and  found  that  the  edge  of  the  coin  had  i^er- 
forated  the  oesophageal  wall  and  lay  in  contact  with  the  carotid  artery.]  -^ 
CEsophagotomy. — If  these  attempts  to  dislodge  the  foreign  body  fail, 
cesophagotomy  should  be  performed.     An  incision  about  three  inches  long  is 


802  TUMORS  OF  THE  (ESOPHAGUS. 

made  iu  tlie  neck  on  the  left  side  just  below  the  level  of  the  cricoid  cartilage 
and  parallel  to  the  anterior  edge  of  the  sterno- mastoid.  The  deep  fascia  is 
opened,  the  sterno-mastoid  and  the  great  vessels  of  the  neck  drawn  backward 
with  a  blunt  retractor,  and  the  larynx  pulled  towards  the  median  line.  A 
blunt  dissection,  passing  well  back  of  the  larynx  so  as  to  avoid  the  recurrent 
laryngeal  nerve,  discloses  the  oesophagus  lying  in  the  depth  of  the  wound. 
A  large  urethral  sound  or  stout  bougie  should  be  passed  by  the  mouth,  and 
made  to  project  into  the  wound  and  press  the  wall  of  the  oesophagus  forward 
so  that  it  can  be  incised.  The  edges  of  the  incision  in  the  oesophagus  should 
be  at  once  secured  by  silk  threads  passed  with  curved  needles.  From  this 
wound  a  pair  of  straight  forceps  may  be  passed  down  the  oesophagus  nearly 
to  the  cardiac  orifice.  Foreign  bodies  high  up  in  the  neck  may  be  removed 
by  a  subhyoid  pharyngotomy.  (See  page  798.)  When  the  foreign  body 
is  extracted,  unless  it  has  lain  a  long  time  and  caused  ulceration  of  the  wall 
or  possibly  an  abscess,  the  incision  in  the  oesophagus  may  be  closed  by  fine 
sutures  and  the  external  wound  lightly  packed  in  order  to  guard  against  the 
chance  of  leakage.  Food  is  administered  by  the  stomach-tube  or  by  the 
rectum  for  a  couple  of  days.  After  recovery,  bougies  should  be  passed  at 
intervals,  to  prevent  contraction. 

Diverticula. — Congenital  diverticula  are  found  and  the  oesophageal 
walls  may  be  stretched  above  a  stricture  by  the  violent  efforts  at  swallowing, 
pressure  diverticula.  Diverticula  may  also  be  formed  by  abscesses  which 
have  appeared  in  the  neighborhood  of  the  oesophagus  and  discharged  into 
it,  leaving  open  cavities  where  food  lodges,  or  by  cicatricial  contraction  of 
the  tissues  about  the  tube,  which  pull  on  a  part  of  its  wall  until  a  sort  of  sac 
is  formed,  traction  diverticula.  These  diverticula  sometimes  form  cavities 
the  size  of  a  fist,  with  a  wide  or  narrow  mouth.  The  symptoms  are  regurgi- 
tation of  food  at  intervals,  although  there  may  be  no  conscious  difficulty  in 
swallowing,  and  pressure  upon  the  cesophagus  and  neighboring  parts  by  the 
diverticulum  when  distended.  On  iDassing  a  bougie  into  the  sac  it  is  arrested, 
and  the  absence  of  a  stricture  is  proved  by  the  free  passage  of  another  bougie 
or  of  food  to  the  stomach.  A  cure  has  been  obtained  by  dissecting  out  the 
sac,  but  the  diagnosis  and  treatment  of  this  condition  are  exceedingly 
difficult. 

Tumors. — The  tumors  of  the  cesophagus  are  mainly  polypi  and  cancer. 
Benign  tumors  are  rare,  and  occur  chiefly  in  the  form  of  polypi  of  fibrous 
or  myxomatous  structure,  most  commonly  seen  in  the  upper  part  near  the 
larynx,  and  sometimes  slipping  up  into  the  pharynx,  or  even  into  the 
mouth.  They  are  rarely  multiijle.  Polypi  seldom  occasion  symptoms 
requiring  ojjeration,  but  those  which  appear  in  the  pharynx  may  be  seized 
with  forceps  and  removed  by  avulsion.  Cancer. — The  most  common  tumor 
is  ej)ithelioma,  which  develops  in  annular  form  with  as  much  contraction  as 
new  tissue  formation,  resulting  in  a  stricture  unless  the  ulceration  is  exten- 
sive. Epithelioma  is  most  usually  found  in  the  lowest  quarter  of  the 
cesophagus,  and  next  in  frequency  near  the  larynx.  The  symptoms  are 
those  of  gradually  increased  difficulty  in  swallowing,  occasionally  with 
pain  shooting  backward  into  the  spine,  or  with  a  reflex  cough  like  that 
caused  by  aneurism.     Vomiting  is  rare,  and.  must  not  be  confounded  with 


INFLAMMATION   OF  THE  THYROID   GLAND.  803 

tLe  regurgitation  of  food  whicli  has  collected  in  the  dilated  oeosophagus 
above  the  stricture.  In  the  later  stages  emaciation  is  marked,  and  the 
patient  i^ractically  dies  of  starvation,  although  there  may  also  be  severe  and 
fatal  hemorrhages,  as  the  ulceration  of  the  tumor  may  erode  one  of  the 
great  vessels.  It  may  also  ulcerate  into  the  pleural  cavity  or  a  bronchus 
and  cause  empyema  or  pneumonia.  The  accessible  glands  in  the  neck  are 
seldom  enlarged,  and  secondary  deposits  are  rare.  The  location  of  the 
stricture  may  be  determined  by  the  passage  of  a  bougie,  but  this  is  attended 
with  great  risk  in  these  cases  on  account  of  the  brittle  character  of  the 
oesophageal  walls  at  the  cancerous  strictm-e,  and  the  greatest  gentleness  must 
be  employed.  Endoscopic  instruments  have  been  invented  for  examination 
of  the  oesophagus,  but  the  method  is  not  yet  practically  useful. 

Treatment. — If  the  diagnosis  can  be  made  very  early  and  the  tumor  is 
high  uj),  a  radical  removal  is  j)ossible,  and  has  been  successfully  j)erformed. 
It  has  even  been  suggested  to  attack  the  lower  oesophagus  from  behind  by 
resecting  several  ribs.  Life  may  be  prolonged  by  making  a  gastric  fistula. 
The  gastrostomy  should  be  performed  by  Stamm's  metliod,  as  soon  as  the 
patient  begins  to  lose  weight,  even  if  fluids  can  still  be  swallowed.  If 
postponed  too  late  it  will  be  of  no  use.  If  gastrostomy  is  refused,  we  may 
resort  to  permanent  catheterization  or  tubage.  A  tube  about  six  inches  long, 
of  the  largest  caliber  that  can  be  passed,  and  with  the  upper  end  funnel- 
shaped,  is  introduced  through  the  stricture  by  a  special  whalebone  bougie 
and  left  in  j)lace,  a  fine  silk  cord  being  attached  to  it  and  brought  out  at  the 
corner  of  the  patient's  mouth.  Excellent  results  have  been  obtained  by  the 
use  of  these  tubes  in  some  cases,  the  patient  gaining  weight  and  being 
relieved  from  the  danger  of  frequently  passing  the  bougie. 

THYEOID  GLAND. 

The  thyroid  gland  varies  greatly  in  size  and  shape  in  different  indi- 
viduals. Supernumerary  masses  of  thyroid  tissue  are  sometimes  found, 
most  frequently  in  the  middle  line  along  the  course  of  the  thyroglossal  duct 
or  at  the  anterior  edge  of  the  sterno-mastoid  in  the  situation  of  those  branchial 
clefts  in  which  the  thyroid  gland  originated.  They  may  also  occur  in  the 
mediastinum  and  far  out  on  the  side  of  the  neck,  and  in  the  case  of  tumors 
growing  in  any  of  these  regions  the  possibility  of  a  supernumerary  thyroid 
should  be  considered.  Complete  atrophy  of  the  gland  is  associated  with 
myxoedema,  a  disease  which  results  in  impairment  of  the  mental  powers, 
a  thickening  of  the  subcutaneous  tissue,  and  loss  of  hair ;  and  a  similar  con- 
dition follows  comijlete  operative  removal  of  the  thyroid  gland,  with  the 
addition  in  some  cases  of  convulsions  which  resemble  those  of  tetanus. 
Simple  hypertrophy  of  the  gland  is  rare,  the  enlargement  being  generally 
adenomatous. 

Inflammation.— A  congestive  swelling  of  the  thyroid  is  seen  occasion- 
ally from  irritation  of  the  sexual  organs,  as  during  menstruation.  Sui)i3U- 
rative  inflammation  of  the  tbyroid  is  rare,  but  it  occasionally  results  in  the 
formation  of  abscesses.  When  tuberculosis  attacks  the  gland  it  grows 
larger  and  hardei',  the  overlying  skin  becomes  discolored,  and  abscesses  and 
sinuses  are  formed,  the  course  of  the  disease  being  slow  but  progressive.     If 


804  TUMORS   OF  THE  THYROID   GLAJs"!). 

the  diagnosis  could  be  made  suificiently  early,  thorough  surgical  treatment 
might  result  in  a  cure,  but  in  no  case  woiild  entire  removal  of  the  gland 
be  permissible. 

Tumors. — Tumors  of  the  thyroid  gland  are  common,  and  the  great 
majority  are  histologically  adenomata,  sometimes  associated  with  angio- 
matous changes  of  the  blood-vessels.  The  normal  gland  is  formed  of  acini 
without  ducts,  and  the  adenomata  have  the  same  structure,  except  that  the 
acini  are  larger.  In  the  parenchyinatous  growths  there  is  a  formation  of 
new  acini.  In  the  colloid  tumors  the  acini  are  simply  distended  by  an 
accumulation  of  colloid  material  but  slightly  different  from  the  normal 
secretion.  The  enlargement  of  the  acini  may  be  uniform  throughout  the 
gland,  or  one  or  several  large  cysts  may  be  produced,  compressing  the  rest 
of  the  lobe  into  a  thin  layer  resembling  connective  tissue,  which  can  be 
recognized  as  thyroid  tissue  only  under  the  microscope.  These^  tumors  may 
aifect  one  lobe  or  the  entire  gland,  and  they  may  attain  a  very  great  size, 
hanging  far  down  on  the  chest  or  extending  upward  at  the  sides  of  the  neck. 
(Fig.  699.)  They  are  known  by  the  name  of 
F^''-  '^■59.  bronchocele,  or  goitre.    Goitre  is  most  com- 

mon in  Switzerland,  and  in  certain  parts  of 
Germany  and  England,  but  it  frequently 
occurs  in  our  native  population.  The  cause 
is  unknown,  but  the  disease  is  endemic  in 
certain  places,  and  Kocher  has  traced  it  to 
some  organic  constituent  of  the  drinking 
water,  for  he  found  goitre  common  in  certain 
valleys  while  the  peojile  of  the  neighboring 
country  with  a  different  water-supply  were 
entirely  free  from  it.  The  sporadic  cases  are 
as  yet  inexplicable.  These  tumors  have  very 
Thyroid  tumor  little  cffcct  upou  the  health  iu  the  majority 

of  cases,  even  when  they  are  of  large  size.  In 
some  instances  they  grow  inward  and  press  upon  the  trachea,  causing  absorp- 
tion of  its  cartilages,  so  that  the  softened  wall  is  flattened  and  there  is 
extreme  obstruction  to  breathing.  Goitre  is  found  at  all  ages,  but  most 
commonly  reaches  a  large  size  about  the  thirtieth  year.  It  generally  grows 
slowly,  taking  ten,  fifteen,  or  twenty  years  to  develop,  and  in  this  country 
we  do  not  see  the  largest  of  these  tumors. 

Treatment. — Many  different  methods  of  treating  adenomatous  tumors 
of  the  thyroid  gland  have  been  suggested.  Iodide  of  potassium  in  full 
doses  has  proved  successful  in  a  few  cases,  but  only  in  small  tumors. 
Injections  of  iodine  into  the  substance  of  the  tumor  have  been  more 
successful,  the  tumors  for  which  it  is  best  suited  being  the  soft  parenchyma- 
tous growths  of  moderate  size,  for  in  the  cysts  it  produces  little  or  no  effect. 
Churchill's  tincture  of  iodine  is  used,  and  ten,  fifteen,  or  twenty  drops  are 
injected  directly  into  the  substance  of  the  gland,  under  conditions  of  abso- 
lute asepsis,  the  needle  being  passed  deep  into  the  gland,  so  as  to  avoid  the 
large  veins  of  the  capsule.  The  treatment  is  not  without  danger  of  infec- 
tion of  the  tissues,  with  consequent  su^jpuration,  or  of  the  injection  of  the 


THYROIDECTOMY.  805 

iodine  directly  into  a  vein,  which  has  caused  instant  death.  There  is  usually 
an  inflammatory  reaction,  lasting  several  days  and  slowly  subsiding,  after 
which  the  gland  becomes  smaller  and  firmer. 

Thyroid  Feeding. — The  internal  administration  of  fresh  thyroid  mate- 
rial or  extract  has  been  recommended,  and  has  proved  efficacious  in  some 
cases,  but  the  remedy  seems  to  be  capricious,  and  sometimes  brings  on  symp- 
toms similar  to  those  of  exophthalmic  goitre. 

Exposure. — Some  French  surgeons  have  recommended  that  instead  of 
removing  the  gland  the  skin  and  the  capsvde  should  be  incised  and  the 
gland  turned  out  and  left  projecting  in  the  wound,  where  it  is  said  to 
undergo  atroijhy.  This  method  leaves  an  unsightly  scar,  and  there  is  danger 
of  infection  while  the  tumor  is  exposed. 

Ligature  of  the  Thyroid  Arteries. — The  gland  atrophies  without 
sloughing,  and  there  appears  to  be  no  danger  of  sloughing  or  myxcedema 
even  when  all  four  vessels  are  tied.  But  the  operation  is  as  difficult  as 
partial  thyroidectomy,  and  the  scars  are  even  more  extensive. 

Thyroidectomy. — Complete  removal  of  the  thyroid  gland  is  not  allow- 
able, on  account  of  the  danger  that  myxcedema  may  follow.  PaHial  thyrcn- 
dectomy  may  be  performed  through  an  oblique  or  a  horizontal  incision,  with 
its  centre  over  the  most  prominent  part  of  the  tumor,  or  an  angular  incision 
forming  part  of  a  Y,  the  upright  of  the  Y  beginning  in  the  middle  line  at 
the  sternum  and  the  oblique  line  passing  ujjward  from  the  level  of  the 
cricoid  cartilage  towards  the  angle  of  the  jaw.  The  skin  is  dissected  back, 
the  muscles  separated,  so  that  the  capsule  of  the  gland  is  exposed,  and  any 
veins  which  cross  the  wound  are  divided  between  double  ligatures.  The 
tumor  is  bluntly  dissected  out.  A  vein  will  be  found  passing  off  from  the 
upper  margin  of  the  lobe  on  the  median  side,  and  should  be  divided  between 
two  ligatures,  and  on  the  outer  side  will  be  found  the  accessory  superior 
thyroid  veins,  which  should  be  similarly  treated.  The  gland  is  then  drawn 
towards  the  middle  line,  and  the  superior  thyroid  artery  and  vein  found  and 
included  in  a  double  ligature  and  divided.  The  inferior  thyroid  vessels  are 
then  sought  and  the  vein  tied  first,  together  with  the  vena  ima  and  any  con- 
necting branches.  The  inferior  thyroid  artery  runs  close  to  the  recurrent 
laryngeal  nerve,  and  therefore  it  should  be  secured  at  some  distance  from 
the  gland  where  it  crosses  the  carotid.  The  gland  is  then  pulled  vigorously 
over  towards  the  middle  line,  the  capsule  is  divided  on  its  posterior  surface 
near  the  isthmus,  and  the  gland  is  separated  from  its  capsule  working 
towards  the  isthmus.  By  thus  leaving  a  part  of  the  capsule  in  situ  the 
laryngeal  nerve  is  effectually  protected.  When  the  isthmus  is  reached  it 
forms  a  natural  pedicle,  and  an  interlocking  ligature  is  passed  through  it 
and  tied  like  that  for  the  pedicle  of  an  ovarian  tumor.  The  isolated  gland 
is  then  cut  away  and  the  wound  sutured. 

Enucleation. — The  tumors  may  also  be  enucleated  from  the  gland,  leaving 
the  healthy  tissues.  The  capsule  of  the  gland  is  exposed  by  a  similar 
incision,  and  divided,  carefully  avoiding  the  numerous  veins.  When  the 
real  capsule  of  the  tumor  is  reached,  the  mass  is  easily  shelled  out  of  the 
gland  substance.  Very  few  blood-vessels  pass  through  the  capsule  of  the 
tumoi',  and,  as  these  are  of  small  size,  hemorrhage  is  readily  controlled  by 

52 


806 


EXOPHTHALMIC  GOITRE. 


pressure  or  ligatures.  The  principal  bleeding  will  come  from  the  bottom 
of  the  pouch  from  which  the  tumor  has  been  removed,  and  this  should  be 
seized  with  forceps  and  drawn  to  the  surface,  when  the  bleeding  points  can 
be  easily  secured.  If  there  is  more  than  one  tumor,  a  sei^arate  incision  of 
the  gland  capsule  may  be  required  for  each.  If  the  bleeding  can  be  arrested 
by  ligatures,  the  wound  is  sutured  ;  if  not,  the  cavity  is  to  be  packed.  Some 
surgeons  prefer  resection  and  others  enucleation.  Enucleation  is  indicated 
for  small  solitary  tumors,  and  also  where  numerous  tumors  are  present  in 
both  lobes.  Eesection  is  usually  simpler  and  involves  less  danger  of  hemor- 
rhage. If  one-half  of  the  gland  is  removed,  the  other  half  usually  remains 
stationary  and  it  may  grow  smaller. 

Exophthalmic  Goitre. — The  disease  known  as  Basedow's  or  Graves's 
disease  or  exophthalmic  goitre  is  a  i^eculiar  affection  of  undetermined 
pathology,  marked  by  enlargement  of  the  thyroid,  exophthalmos,  rapid  and 
irregular  heart-action,  and  various  nervous  symptoms,  such  as  tremor, 
hysteria,  insomnia,  and  lack  of  coordination  between  the  movements  of  the 
eyelids  and  the  eyeballs.     (Fig.  700.)    In  the  well-developed  cases  a  cure 

can   seldom  be  brought   about  by 
Fig.  700.  medical  treatment,  but  a  partial  re- 

moval of  the  gland  cures  about 
three-quarters  of  the  cases.  Tlie 
cases  vary  greatly  in  their  intensity 
and  also  in  their  symptoms,  the  ner- 
vousness, the  tachycardia,  the  ex- 
ophthalmos, and  the  enlargement  of 
the  thyroid  being  found  variously 
combined,  or  only  two  of  them  being- 
present.  Cases  without  exophthal- 
mos or  without  goitre  are  quite  fre- 
quent. While  the  disease  has  been 
ascribed  to  various  causes,  such  as 
some  central  nervous  lesion  or 
changes  in  the  sympathetic  nerve,, 
the  fact  that  it  can  be  cured  by  a 
partial  removal  of  the  gland  renders 
ExoiihiiiuJmic  guiue.  it  probablc  that  the  symptoms  are 

due  to  an  exaggerated  or  imj^roper 
function  of  the  gland.  There  may  be  an  oversupply  of  some  peculiar 
product  of  the  gland,  or  the  organ  may  fail  to  eliminate  from  the  system 
some  toxic  material  which  it  should  normally  dispose  of  The  former  theory 
is  rendered  the  more  likely  because  of  the  close  resemblance  between  these 
symptoms  and  those  produced  by  poisoning  with  the  thyroid  extract,  so 
often  given  now  for  therapeutic  purposes.  The  changes  in  the  thyroid 
gland  in  this  disease  may  be  simple  hypertrophy,  parenchymatous  or  cystic 
adenoma,  or  an  angiomatous  degeneration.  It  was  formerly  thought  that 
operations  in  this  condition  were  very  dangerous,  but,  in  spite  of  the  rapid 
and  irregular  heart-action,  comparatively  few  deaths  are  now  met  with. 
One  peculiar  mode  of  death  after  operation  is  apparently  due  to  an  acute 


MALIGNANT  TUMORS.  807 

thyroid-substance  poisoning.  In  these  cases,  with  absolute  freedom  from 
septic  conditions  in  the  wound,  the  temperature  rises  immediately  after 
operation,  and  may  reach  107°  F.  Extreme  tachycardia,  restlessness,  mus- 
cular twitchings,  and  albuminuria  develop,  and  death  follows  in  from 
twenty-four  to  forty-eight  hours  from  cardiac  failure  and  oedema  of  the  lungs. 

Treatment. — The  operation  to  be  done  generally  consists  in  a  partial 
removal  of  the  organ,  the  larger  half  being  selected.  The  tumors  may  also 
be  enucleated  separately.  The  heart-action  will  usually  be  quieted  within  a 
short  time  and  the  nervous  symptoms  rapidly  disappear,  but  the  exophthal- 
mos may  persist  indefinitely,  although  it  is  generally  improved.  Eecently 
a  considerable  number  of  cases  have  been  treated  with  fair  success  by  resec- 
tiou  of  the  sympathetic  cord  with  the  three  cervical  ganglia  on  each  side.  We 
have  had  a  successful  case.  The  gland  shrinks  and  the  other  symptoms 
improve  after  this  operation,  but  further  experience  is  needed  to  determine 
its  value. 

Malignant  Tumors. — Malignant  disease  of  the  thyioid  gland  may  be 
carcinoma  or  sarcoma.  The  tumors  are  rather  slow  in  their  growth  at  first, 
and  the  diagnosis  is  difficult.  Carcinoma  is  to  be  suspected  in  cases  of  uni- 
form, rather  hard  enlargement  of  the  gland  in  persons  over  forty  years  of  age. 
The  tumors  compress  the  trachea,  and  death  generally  results  from  this  cause. 
In  malignant  disease  the  only  possible  treatment  is  com^jlete  extirpation  of 
the  gland,  in  spite  of  the  danger  of  myxcedema  or  cretinism  ;  and  perhaps 
the  administration  of  the  thyroid  extract  may  prevent  these  consequences. 
To  be  of  any  service  the  removal  must  take  place  very  early.  Palliative 
treatment  is  necessary  when  removal  is  impossible  and  the  symj)toms  become 
urgent  on  account  of  the  pressure  exercised  on  the  trachea  by  the  tumor. 
Tracheotomy  and  the  insertion  of  a  very  long  and  flexible  tiibe  (Kocher's) 
will  relieve  some  cases.  If  this  is  impossible  because  the  tumor  entirely 
covers  the  trachea,  the  gland  should  be  divided  in  the  middle  line  with  the 
thermo-cautery,  taking  advantage  of  the  natural  separation  of  the  lobes  at 
the  isthmus.  In  one  case  of  inoperable  carcinoma  we  obtained  temj)orary 
relief  by  removing  a  large  portion  by  the  curette.  It  is  well  to  note  that 
every  tumor  of  the  thj'roid  which  causes  secondary  deposits  is  not  malignant, 
for  adenoma  has  been  known  to  occasion  them  in  various  bones,  and  espe- 
cially in  the  skull.  Although  the  metastasis  of  adenoma  is  rare,  quite  a 
number  of  instances  are  now  on  record. 


CHAPTEE    XXXII. 

surgery  of  the  air-passages. 
By  Heney  E.  Wharton,  M.D. 

Wounds  and  Injuries  of  the  Larynx  and  Trachea. — The  larynx 
or  trachea  may  suifer  from  contusion  ov  fracture  of  the  cartilages,  with  lacer- 
ation of  the  mucous  membrane,  from  blows,  or  from  falls  upon  the  neck. 
Incised  and  lacerated  wounds  of  the  larynx  or  trachea  may  result  from  sharp 
or  blunt  instruments  applied  to  the  neck,  as  in  stab  or  ciitthroat  wounds, 
or  from  sharp  or  irregular  foreign  bodies  which  find  their  way  into  the 
larynx ;  gunshot  wounds  of  the  larynx  or  trachea  are  also  occasionally 
observed.  Cutthroat  wounds  are  those  most  commonly  met  with,  and  in 
these  the  larynx,  the  trachea,  or  the  crico-thyroid  or  thyro-hyoid  membrane 
may  be  incised.  The  would-be  suicide  usually  makes  a  transverse  incision 
over  the  most  prominent  part  of  the  larynx,  and  often  opens  the  thyro- 
hyoid space  and  injures  the  epiglottis,  and  as  soon  as  air  escapes  from  the 
wound  he  desists,  so  that  the  great  vessels  of  the  neck  seldom  are  injured ; 
the  superficial  jugular  veins  are  occasionally  divided  in  the  incision. 

Symptoms. — In  contusions  and  lacerations  of  the  larynx  or  trachea  the 
most  prominent  symptom  is  dj^spnoea,  which  results  from  hemorrhage,  swell- 
ing and  oedema  of  the  mucous  membrane,  or  from  displacement  of  the  lacer- 
ated cartilages  ;  expectoration  of  blood  and  of  frothy,  blood-stained  mucus 
may  also  be  observed  if  the  mucous  membrane  has  been  ruptured.  The 
symptoms  in  stab,  lacerated,  or  cutthroat  wounds  involving  the  larynx  or 
trachea  are  the  escape  of  bloody,  frothy  mucus  from  the  wound,  dyspnoea, 
dysphagia,  and  retraction  of  the  ends  of  the  divided  tube,  if  the  division 
has  been  a  complete  one.  The  symptoms  following  wounds  of  the  larynx 
or  trachea  from  foreign  bodies  are  the  expectoration  of  mucus  and  blood, 
and  more  or  less  dyspnoea.  The  immediate  danger  in  all  cases  of  injury  or 
wound  of  these  organs  is  swelling  or  oedema  of  the  mucous  membrane, 
which  may  produce  death  by  suffocation  unless  relieved  by  operative  treat- 
ment. Death  from  hemorrhage  is  comparatively  rare,  but  may  occur ;  but 
the  escape  of  a  moderate  amount  of  blood  into  the  lungs  may  later  give  rise 
to  a  septic  pneumonia  which  may  prove  fatal. 

Treatment. — Contusions  and  lacerations  of  the  trachea  and  larynx,  if 
there  is  no  marked  displacement  of  the  fragments  nor  dyspnoea,  should  be 
treated  by  rest  in  bed  and  the  application  of  an  ice-bag  to  the  neck  over  the 
injured  organ,  the  patient  being  carefully  watched.  If  the  breathing  is 
obstructed,  an  intubation-tube  should  be  used,  or  the  trachea  opened  and  a 
tracheotomy-tube  introduced.  In  incised,  lacerated,  or  cutthroat  wounds 
the  hemorrhage  should  be  controlled,  and  the  edges  of  the  incision  in  the 
walls  of  the  larynx  or  trachea  should  be  brought  together  with  catgut  sutures. 
If  the  epiglottis  has  been  partly  detached,  it  should  be  carefully  apiDroxi- 


FRACTURES   OF  THE  LARYNX  AJSTD  TRACHEA.  809 

mated  with  sutures,  and  the  superficial  wound  closed.  If  dyspnoea  occurs 
after  the  wound  has  been  closed,  the  trachea  should  be  opened  below  the 
wound  and  a  tracheotomy-tube  introduced.  In  cases  of  extensive  incised 
and  lacerated  wounds,  it  is  safer  to  perform  tracheotomy  and  introduce  a 
tube,  plugging  the  trachea  above  the  tube  with  iodoform  gauze,  to  prevent 
the  entrance  of  blood  into  the  lungs,  the  packing  also  serving  to  retain  the 
fragments  in  position.  The  tracheotomy-tube  should  be  worn  for  a  week  or 
ten  days,  until  the  wound  is  healed,  the  patient  being  kept  in  bed  with  the 
head  thrown  forward,  so  as  to  relieve  the  wound  from  tension,  and  for  a  few 
days  fed  with  a  stomach-tube  or  by  nutritious  enemata,  as  swallowing  is 
painful  and  tends  to  disturb  the  parts. 

Fractures  of  the  Larynx  and  Trachea.— These  may  occur  at 
any  age,  although  ossification  of  the  cartilages  does  not  take  place  until 
advanced  life.  They  may  be  produced  by  blows,  or  by  violent  compression 
of  the  parts,  or  by  hanging.  Symptoms. — Pain,  followed  by  rapid  swell- 
ing and  deformity  of  the  neck,  is  a  prominent  symptom  ;  bloody  expectora- 
tion, emphysema  of  the  neck,  and  alteration  or  loss  of  voice,  are  often 
present,  and  respii-ation  and  deglutition  soon  become  difficult.  Marked 
dyspnoea  is  a  very  common  symptom.  Every  fracture  of  the  larynx  or 
trachea  should  be  considered  a  most  serious  injury,  for  even  if  dangerous 
symptoms  do  not  immediately  follow,  inflammatory  sym^itoms  may  super- 
vene later,  which  will  cause  a  fatal  termination  unless  prompt  treatment  is 
resorted  to.  In  twenty-seven  cases  of  fracture  of  the  larynx  reported  by 
Hunt,  ten  recovered  and  seventeen  died. 

Treatment. — Where  there  is  little  displacement  of  the  cartilages  and 
dyspnoea  is  not  marked,  the  parts  should  be  supported  by  the  application  of 
a  compress  of  lint  held  iu  i)lace  by  adhesive  straps,  and  the  patient  should 
be  kept  at  rest  iu  bed  with  the  head  and  neck  immobilized  as  far  as  pos- 
sible. If,  however,  there  is  free  expectoration  of  blood,  and  the  respiration 
is  embarrassed,  tracheotomy  should  be  promptly  performed,  and  if  the 
injury  is  seated  in  the  larynx  the  displacement  of  the  fragments  may  be 
overcome  by  manipulation  with  the  finger  or  a  director  through  the  tracheal 
wound,  or  the  larynx  may  be  packed  with  strips  of  antiseptic  gauze  to  con- 
trol hemorrhage  and  hold  the  fragments  in  position,  the  patient  in  the  mean 
time  breathing  through  a  tracheotomy-tube  secured  in  the  tracheal  wound. 
The  packing  should  be  removed  in  a  few  days,  the  tracheotomy-tube  being 
permanently  removed  as  soon  as  the  patient  can  breathe  comfortably  through 
the  larynx  with  the  tracheal  wound  closed.  In  fractures  of  the  trachea,  if 
possible,  the  opening  into  the  trachea  should  be  below  the  seat  of  injury. 

Scalds  or  Burns  of  the  Larynx. — These  injuries  arise  from  the 
inhalation  of  steam  or  flame,  or  may  result  from  the  action  of  caustic  sub- 
stances, such  as  lye  or  ammonia,  which  are  swallowed  and  come  in  contact 
with  the  epiglottis  or  find  their  way  into  the  larynx.  Scalds  of  the  larynx 
arising  from  the  inhalation  of  steam  are  the  most  frequent  of  these  injuries, 
and  are  commonly  seen  in  children  who  have  attempted  to  drink  from  the 
spout  of  a  tea-kettle  containing  hot  water.  Symptoms. — Pain  and  grad- 
ually increasing  difficulty  in  respiration  are  the  most  marked  symptoms. 
In  all  these  cases  the  lips,  tongue,  cheeks,  and  pharynx  will  show  evidence 


810  (EDEMA  OF  THE  GLOTTIS. 

of  the  action  of  the  irritant ;  in  scalds,  these  parts  are  first  white,  and  the 
mucons  membrane  soon  becomes  congested  ;  a  very  similar  appearance  may 
be  pi-esented  from  the  application  of  escharotics.  Dyspnoea  is  due  to  oedema 
of  the  mucous  membrane  of  the  epiglottis  and  larynx,  preventing  the 
entrance  of  air,  which,  if  not  relieved,  soon  produces  death  by  asphyxia. 
If  the  latter  is  averted,  these  cases  may  terminate  fatally  later  from  bron- 
chitis, from  pneumonia,  or  from  stenosis  resulting  from  cicatricial  contrac- 
tion. Treatment. — In  cases  where  the  scald  or  burn  has  not  been  severe 
and  the  dyspnoea  is  not  marked,  the  patient  should  be  placed  in  bed,  cold 
compresses  or  an  ice-bag  being  applied  to  the  neck,  and  the  patient  should 
inhale  the  vapor  from  a  steam  spray.  Under  this  treatment  in  mild  cases 
I'ecovery  may  take  place.  If,  however,  the  difficulty  in  breathing  is  marked 
when  the  patient  is  first  seen,  or  is  gradually  increasing  in  spite  of  treat- 
ment, the  sooner  au  operation  is  undertaken  to  relieve  the  dyspnoea  the 
better  Mill  be  the  patient's  chances  of  recovery.  The  operation  indicated  in 
these  cases  is  tracheotomy  or  intubation  of  the  larynx  ;  the  former  we  think 
the  wiser  procedure,  for  intubation  is  not  likely  to  be  of  service  if  the  epi- 
glottis is  involved,  though  it  may  be  of  benefit  if  the  oedema  is  confined  to 
the  mucous  membrane  of  the  larynx.  These  operations  relieve  the  dys- 
pnoea, but  a  certain  number  of  cases,  even  after  the  obstruction  to  breathing 
is  removed,  die  of  bronchitis,  or  i^neumonia. 

CEdema  of  the  Glottis. — This  affection,  characterized  by  the  effusion 
of  serum  in  the  submucous  connective  tissue  of  the  epiglottis,  the  larynx, 
or  the  vocal  cords,  rarely  involving  the  larynx  below  the  cords,  may  arise 
from  various  causes.  It  may  develop  rapidly  after  burns  or  scalds  of  the 
epiglottis  or  larynx,  or  may  follow  wounds  of  the  base  of  the  tongue,  impac- 
tion of  foreign  bodies  in  the  larynx,  fracture  of  the  hyoid  bone  or  cartilages 
of  the  larynx,  or  caustic  applications  to  the  larynx.  It  may  appear  as  a 
secondary  complication  of  acute  or  chronic  laryngitis,  of  acute  tojisilitis,  of 
syphilitic  or  tuberculous  ulceration  of  the  larynx,  or  of  carcinoma  of  the 
larynx.  CEdema  may  also  arise  in  the  course  of  chronic  nephritis,  measles, 
scarlet  fever,  erysipelas,  or  cellulitis  of  the  neck. 

Symptoms. — These  may  develop  rajjidly  or  slowly,  and  consist  of  pain 
and  discomfort  in  the  region  of  the  larynx,  suppression  of  voice,  a  constant 
cough,  unattended  with  expectoration,  and  stridor  in  breathing,  especially 
in  inspiration.  Dyspnoea  and  dysphagia  develop,  and  in  extreme  cases,  as 
the  dyspnoea  becomes  urgent,  the  face  is  cyanosed,  the  eyeballs  protrude, 
and  the  patient  presents  a  marked  picture  of  mental  and  physical  distress. 
If  the  conditions  are  not  relieved  by  operation,  the  patient  soon  dies  of 
suffocation.  The  diagnosis  of  oedema  of  the  glottis  may  be  made  by  inspec- 
tion of  the  parts  with  a  laryngoscope,  or,  if  this  is  not  at  hand,  the  intro- 
duction of  the  finger  will  often  disclose  the  condition  of  the  epiglottis,  which 
will  be  felt  as  a  soft  elastic  tumor  the  size  of  a  horse-chestnut,  its  cartilagi- 
nous outline  being  entirely  masked  by  the  swollen  tissues.     (Fig.  701.) 

Treatment.— If  the  symptoms  are  not  extremely  urgent,  scarification  of 
the  epiglottis  with  a  sharp-pointed  knife  may  be  employed  ;  a  curved  bis- 
toury, wrapped  with  adhesive  plaster  to  within  one-third  of  an  inch  of  its 
point,  is  a  satisfactory  instrument  for  this  purpose,  the  part  being  exposed 


CATARRHAL  LARYNGITIS.  811 

by  a  laryngoscopic  mirror,   or,  if  this  is  not  at  hand,  the  incision  being- 
guided  by  the  index  finger  placed  ujjon  the  epiglottis.      Scarification  is 
followed  by  free  escape  of  blood  and  serum,  and 
usually  raj)id  improvement  in  the  symptoms.     If,  Fig  701 

however,  the  dyspnoea  is  urgent,  or  recurs  after  '  '       ^  ^ 

scarification,  tracheotomy  or  intubation  should  be  i 

performed.  Tracheotomy  is  the  operation  which 
is  likely  to  be  followed  by  the  best  results,  for  if  the 
epiglottis  is  (ledematous,  as  is  usually  the  case,  the 
introduction  of  an  intubation-tube  is  difficult,  and 
^\'hen  introduced  the  swollen  epiglottis  prevents  the 
entrance  of  air.  The  immediate  result  of  tracheot- 
omy in  these  cases  is  usually  satisfactory,  the  dys- 
pnoea being  relieved,  and  the  swelling  of  the  (Edem- 
atous tissues  rapidly  subsiding  ;  but  many  cases  " 
subsequently  die,    especially  those  in  which  the 

affection  has  developed  as  a  sequel  of  nephritis,    cEdema  of  the  glottis.   (Cohen.) 
scarlet  fever,  or  erysipelas. 

Laryngitis. — This  affection  may  exist  as  an  acute  catarrhal  laryngitis, 
simf)le  membranous  laryngitis,  diphtheritic  laryngitis,  acute  oedematous 
laryngitis,  or  tuberculous  or  syphilitic  laryngitis. 

Acute  Catarrhal  Laryngitis. — This  affection  may  arise  from  exten- 
sion of  inflammation  fi'om  the  pharynx,  from  exposure  to  cold  and  damp- 
ness, from  the  inhalation  of  irritating  substances  or  gases,  or  from  overuse 
of  the  parts  in  speaking  or  singing.  The  prominent  symptoms  are  fever, 
cough,  hoarseness  or  complete  loss  of  voice,  and  more  or  less  mucopurulent 
expectoration  following  frequent  efforts  to  clear  the  throat.  Dyspnoea  is 
usually  not  xjreseut  in  these  cases  unless  submucous  oedema  causes  marked 
swelling  of  the  inflamed  mucous  membrane.  Laryngoscopic  examination 
shows  the  mucous  membrane  of  the  larjaix  to  be  congested,  red,  and  swollen, 
the  cords  being  ijarticularly  involved.  Treatment. — This  consists  in  keep- 
ing the  ijatient  free  from  cold  and  exposure,  at  the  same  time  leeches  or  cold 
compresses  being  applied  to  the  neck  over  the  larynx ;  and  great  relief  is 
often  experienced  from  the  inhalation  of  steam  impregnated  with  sedatives 
and  astringent  substances.  A  mixture  of  menthol,  niv,  compound  tinc- 
ture of  benzoin,  f  3  ii,  added  to  boiling  water,  Oi,  is  a  very  satisfactory  inhala- 
tion. The  use  of  an  aperient  is  often  followed  by  benefit.  Under  this 
treatment  the  affection  usually  subsides  rapidly,  but  if  the  dyspnoea  should 
become  marked  from  cedema,  intubation  or  tracheotomy  may  be  required. 

Simple  Membranous  Laryngitis. — This  was  formerly  considered  a 
common  affection  of  the  larynx  in  childhood,  and  was  described  clinically 
as  membranous  croup.  We  now  recognize  that  a  membranous  exudation 
may  develop  in  the  larynx  and  trachea  as  the  result  of  inflammation  due  to 
burns,  scalds,  injuries,  or  foreign  bodies,  but  that  the  cases  of  membranous 
exudation  arising  independently  of  these  causes  are  of  bacterial  origin, 
being  due  to  the  presence  of  the  Klebs-Loeftier  bacillus,  and  are  really  cases 
of  diphtheritic  laryngitis.  Symptoms. — The  symptoms  of  membranous 
laryngitis  following  non-infective  inflammation  are  fever,  restlessness,  and 


812  DIPHTHERITIC  LARYNGITIS. 

gradually  increasing  dyspnoea,  with  cyanosis  of  the  face.  Treatment. — 
This  consists  in  the  use  of  an  alkaline  steam  spray,  the  application  of  leeches 
or  iced  comi^resses  to  the  neck  over  the  larynx,  and  the  administration  of 
calomel  in  small  and  frequently  repeated  doses,  and,  if  obstruction  of  the 
breathing  becomes  urgent,  intubation  or  tracheotomy  should  be  resorted  to. 

Tuberculous  Laryngitis. — Primary  tuberculosis  of  the  larynx  is  a 
rare  affection,  but  its  occurrence  secondary  to  pulmonary  tuberculosis  is 
not  uncommon.  Thickening  of  the  mucous  membrane  first  occurs,  and  soon 
minute  ulcers  are  developed,  which  run  together  and  cause  large  patches 
of  ulceration,  l^o  part  of  the  larynx  is  exempt  from  the  disease,  but  the 
pyriform  swelling  of  the  mucous  membrane  covering  the  arytenoid  carti- 
lages, and  the  presence  of  ulceration  upon  the  aryteno-epiglottic  folds,  the 
false  cords,  and  lower  surface  of  the  epiglottis,  point  very  strongly  to  the 
tuberculous  origin  of  the  affection.  When  the  ulceration  is  extensive  the 
cartilages  may  be  involved  and  necrosis  may  occur.  Symptoms. — These 
are  hoarseness  of  the  voice  with  a  frequent  cough,  pain  and  difficulty  in 
swallowing ;  dyspnoea  is  not  often  marked  unless  acute  oedema  occurs. 
Treatment. — The  patient  should  be  placed  upon  treatment  applicable  for 
the  tuberculous  condition.  Curetting  of  the  ulcerated  surface  and  the 
insufflation  of  iodoform  are  often  employed  with  benefit,  and  the  local  use 
of  medicated  sprays  may  add  much  to  the  laatient's  comfort ;  if  oedema 
develops  and  is  followed  by  obstruction  to  the  breathing,  tracheotomy  or 
intubation  may  be  required. 

Syphilitic  Laryngitis. — This  may  appear  in  the  early  or  the  late  sec- 
ondary stage  or  in  the  tertiary  stage  of  the  disease.  In  the  early  secondary 
stage  there  sometimes  develops  a  laryngitis,  corresponding  to  the  sore  throat 
noticed  in  this  stage  of  the  affection.  In  the  tertiary  stage,  gummatous 
infiltration  of  the  mucous  and  submucous  tissues  of  the  larynx  occurs,  which 
may  break  down,  giving  rise  to  typical  gummatous  ulcers.  The  cartilages 
are  frequently  involved  in  the  disease,  and  may  be  largely  destroyed  ;  and 
as  the  result  of  extensive  ulceration  and  the  subsequent  cicatrization 
marked  stenosis  may  occur.  Treatment. — This  consists  in  the  administra- 
tion of  mercury  or  iodide  of  potassium  in  full  doses,  according  to  the  stage 
of  the  disease,  and  the  local  use  of  antiseptic  sprays  or  those  containing 
mercury  in  solution.  If  acute  oedema  of  the  larynx,  or  stenosis  from  cica- 
tricial contraction,  develops,  causing  urgent  dyspnoea,  intubation  or  trache- 
otomy may  be  demanded. 

Diphtheritic  Laryngitis. — This  forju  of  laryngitis,  which  is  also 
described  as  membranous  laryngitis,  is  characterized  by  inflammation  of  the 
mucous  membrane  of  the  larynx,  with  the  deposit  of  a  tough  fibrous  exuda- 
tion or  membrane,  in  which  are  incorporated  pus-corpuscles  and  epithelial 
elements  from  the  underlying  mucous  membrane.  The  membrane  may 
develop  primarily  in  the  larynx,  or  it  may  spread  to  it  secondarily  from  the 
pharynx,  and  may  extend  into  the  trachea  and  bronchi.  (Fig.  702. )  The 
invariable  presence  in  the  exudation  of  a  special  organism,  the  Klebs-Loeffler 
bacillus,  has  led  to  the  recognition  of  this  organism  as  the  specific  cause  of 
the  disease.  This  form  of  laryngitis  is  very  common  in  children,  but  is 
rarely  seen  in  adults,  is  often  epidemic,  and  is  accompanied  by  fever,  rapid 


PEEICHONDEITIS  AND  CHONDRITIS   OF  THE  LARYNX. 


813 


Tubular  cast  oJ  mem- 
brane in  larynx  and  tra- 
chea extending  into  the 
bronchial  tubes. 


pulse,  enlargement  of  the  submaxillary  glands,  and  marked  constitutional 
depression.  Symptoms. — These  are  a  croupy  cough,  suppression  of  the 
voice,  gradually  increasing  dyspnoea,  and  cyanosis  of  the  face,  with  restless- 
ness ;  as  the  dyspnoea  becomes  more  marked  the  patient  sits  up  in  bed  and 
assumes  the  position  in  which  the  accessory  muscles 
of  respiration  are  brought  into  play.  Inspection  of  the 
chest  shows  sinking  in  of  the  lower  part  of  the  chest 
and  the  upper  part  of  the  abdomen  in  inspiration,  as 
well  as  of  the  tissues  of  the  suprasternal  notch  and  the 
supraclavicular  spaces.  Treatment. — This  consists 
in  the  administration  of  strychnine  and  stimulants, 
and  the  patient  should  be  given  an  easily  assimilated 
and  nutritious  diet.  The  extensive  use  of  the  anti- 
toxine  of  diphtheria  during  the  last  few  years  has 
demonstrated  its  value,  and  it  should  be  given  hypo- 
dermically  in  doses  of  two  thousand  units,  for  a  child 
three  years  of  age,  the  injection  being  repeated  within 
twelve  or  twenty-four  hours  if  necessary,  the  action  of 
the  antitoxine  being  shown  by  the  thinning  and  disap- 
pearance of  the  membrane,  which  usually  occurs  within 
fi-om  twenty-four  to  seventy-two  hours.  In  addition  to 
the  constitutional  infection  in  these  cases  there  is  often 
more  or  less  dyspnoea,  from  the  presence  of  the  exuda- 
tion and  the  swollen  and  cedematous  condition  of  the 
mucous  membrane  of  the  larynx.  If  the  dyspnoea  is  not  urgent,  we  have 
found  the  use  of  a  steam  or  hand  spray  of  soda  solution  (Parker's  solution), 
comxjosed  of  carbonate  of  sodium,  3i;  glycerin,  ,si;  water,  fsvi,  to  be 
followed  by  the  most  satisfactory  results.  This  spray  should  be  used  at 
frequent  intervals,  and  in  many  cases  we  think  its  persistent  use  will  obviate 
the  necessity  for  operative  treatment.  If,  however,  the  dyspnoea  increases 
in  spite  of  this  treatment,  intubation  or  tracheotomy  should  be  promptly 
performed.  These  operations  should  not  be  postponed  until  the  patient  is 
exhausted  by  prolonged  struggles  for  breath  and  imperfect  aeration  of  the 
blood,  and  is  dying  from  cardiac  failure. 

Perichondritis  and  Chondritis  of  the  Larynx.— These  affec- 
tions are  clinically  difficult  to  differentiate,  although  chondritis  is  probably 
always  preceded  by  perichondritis.  They  seldom  are  observed  as  primary 
affections,  but  usually  follow  an  injury,  or  syphilitic,  tuberculous,  or  can- 
cerous ulceration,  and  occasionally  are  observed  as  sequelfe  of  typhoid 
fever  or  the  exanthemata.  The  cricoid  and  arytenoid  cartilages  are  those 
most  commonly  involved.  When  an  abscess  forms  beneath  the  perichon- 
drium, necrosis  of  the  cartilage  usually  results,  and  the  pus  may  be  dis- 
charged into  the  larynx,  or  may  perforate  the  cartilage  and  open  into  the 
tissues  of  the  neck  ;  a  perforation  involving  the  mucous  membrane  and  the 
cartilage  may  be  followed  by  emphysema  of  the  neck.  Symptoms. — - 
These  are  similar  to  those  of  laryngitis,  and  consist  of  pain  on  pressure,  in 
swallowing,  and  in  phonation,  hoarseness,  cough,  and  in  some  cases  rapidly 
developing  dyspnoea.     Treatment. — In  the  early  stages  of  the  affection 


814  STRICTURE   OF  THE  LARYNX   OR  TRACHEA. 

leeches  or  an  ice-bag  may  be  employed,  as  well  as  medicated  steam  sprays. 
The  difficulty  in  swallowing  may  be  so  great  that  for  the  proper  administra- 
tion of  fluids  and  food  the  stomach-tube  will  be  required.  If  the  symptoms 
do  not  improve  and  dyspnoea  becomes  marked,  intubation  or  tracheotomy 
should  be  performed.  External  sinuses  resulting  from  abscess  may  persist, 
and  to  obtain  healing  in  these  cases  it  is  often  necessary  to  lay  them  freely 
open  and  remove  the  necrosed  cartilage. 

Abscess  of  the  Larynx. — This  may  arise  from  traumatism  or  develop 
in  the  course  of  typhoid  fever  or  the  exanthemata,  but  most  frequently 
follows  perichondritis  or  chondritis.  The  abscess  may  be  situated  within 
the  larynx  or  outside  of  the  larynx.  Symptoms. — The  symptoms  of  intra- 
lanjngeal  abscess  are  similar  to  those  of  laryngitis, — pain,  hoarseness,  cough, 
difficulty  in  swallowing,  and  dyspnoea ;  if  oedema  of  the  larynx  occurs, 
sitdden  suffocative  symptoms  develop.  In  extralaryngeal  abscess  pain  and 
dysphagia  are  present,  but  dyspnoea  is  not  often  marked  unless  oedema  of 
the  larynx  develops.  A  laryngoscopic  examination  in  the  case  of  an  intra- 
laryngeal  abscess  will  reveal  the  presence  and  seat  of  the  abscess.  Spon- 
taneous evacuation  of  these  abscesses  often  occurs,  and  is  followed  by 
marked  relief  of  the  symptoms ;  but  in  cases  in  which  dyspnoea  is  well 
developed  it  is  not  safe  to  wait  for  this  to  take  place.  Treatment. — If 
the  abscess  can  be  exposed  by  the  use  of  a  laryngoscope,  it  should  be 
promptly  opened  with  a  laryngeal  knife  or  a  director,  if  its  walls  are  thin  ; 
if,  however,  dyspnoea  is  marked  and  the  abscess  cannot  be  exj)osed,  trache- 
otomy should  first  be  performed,  and  the  abscess  opened  subsequently  or 
allowed  to  rupture  spontaneously.  As  soon  as  the  abscess  has  been  opened, 
the  head  should  be  lowered,  to  favor  the  escape  of  pus  and  prevent  it  from 
being  drawn  into  the  trachea.  Extralaryngeal  abscess  should  be  opened 
by  an  incision  in  the  neck. 

Ulceration  of  the  Larynx. — This  may  result  from  injury,  from 
foreign  bodies,  from  catarrhal,  tuberculous,  or  syphilitic  inflammation,  or 
from  malignant  disease.  The  symptoms  are  practically  those  of  laryngitis, 
and  the  treatment  depends  upon  the  cause  of  the  ulceration.  (See  Laryn- 
gitis.) 

Stricture  of  the  Larynx  or  Trachea.— Diminution  of  the  caliber 
of  the  larynx  or  trachea  from  pressure  from  without  is  described  as  com- 
pression stenosis,  and  may  arise  from  the  pressure  of  tumors  upon  these 
organs,  diminishing  the  caliber  of  the  respiratory  canal,  or  from  deflection 
or  kinking  of  the  trachea  from  the  presence  of  a  growth  in  the  neck  in  close 
relation  with  it.  Tumors  of  the  thyroid  gland,  enlarged  lymijhatic  glands, 
aneurisms,  and  malignant  growths  of  the  neck  often  i^roduce  stricture  or 
narrowing  of  the  larynx  or  trachea  in  this  manner.  Stricture  or  nar- 
rowing of  the  caliber  of  these  organs  from  M'ithin  is  described  as  occlu- 
sion stenosis,  and  may  arise  from  cicatricial  contraction  following  ulcera- 
tion, from  fracture  of  the  cartilages,  from  wounds  of  the  larynx  or  trachea, 
such  as  cutthroat  wounds,  or  from  inflammatory  adhesions  or  tumors  grow- 
ing from  the  mucous  membrane.  Symptoms. — These  usually  develop 
slowly,  and  consist  in  stridulous  respiration  and  more  or  less  dj^s^jncea,  most 
marked  in  inspiration,  varying  with  the  amount  of  narrowing  of  the  caliber 


BENIGN  TUMORS   OF  THE   LARYNX.  815 

of  the  larynx  or  trachea,  and  cyanosis,  if  the  dyspnoea  is  urgent.  The 
greatest  danger  in  these  cases  arises  from  the  occurrence  of  oedema,  wiiich 
may  raiiidly  diminish  the  already  obstructed  breathing-space.  Treatment. 
— If  the  stenosis  is  due  to  pressure  upon  or  to  stricture  of  the  larj'ux,  the 
introduction  of  an  intubation-tube  may  relieve  the  symptoms  promptly,  and 
by  introducing  tubes  of  different  sizes  gradual  dilatation  of  the  stricture 
may  be  accomplished.  If,  however,  the  dyspnoea  is  very  urgent,  trache- 
otomy should  be  performed  to  relieve  the  immediate  danger,  and  dilatation 
of  the  stricture  should  be  practised  later.  When  the  dyspnoea  arises  from 
tracheal  obstruction,  if  it  is  possible  the  trachea  should  be  opened  below  the 
seat  of  obstruction  :  this  may  be  difficult  if  the  cause  of  the  obstruction  is  a 
large  tumor  occupying  the  anterior  portion  of  the  neck,  as  little  space  may 
be  left  between  the  growth  and  the  sternum.  Tracheal  obstruction  due  to 
goitre  may  require  division  of  the  tiimor  in  the  median  line  down  to  the 
trachea  for  its  relief.  When  the  obstruction  is  due  to  deflection  oi-  kinking 
of  the  trachea,  the  operation  may  be  a  most  difficult  one,  as  the  trachea  may 
be  much  displaced  and  its  anatomical  relations  disturbed. 

Tumors  of  the  Larynx. — Laryngeal  tumors  may  be  either  benign 
or  malignant ;  the  great  majority  of  such  tumors  fortunately  belong  to  the 
former  class. 

Benign  Tumors  of  the  Larynx. — These  are  papillomata  and  fibro- 
mata, but  cystic  tumors,  adenomata  and  angiomata,  are  occasionally  observed 
in  this  location.  Papillomata  are  the  tumors  most  commonly  observed,  and 
constitute  fully  two-thirds  of  all  laryngeal  tumors.  They  are  frequently 
observed  in  children,  but  may  also  occur  in  adults  who  use  the  voice  con- 
stantly, such  as  singers  and  piiblic  speakers,  and  are  often  multiple ;  they 
vary  in  size  from  that  of  a  grain  of  wheat  to  that  of  a  mass  which  almost 
fills  the  cavity  of  the  larynx  ;  thej'  also  have  a  marked  tendency  to  recur 
after  removal.  Paiiillary  tumors  generally  have  their  origin  from  the  vocal 
cords.  The  tendency  of  benign  tumors  of  the  larynx  in  adults  to  be  trans- 
formed into  malignant  growths  is  very  marked  ;  papilloma  may  be  trans- 
formed into  epithelioma,  fibroma  into  fibrosarcoma,  and  adenoma  into  car- 
cinoma. 

Symptoms. — Benign  tumors,  as  a  rule,  produce  few  symptoms  other 
than  hoarseness  and  partial  loss  of  voice  until  they  attain  sufficient  size  to 
obstruct  respiration  or  cause  oedema  of  the  adjacent  parts.  In  children  the 
expectoration  of  mucus  tinged  with  blood,  and  hoarseness,  even  if  dyspnoea 
is  not  present,  should  direct  attention  to  the  possible  presence  of  laryngeal 
papilloma ;  j)aiu  is  not  usually  present.  The  definite  diagnosis  of  the  con- 
dition can  be  made  ouly  by  the  laryngoscope,  the  use  of  which  is  often  very 
difficult  in  young  children.  Many  cases  of  papilloma  in  young  children  are 
recognized  only  when  the  dyspnoea  becomes  so  marked  that  tracheotomy  is 
required  to  prevent  suffocation.  Papilloma  in  adults  well  advanced  in  years 
may  be  easily  confounded  with  epithelioma. 

Treatment. — The  intralaryngeal  method,  by  which  the  growth  is  exijosed 
by  the  laryngoscope  and  is  then  removed  by  a  snare  or  larj^ngeal  forcei)S, 
is  one  of  the  best  methods  of  treatment,  but  requires  special  skill  in  the 
use  of  these  instruments,  and  is  often  impossible  in  the  case  of  children, 


816 


MALIGNANT  GROWTHS  OF  THE  LARYNX. 


Fig  703. 


unless  they  have  had  considerable  training  to  accustom  them  to  their  use. 
If  dyspnoea  is  marked,  attempts  to  remove  the  growth  by  the  intralaryngeal 
operation  should  not  be  made,  but  the  trachea  should  be  opened,  and  after- 
wards the  removal  accomplished  by  forceps  or  a  snare.  In  adults  the  intra- 
laryngeal method  can  often  be  employed  with  success.  The  tendency  to 
recurrence  of  the  growths  requires  the  treatment  to  be  prolonged  for  a  con- 
siderable time.  When  the  intralaryngeal  method  cannot  be  employed,  or 
when  it  is  important,  for  the  purpose  of  diagnosis  in  adults  between  a  benign 
and  a  malignant  growth,  to  expose  the  growth,  this  may  be  accomplished 
by  exposing  the  cavity  of  the  larynx  by  incision^  thyrotomy. 

Malignant  Growths  of  the  Larynx.    The  growths  of  this  nature 

occurring  in  the  larynx  are  sarcoma  and  carcinoma.. 

Sarcoma. — -This  is  a  rare  growth  in  the  larynx,  and  the  diagnosis  can 
be  made  only  by  removing  a  portion  of  the  growth  and  examining  it  micro- 
scopically. Sarcoma  of  the  larynx,  if  situated  entirely  within  the  cavity 
of  the  organ,  should  be  treated  by  a  ijreliminary  tracheotomy,  followed  by 
thyrotomy  to  expose  the  growth,  which  should  be  thoroughly  removed. 
The  results  following  the  removal  of  sarcomata  of  the  larynx  are  more 
favorable  than  those  of  epitheliomata. 

Epithelioma. — This  disease  may  originate  in  the  vocal  cords  or  other 
parts  of  the  larynx  (Pigs.  703  and  704),  or  may  involve  the  larynx  by  exten- 
sion from  the  jjharynx,  and 
usually  is  observed  between 
the  ages  of  forty-five  and  sixty- 
five.  The  transformation  of 
benign  growths  into  epithe- 
liomata is  not  uncommon. 

Symptoms. — Epithelioma 
developing  within  the  larynx 
Epithelioma  involving  may  present  the  same  symp- 

one    side    ol    the    larynx,    tojjjg     3,3     a     benign      growth, 
(Cohen.)  j     t 

hoarseness  and  dyspnoea  as 
the  tumor  increases  in  size,  but  soon  neuralgic  pain, 
dysphagia,  and  fixation  and  enlargement  of  the 
neighboring  lymphatic  glands  occur.  The  most 
suggestive  symptoms  of  epithelioma  of  the  larynx 
are  gradually  developing  hoarseness  and  a  tendency 
to  infiltration,  with  fixation  of  the  vocal  cord  on 
the  side  of  the  disease.  Laryngoscopic  examination 
reveals  the  presence  of  an  ulcerating  growth,  and 
if  a  portion  of  this  is  removed  the  characteristic 
structure  of  epithelioma  is  found.  In  cases  where 
the  larynx  is  involved  secondarily  no  difficulty  in 
the  diagnosis  can  occur.  Death  results  from  ex- 
haustion following  the  inability  to  take  sufficient  food,  or  from  obstruction 
to  the  breathing,  or  from  septic  pneumonia. 

Treatment. — In  many  cases  in  which  the  larynx  and  the  surrounding 
parts  are  extensively  involved,  or  in  those  in  which  the  disease  has  spread 


Epithelioma  of  the  lanmx 
( Agnew. ) 


THYEOTOMY. 


817 


to  the  larynx  from  other  parts,  radical  operative  treatment  cannot  be  con- 
sidered. In  such  cases,  as  soon  as  dyspnoea  is  developed,  a  low  tracheotomy 
should  be  performed  and  a  tube  introduced,  which  relieves  the  obstructed 
breathing,  prolongs  life  for  a  considerable  period,  and  renders  the  patient's 
condition  comfortable  until  death  shall  result  fi'om  extension  of  the  disease, 
exhaustion,  or  sei^tic  pneumonia.  Wlien  the  disease  is  confined  to  the 
cavity  of  the  larynx  and  involves  only  one  side  of  the  organ,  and  the 
neighboring  lymphatic  glands  are  not  involved,  the  question  of  complete 
or  partial  excision  of  the  larynx  should  be  considered.  When  the  tumor 
is  so  small  that  the  operation  can  be  limited  to  the  removal  of  one-half  of 
the  larynx,  the  chances  of  recurrence  are  less,  and  the  functional  results 
as  regards  breathing  and  the  preservation  of  the  voice  are  often  satisfactory. 
After  complete  excision  the  patient  may  be  compelled  to  wear  a  tracheal 
tube,  and  often  suffers  much  trouble  from  the  saliva  and  food  passing  into 
the  trachea,  unless  some  of  the  recently  devised  methods  of  shutting  off  the 
communication  of  the  larynx  with  the  pharynx  be  adopted.  Eecurrence 
often  takes  place  in  a  short  time,  but  a  number  of  cases  have  been  reported 
in  which  the  patients  have  lived  for  years  and  were  in  some  instances  able 
to  breathe  comfortably  without  a  tracheotomy-tube.  Sendzick  records  188 
cases  of  complete  extirijation  of  the  larynx  with  mortality  of  44.7  per  cent., 
and  at  the  end  of  three  years  5.85  per  cent,  of  the  cases  were  free  from 
recurrence.  In  85  cases  of  thyrotomy  the  mortality  was  9.8  per  cent.,  and 
8.7  per  cent,  of  the  cases  were  free  from  recurrence  at  the  end  of  three  years. 
Thyrotomy. — A  preliminary  tracheotomy  should  first  be  performed, 
and  the  trachea  above  the  tube  should  be  plugged  with  gauze,  either 
through  the  tracheal  wound  or  that  in  the  larynx,  or  a  tampon  tracheotomy- 
tube  should  be  employed  to  prevent  the  entrance  of  blood  into  the  trachea. 
This  consists  of  a  tracheotomy-tube  whose  lower  portion  is  surrounded 
by  a  sac  of  india-rubber,  which  can  be  inflated  when  the  tube  is  in  place, 


I'amiK^n  tracheotomy-tube. 


and  thus  occludes  the  trachea  above  the  lower  opening  of  the  tube  and 
prevents  the  entrance  of  blood  fi-om  above.  (Fig.  705.)  The  thyroid  and 
cricoid  cartilages  should  be  exposed  by  an  incision  in  the  median  line  of 
the  neck,  and  the  thyroid  divided  in  the  median  line  from  its  lowest  por- 


818  EXCISION   OF  THE  LARYNX. 

tion  to  within  a  few  lines  of  its  upper  limit,  so  that  the  alse  can  be  held 
apart  by  retractors.  It  is  often  necessary  to  divide  the  crico-thyroid  mem- 
brane and  the  cricoid  cartilage  to  obtain  free  exposure  of  the  cavity  of  the 
larynx.  When  this  has  been  accomplished,  the  growth  may  be  removed  by 
scissors  or  a  curette,  and  its  base  touched  with  chromic  acid  or  the  actual 
cautery  ;  care  should  be  taken  to  remove  the  growth  thoroughly,  as  it  has 
a  great  tendency  to  recur.  After  removal  of  the  growth  the  edges  of  the 
cartilages  should  be  brought  together  accurately  by  fine  catgut  sutures  and 
the  external  wound  should  be  closed.  The  tracheotomy  tube  should  be 
worn  for  a  week  or  ten  days,  and  as  the  tracheotomy-wound  closes  the 
respiratory  function  is  gradually  restored  through  the  larynx.  Thyrotomy 
may  also  be  employed  to  remoA'e  necrosed  portions  of  the  cartilages,  or  in 
cases  of  cicatricial  stenosis  following  syphilitic  or  diphtheritic  ulceration, 
when  it  becomes  necessary  to  remove  cicatricial  tissue  to  increase  the 
caliber  of  the  larynx.  The  operation  of  thyrotomy  is  not  attended  with 
much  risk,  especially  if  a  preliminary  tracheotomy  is  done,  and,  if  the 
cartilages  are  accurately  brought  together  by  sutures,  prompt  healing 
results  with  little  change  in  the  voice. 

Excision  of  the  Larynx. — Excision  of  the  larynx,  partial  or  com- 
plete, is  a  most  serious  operation.  Death  may  result  from  the  operation 
itself,  from  shock  or  hemorrhage,  or  later  from  bronchoj)neumonia,  from 
purulent  bronchitis,  from  the  passage  of  food  or  blood  into  the  trachea,  or 
from  septic  cellulitis  of  the  neck  or  the  anterior  mediastinum.  Eecurrence 
of  the  disease  has  commonly  taken  place  in  a  short  time,  in  spite  of  the 
complete  removal  of  the  growth,  so  that  the  advisability  of  the  operation 
should  always  be  carefully  considered. 

A  low  tracheotomy  should  be  done  some  days  before  the  operation  upon 
the  larynx  is  undertaken.  The  cavity  of  the  trachea  above  the  tube  should 
be  packed  with  iodoform  gauze,  or  a  tampon  tracheotomy-tube  should  be 
introduced.  A  long  incision  is  made  in  the  median  line  of  the  neck,  and 
the  larynx  freely  exposed  by  blunt  dissection ;  the  thyroid  cartilage  is 
then  split  in  the  median  line  and  the  cavity  of  the  larynx  exposed.  If  the 
disease  is  confined  to  one  side  of  the  larynx,  this  should  be  removed ;  if 
the  whole  larynx  is  implicated,  it  should  be  carefully  dissected  out,  bleed- 
ing Ijeing  controlled  as  the  dissection  is  made.  When  the  entire  larynx  is 
removed,  the  opening  in  the  pharynx  should  be  closed  by  sutures,  and  the 
upper  end  of  the  trachea  secured  in  the  lower  angle  of  the  wound,  thus 
completely  shutting  off  the  latter  from  communication  with  the  pharynx. 
The  wound  should  be  lightly  packed  with  iodoform  gauze,  and  at  the  end 
of  a  few  days  the  packing  should  be  removed  and  replaced  by  a  fresh  one. 
The  wound  should  be  dressed  daily,  and  great  care  taken  to  keep  it  aseptic. 
The  ijatient  should  be  fed  for  a  few  days  by  means  of  au  oesophageal  tube 
or  by  nutrient  enemata.  After  partial  removal  of  the  larynx,  the  soft 
parts  and  the  skin  are  closed  by  sutures,  and  after  healing  has  occurred 
the  tracheotomy-tube  may  be  removed,  and,  if  breathing  is  satisfactorily 
carried  on  through  the  larynx,  the  tube  need  not  be  replaced  unless  subse- 
quent contraction  makes  its  use  necessary.  Aiter  complete  removal  of  the 
larynx,  the  tracheotomy-tube  or  some  form  of  artificial  larynx  may  have  to 


TUMORS   OF  THE  TRACHEA.  819 

be  worn  contiuuously,  but  in  some  cases  even  these  appliances  may  not  be 
required. 

Thyrotomy  with  excision  of  the  growth,  following  a  preliminary  trache- 
otomy, is  considered  by  some  surgeons  a  more  satisfactory  procedure  than 
excision  of  the  larynx.  When  the  growth  is  exposed  it  is  carefully  removed 
by  dissecting  it  from  the  cartilaginous  walls  of  the  larynx,  and  the  car- 
tilages are  not  removed,  as  they  are  usually  not  involved  until  late  in  the 
disease.  The  wound  is  closed  with  sutures,  and  the  tracheotomy-tube 
should  be  worn  for  some  weeks  until  the  union  in  the  laryngeal  wound  is 
complete.    The  voice  in  these  cases  may  be  preserved  to  a  certain  extent. 

Tumors  of  the  Trachea. — The  same  varieties  of  tumors  observed  in 
the  larynx  may  be  found  in  the  trachea  ;  papillomata  and  epitheliomata  are 
those  most  commonly  observed.  Papillomata  are  usually  pedunculated, 
while  epitheliomata  arise  from  the  trachea  by  a  broad  base.  They  are  gen- 
erally situated  at  the  upper  portion  of  the  trachea,  and  are  most  common  in 
male  adults.  The  principal  symptom  of  tracheal  tumor  is  dy.spncea  without 
marked  affection  of  the  voice.  In  all  cases  a  careful  laryngoscoi^ic  exami- 
nation should  be  made  to  prove  that  the  growth  does  not  occupy  the  larynx, 
and  at  the  same  time  in  many  cases  the  tumor  can  be  seen  in  the  trachea. 
Treatment. — This  consists  in  performing  tracheotomy  as  soon  as  the  posi- 
tion of  the  tumor  can  be  located  or  dyspnoea  becomes  marked.  The 
tracheal  wound  should  be  dilated,  and  in  many  cases  the  growtli  can  be 
removed,  when  its  base  should  be  touched  with  chromic  acid  or  the  actual 
cautery.  The  tiucheotomy-tube  should  be  worn  for  some  time,  until  it  is 
evident  that  there  is  no  tendency  for  the  recurrence  of  the  growth,  and 
should  then  be  dispensed  with. 

Tracheocele. — This  rare  condition  consists  of  a  hernia  of  the  mucous 
membrane  of  the  trachea  between  the  tracheal  rings,  and  may  arise  from  a 
congenital  defect  in  the  trachea,  or  may  follow  subcutaneous  rupture  of  the 
trachea  from  contusion  or  incomplete  wound  of  the  organ.  The  tumor  may 
occupy  the  anterior  or  the  lateral  asi^ect  of  the  trachea,  and  vary  in  size 
from  that  of  a.  bean  to  that  of  an  egg.  The  most  marked  symptom  is  the 
j)resence  of  a  soft  tumor  which  increases  in  size  when  the  patient  makes 
forced  expiration  with  the  mouth  and  nose  closed,  and  can  be  diminished  in 
size  by  manijoulation  ;  a  certain  amount  of  dyspnoea  and  change  in  the  voice 
may  be  present.  Treatment. — If  tbe  tumor  is  small  and  is  attended  by  no 
discomfort,  no  special  treatment  is  required.  If,  however,  it  is  large  and 
produces  discomfort  or  marked  change  in  the  voice,  pressure  should  be 
applied  by  means  of  a  compress  and  bandage,  and  if  this  is  not  followed  by 
good  results  the  tumor  should  be  exposed  and  excised,  and  the  edges  of  the 
tracheal  wound  and  the  external  wound  closed  by  sutures. 

Foreign  Bodies  in  the  Air-Passages. — The  entrance  of  a  foreign 
body  into  the  larynx  or  trachea  is  an  accident  of  frequent  occurrence,  and 
is  most  commonly  observed  in  children.  A  body  held  in  the  mouth  may 
suddenly  be  drawn  into  the  larynx  by  an  inspiratory  act,  when  it  usually 
excites  violent  coughing  and  is  soon  expelled,  or  it  may  pass  below  the  cords 
and  enter  the  trachea  or  a  bronchus.  A  gTcat  variety  of  objects  have 
entered  the  larynx  and  trachea  and  have  been  subsequently  expelled  or 


820 


FOREIGN  BODY   IN  THE  BRONCHUS. 


'".M 


removed  by  operation, — beads,  pebbles,  beans,  pins,  needles,  teeth,  coins, 
pencils  (Fig.  706),  particles  of  food,  seeds  of  fruit,  grains  of  corn,  nuts, 
toys,  etc.  In  Weist's  collection  of  cases  of  foreign  bodies  in  American  cases 
a  grain  of  corn  was  the  body  most  frequently  noted. 

Symptoms. — These  are  spasmodic  cough,  spasm  of  the  larynx,  and  a 
feeling  of  suffocation.  If  the  body  is  a  large  one,  or  is  so  situated  that  it 
obstructs  the  admission  of  air,  urgent  dyspnoea  and 
cyanosis  soon  develop,  and  if  relief  is  not  afforded 
by  operation  the  patient  perishes  rapidly  from 
suffocation.  If  dangerous  symptoms  do  not  develop 
immediately  upon  the  introduction  of  the  foreign 
body,  the  patient  may  be  subject  to  recurrent 
attacks  of  suffocation  if  the  body  is  a  movable  one 
and  is  carried  up  against  or  lodged  in  the  glottis. 
Profuse  muco-pui'ulent  expectoration  may  occur  if 
the  body  has  remained  in  the  trachea  or  larynx 
for  some  time,  and  is  accompanied  by  loud  wheezing 
and  r^les  heard  over  the  trachea.  The  body,  if  a 
movable  one,  may  become  impacted  in  a  bronchus 
or  in  the  glottis,  causing  sudden  death.  With  an 
impacted  foreign  body  the  greatest  respiratory  diffi- 
culty is  observed  in  inspiration,  while  if  the  body 
is  movable  the  difficulty  is  most  marked  in  eocpira- 
tion.  The  pressure  of  enlarged  or  caseating  lym- 
phatic glands  of  the  mediastinum  upon  the  trachea 
or  upon  a  bi-onohus  may  produce  symptoms  resem- 
bling those  caused  by  an  impacted  foreign  body, 
and  the  possibility  of  this  condition  should  not  be 
lost  sight  of  when  the  history  of  a  foreign  body  entering  the  air-passages 
is  indefinite. 

Foreign  Body  in  the  Bronchus. — A  foreign  body  is  more  likely  to  pass 
into  the  right  bronchus  than  into  the  left,  as  the  septum  at  the  bifurcation  is  to 
the  left  of  the  middle  line.  If  the  bronchus  is  only  i^artially  occluded,  there 
wUl  be  noticed  diminished  expansion  of  the  lung  on  the  affected  side,  and  a 
loud  murmur  at  the  seat  of  obstruction  may  be  detected  upon  auscultation. 
If  the  bronchus  is  completely  closed  by  the  foreign  body,  resonance  on 
percussion  is  at  first  present,  but  collapse  of  the  lung,  with  retraction  of  the 
chest,  soon  appears.  If  the  body  is  impacted  in  one  of  the  divisions  of  the 
primary  bronchus,  the  respiratory  action  of  a  limited  area  of  the  lung  may 
be  arrested.  A  body  impacted  in  a  bron- 
chus may  remain  in  place  for  some  time 
and  then  become  suddenly  loosened  by  an 
attack  of  coughing  and  be  arrested  at  the 
glottis,  producing  death  by  suffocation,  or 
may  be  expelled  through  the  larynx.  The  pin  shown  in  Pig.  707  was  im- 
pacted in  the  right  bronchus  for  twenty -three  months,  and  was  then  coughed 
up  and  expelled,  the  patient  making  a  good  recovery.  The  termination  of 
all  cases  is  not  so  satisfactory  as  this,  for  the  body  may  set  up  inflammation, 


Lead-pencil  impacted  iu  larynx 
and  trachea.    (Cattell.) 


Fig.  707. 


Pin  which  was  impacted  in  right  bronchus. 


TRACHEOTOMY.  821 

abscess  or  gangrene  of  the  lung  may  occur,  and  death  result  from  septic 
infection  or  exhaustion. 

Treatment. — When  the  symptoms  are  urgent,  laryngotomy  or  trache- 
otomy should  be  immediately  performed.  The  foreign  body,  if  it  be  movable 
in  the  trachea,  is  often  expelled  by  a  violent  expii-atory  effort  as  soon  as  the 
trachea  is  opened,  or  may  be  removed  from  the  trachea  or  larynx  with  forceps. 
When  it  has  been  in  the  air-passages  for  but  a  short  time  and  no  inflammatory 
symptoms  have  developed,  the  wound  in  the  trachea  should  be  closed  by 
sutures.  If,  on  the  other  hand,  the  body  has  remained  for  some  days  and  has 
set  up  inflammation  of  these  organs,  as  evidenced  by  the  presence  of  rales 
and  the  expectoration  of  muco-purulent  discharge,  after  the  body  has  been 
removed  a  tracheotomy-tube  should  be  introduced  and  worn  for  some  days, 
until  inflammation  of  the  jjarts  has  subsided.  If  the  foreign  body  cannot  be 
located,  a  tracheotomy-tube  should  be  introduced,  and  attempts  at  removal 
of  the  body  made  later.  Inversion  of  the  patient,  with  slapping  of  the  back 
and  chest,  which  is  sometimes  recommended,  is  an  unsafe  procedure,  unless 
the  trachea  or  larynx  has  been  previoiisly  opened.  In  cases  in  which  a 
foreign  body  has  entered  the  air-jjassages,  after  the  first  symptoms  of  its 
presence  have  passed  off  and  if  the  patient  presents  no  urgent  symptoms, 
careful  laryngoscopic  examination  may  reveal  the  location  of  the  body,  and 
it  may  be  removed  with  laryngeal  forcejis  ;  this  method  of  treatment  may  be 
employed  in  adults,  but  is  rarely  possible  in  children. 

In  the  case  of  a  foreign  body  lodged  in  the  bronchus,  a  low  tracheotomy 
should  be  performed,  and  by  means  of  delicate  curved  forceps,  or  a  short 
silver  probe  whose  extremity  is  bent  to  form  a  hook,  the  body  may  be 
dislodged  and  removed.  If  it  cannot  be  removed  in  this  way,  inversion  of 
the  patient,  with  slapping  of  the  chest,  may  be  practised.  If  all  these  pro- 
cedures are  unsuccessful,  the  tracheotomy-tube  should  be  worn  to  keep  the 
wound  open,  and  after  some  time  the  body  may  become  loose  and  pass  into 
the  trachea,  whfen  it  can  be  removed  by  taking  out  the  tracheotomy-tube 
and  dilating  the  wound.  Where  a  foreign  body  is  lodged  in  the  bronchus 
its  removal  by  external  operation  is  possible.    (See  Posterior  Thoracotomy.) 

Tracheotomy. — This  operation  consists  in  dividing  the  tissues  over 
the  trachea  in  the  median  line  of  the  neck,  and,  after  the  trachea  has  been 
exposed,  opening  it  by  dividing  two  or  three  of  the  tracheal  rings.  It  may 
be  required  to  relieve  the  dyspncea  dependent  uj)on  diphtheritic  laryngitis, 
growths  in  the  larynx  or  trachea,  growths  external  to  these  organs,  causing 
pressure  upon  them,  and  oedema  of  the  mucous  membrane  of  the  larynx  or 
trachea  from  inflammation,  from  burns  or  scalds,  or  from  the  inhalation  of 
irritating  gases,  or  the  swallowing  of  corrosive  liquids.  The  operation  may 
also  be  i-equired  for  the  removal  of  foreign  bodies  from  the  larynx  or  trachea, 
or  fi-om  the  bronchi,  as  well  as  for  the  relief  of  dyspnoea  due  to  their 
presence.  It  is  sometimes  demanded  in  contusion,  laceration,  or  fracture  of 
the  larynx  or  trachea,  and  occasionally  in  spasm  of  the  glottis,  and  in 
glossitis,  to  overcome  the  mechanical  obstruction  wliich  j)revents  the 
entrance  of  air  into  the  air-passages. 

The  ease  with  which  the  trachea  is  exposed  and  opened  varies  much  in 
diffei'ent  cases ;  as  a  rule,  it  is  a  much  simpler  operation  in  adults  than  in 

53 


822 


TRACHEOTOMY. 


cliildren.  The  most  difficult  tracheotomies  in  adults  are  those  in  which  the 
operation  is  done  for  stenosis  of  the  trachea  or  larynx  produced  by  tumors 
of  the  neck.  In  such  cases  a  very  limited  portion  of  the  trachea  may  be 
accessible  for  operation,  or  it  may  be  so  much  displaced  by  the  growth  that 
its  anatomical  relations  are  greatly  disturbed.  In  children  the  shortness  of 
the  neck  and  the  abundance  of  adipose  tissue  cause  the  trachea  to  be  deeply 
seated,  while  the  relatively  greater  size  of  the  thyroid  gland  and  the  presence 
of  the  thymus  body  render  the  trachea  difficult  to  expose  and  open.  After 
the  trachea  has  been  opened  a  tracheotomy-tube  is  usually  introduced. 

Tracheotomy-Tubes. — These  are  made  of  silver,  aluminum,  and  hard 
rubber  ;  the  most  satisfactory  tube  is  a  silver  quarter-circle  tube,  without  a 
fenestrum,  and  with  a  movable  collar  (Fig.  708)  which  should  be  provided 


Fig.  708. 


Fig.  709. 


Tracheotomy-tube. 


Traeheotomy-tulie  with  fenestrated  guide. 


with  a  fenestrated  guide  to  facilitate  its  introductiou.     (Fig.  709.)    The 
tracheotomy-tube  is  held  in  position  after  it  is  introduced  by  means  of  tapes 

attached  to  the  shield  of  the  tube 
Fig.  710.  and   tied   around  the  neck.      The 

size  of  the  tube  to  be  employed 
varies  with  the  age  of  the  patient. 
Position  of  the  Patient  for 
Tracheotomy. — The  most  satis- 
factory position  is  obtained  by  lay- 
ing the  patient  upon  his  back  on 
a  firm  table,  and  placing  under  the 
shouldei'S  a  round  cushion,  or  an 
empty  wine-bottle,  or  a  roller-pin 
wrapped  in  a  towel.     (Fig.  710.) 
In  cases  of  great  emergency  the 
trachea    can    be    rendered    more 
superficial  by  allowing  the  head  to 
drop  over  the  edge  of  a  table  or 
the  end  of  a  lounge. 
The  Use  of  an  Anaesthetic  in  Tracheotomy. — As  a  rule,  it  is  better 
not  to  administer  an  anesthetic  in  j)erforming  this  operation,  as  little  ijain  is 
experienced,  in  cases  in  which  the  dyspnoea  is  well  marked,  after  the  incision 


Position  of  patient  for  tracheotomy. 


INDICATIONS  FOR  TRACHEOTOMY.  823 

in  the  skin  lias  been  made.  "We  object  to  the  use  of  an  auresthetic  from  the 
fact  that  we  have  seen  the  dyspnoea,  which  was  not  lu-gent  before  the  use  of 
the  anaesthetic,  suddenly,  under  its  employment,  become  alarming,  or  the 
breathing  cease  altogether,  so  that  the  trachea  had  to  be  opened  before  it 
was  thoi'oughly  exposed,  which  is  a  procedure  always  attended  with  risk. 
In  adults  we  often  employ  a  two  per  cent,  solution  of  cocaine  hypodermi- 
cally,  but  in  children  its  use  is  not  accompanied  by  good  results,  iis  their 
struggles  are  probably  caused  as  much  by  restraint  and  the  terror  produced 
by  the  manipulations  as  by  actual  pain. 

Indications  for  Tracheotomy. — The  prominent  symptom  calling  for 
tracheotomy  is  obstructive  dyspnoea,  characterized  by  sujjpression  of  the 
voice,  great  difficulty  in  respiration,  usually  in  inspiration,  lividity  of  the 
lips,  depression  of  the  suprasternal  and  supraclavicular  spaces,  sinking  in 
of  the  lower  part  of  the  chest,  inability  to  breathe  in  the  recumbent  pos- 
ture, and  great  restlessness.  The  mistake  should  not  be  made  of  confound- 
ing labored  breathing,  which  is  always  present  in  cases  where  there  exists 
mechanical  obstruction  to  the  entrance  of  air  into  the  lungs,  with  frequent 
breathing,  which  depends  upon  diminished  air-capacity  of  the  lungs. 

Operation. — The  trachea  may  be  opened  above  the  isthmus  of  the 
thyroid  gland  or  below  it,  and  these  operations  constitute  respectively  the 
high  and  the  low  operation.  The  high  operation  is  generally  selected, 
becavrse  at  this  point  the  trachea  is  more  superficial,  and  is  easier  to 
expose ;  it  should  therefore  be  ijreferred  in  the  case  of  young  children, 
when  the  dyspncea  is  urgent  and  time  is  an  important  element.  The  low 
operation  is  the  one  in  which  the  trachea  is  opened  below  the  isthmus  of  the 
thyroid  gland.  In  this  region  the  trachea  is  more  difficult  to  expose,  by 
reason  of  its  i-elatively  greater  dej^th,  the  large  size  and  number  of  the  veins 
covering  it,  and  its  proximity  to  the  large  veins  and  arterial  trunks  at  the 
root  of  the  neck.  The  low  operation  should  be  preferred  for  the  removal  of 
a  foreign  body  impacted  in  a  bronchus,  or  when  tracheotomy  is  required 
to  relieve  dyspncea  caused  by  a  tumor  of  the  thyroid  gland  or  other  growth 
pressing  upon  the  upper  portion  of  the  trachea  or  the  larynx. 

The  patient  being  placed  in  position,  shown  in  Fig  710,  an  assistant  liolds 
the  head  firmly,  and  an  incision  is  made  through  the  skin  in  the  median 
line  of  the  neck,  from  one  and  a  half  to  two  inches  in  length,  the  position 
of  the  cricoid  cartilage  being  the  middle  point.  Having  divided  the  skin, 
any  large  veins  lying  in  the  superficial  fascia  should  be  displaced  and  the 
fascia  divided  between  them  upon  a  director.  The  surgeon  should  keep  his 
incisions  strictly  in  the  median  line  of  the  neck,  for  this  is  the  line  of  safety, 
and  should  be  careful,  as  the  wound  increases  in  depth,  not  to  make  the 
incisions  too  short,  so  that  the  wound  becomes  fnnnel-shaped.  "When  the 
deep  fascia  is  exf)osed  it  should  be  picked  up  and  divided  upon  a  director, 
and  any  enlarged  veins  in  the  line  of  the  wound  displaced  or  ligated  on 
each  side  and  divided  between  the  ligatures.  The  operator  next  looks  for 
the  intermuscular  space  between  the  sterno-hyoid  and  sterno-thyroid  mus- 
cles, which  can  generally  be  found  without  difficnltj^,  and  the  muscles  are 
separated  with  the  handle  of  a  knife  or  with  a  director,  when  the  isthmus 
of  the  thyroid  gland  will  be  exposed.     The  muscles  should  be  held  iiside  by 


824  AFTER-TREATMENT  OF  TRACHEOTOMY. 

retractors  placed  on  eacli  side,  care  being  taken  that  the  movable  trachea  is 
not  included  in  the  grasp  of  the  retractor,  which  would  draw  it  out  of  its 
normal  position.  This  accident  has  occurred,  and  the  cervical  vertebrae 
have  been  exjjosed  in  searching  for  the  trachea.  The  thyroid  isthmus  is 
next  drawn  upward  or  downward,  according  as  the  surgeon  desires  to  open 
the  trachea  below  or  above  this  body,  and  the  trachea,  yellowish  white  in 
appearance,  covered  by  the  tracheal  faspia,  will  be  exposed.  This  fascia 
should  next  be  thoroughly  broken  up  with  a  director  or  the  handle  of  the 
knife,  so  as  to  bare  the  trachea,  and  in  doing  this  the  operator  can  feel  the 
fascia  crepitate  under  the  finger  from  the  presence  of  the  air  drawn  in  with 
inspiration. 

The  operator  should  examine  the  wound  to  see  that  it  is  free  from  hem- 
orrhage, and  replace  the  retractors,  so  as  to  expose  as  large  a  portion  as 
possible  of  the  trachea.  The  trachea  is  next  fixed  with  a  tenaculum,  intro- 
duced a  little  to  one  side  of  the  median  line,  and  an  incision  is  made  into  it 
with  a  narrow  knife  from  below  upward,  from  one-half  to  three-fourths  of 
an  inch  in  length,  care  being  taken  that  this  incision  is  in  the  median  line 
of  the  trachea,  for  if  it  be  opened  by  a, lateral  incision  the  wound  will  not 
heal  so  promptly,  and  the  tracheotomy-tube  will  not  fit  well.  If  the  trachea 
be  deeply  seated,  after  fixing  it  with  a  tenaculum  it  may  be  lifted  slightly 
from  its  bed,  thereby  making  it  more  superficial  in  the  wound. 

As  soon  as  the  incision  is  made  in  the  trachea  there  is  a  gush  of  air  from 
the  wound,  mixed  with  blood  or  membrane  ;  this  should  be  wiped  away  with 
a  sponge,  a  tracheal  dilator  introduced,  and  the  trachea  cleared  of  mem- 
brane, if  it  is  present  in  the  region  of  the  wound,  with  a  sterilized  feather  or 
with  forceps ;  the  tracheotomy-tube  is  next  introduced,  and  is  secured  in 
position  by  tapes  tied  around  the  neck.  If'  a  tracheotomy-tube  is  not  at 
hand,  the  tracheal  wound  may  be  kept  open  by  suturing  the  edge  of  the 
trachea  on  each  side  to  the  skin.  It  is  not  unusual  after  the  trachea  has 
been  opened  to  have  a  sudden  arrest  of  resi^iration ;  this,  although  alarm- 
ing, is  usually  only  momentary.  If  the  patient's  face  and  chest  be  slapped 
with  a  wet  towel,  or  if  artificial  respiration  be  employed,  normal  respiratory 
movements  will  soon  be  re-established.  ,A  sudden  arrest  of  respiration 
.during  the  operation  is  a  most  dangerous  symptom,  calling  for  prompt 
action  on  the  part  of  the  oijerator.  The  surgeon's  duty  under  such  circum- 
stances is  to  open  the  trachea  as  rapidly  as  possible,  introduce  a  tracheal 
dilator  or  tube,  and  make  artificial  respiration. 

After-Treatment. — If  the  operation  has  been  done  for  an  inflammatory 
condition  of  the  larynx  or  trachea  it  is  well  to  have  the  patient  kept  in  a 
moist  atmosphere.  This  may  be  accomplished  by  having  a  steam  spray,  or 
a  spray  composed  of  the  soda  solution  given  below,  constantly  playing  in 
the  room,  or  a  croup  tent  may  be  formed  around  the  bed  or  cot  by  securing 
a  wooden  framework  to  the  cot  and  covering  this  with  sheets ;  under  this 
tent  the  use  of  a  small  steam  spray  will  keep  the  air  in  a  moist  condition. 

Care  of  the  Tracheotomy-Tube. — This  is  a  matter  of  great  impor- 
tance ;  the  inner  tube  should  be  removed  at  short  intervals,  washed,  and 
replaced ;  a  moistened  sterilized  feather  should  occasionally  be  passed 
through  the  tube  into  the  trachea  to  withdraw  any  mucus  or  membrane 


COMPLICATIONS  AFTER  TRACHEOTOMY. 


825 


Fig.  711. 


which  is  present.  In  these  cases  the  use  of  a  spray  of  steam,  or  a  spray 
composed  of  carbonate  of  sodium,  3i  to  3ii ;  glycerin,  gi ;  water  gvi,  ap- 
plied by  means  of  a  steam  atomizer,  the  spray  being  directed  over  the  open- 
ing of  the  tube,  will  be  found  most  satisfactory  in  softening  the  membrane 
and  thus  facilitating  its  exi^ulsion  through  the  tube.  The  tracheotomy- 
tube  is  usually  allowed  to  remain  in  the  trachea  for  from  five  to  ten  days, 
being  changed  at  intervals  of  two  or  three  days,  and  its  permanent  removal 
is  indicated  as  soon  as  the  patient  is  able  to  breathe  through  the  larynx  with 
the  wound  in  the  trachea  closed.  After  its  removal  the  wound  rapidly 
diminishes  in  size ;  for  a  few  days  air  escapes  from  it  upon  coughing,  but 
the  wound  is  usually  permanently  healed  at  the  end  of  a  week. 

Complications  after  Tracheotomy. — Diphtheritic  Infection  of 
the  Wound. — This  complication  is  occasionally  seen  after  tracheotomy  for 
diphtheritic  laryngitis,  and  is  one  which  is  grave,  although  not  necessarily 
fatal.  The  treatment  consists  in  the  local  application  of  peroxide  of  hydro- 
gen and  the  subsequent  curetting  of  the  surface  of  the  wound  and  swabbing 
it  with  a  solution  of  1  to  500  bichloride  of  mercury.  Secondary  Hemor- 
rhage.— This  is  a  rare  complication,  which  may  arise  from  septic  infection 
of  the  wound  or  from  perforation  of  the  trachea  by  a  badly  fitting  trache- 
otomy-tube, causing  erosion  of  the  great  vessels  of  the  neck.  Its  treatment 
consists  in  ligating  the  bleeding  vessels.  Emphysema. — This  affection  is 
occasionally  met  with  after  tracheotomy,  the  air  being  sucked  into  the 
tracheal  fascia  and  diffused  through  the 
tissues.  It  is  more  common  after  trache- 
otomy in  which  the  incision  in  the  tra- 
chea is  not  in  the  median  line  and  does 
not  correspond  with  the  wound  in  the 
soft  parts  in  trout  of  the  trachea.  A 
moderate  amount  of  emphysema  in  the 
immediate  neighborhood  of  the  wound 
is  not  uncommon,  but  sometimes  the 
condition  is  developed  to  such  an  extent 
that  the  cellular  tissues  of  the  neck,  face, 
arms,  chest,  and  abdomen  become  greatly 
distended  with  air.  The  most  fatal  form 
of  emphysema  after  tracheotomy  is  that 
of  the  connective  tissue  of  the  medias- 
tinum, constituting  what  is  known  as 
mediastinal  emphysema.  Emphysema  of 
a  moderate  exteirt  seems  to  do  no  harm, 
as  the  air  is  quickly  absorbed  ;  but  when 
it  becomes  general  and  the  mediastinum 
is  involved,  marked  dyspnoea  is  apt  to 
develop,  and  the  prognosis  is  extremely 
grave.  Tracheal  Granulations. — Granulations  about  the  tracheal  wound 
occur  in  certain  cases  where  it-is  necessary  to  wear  the  tube  for  a  considerable 
time.  The  jaresence  of  granulations  may  be  suspected  if  the  patient  coughs 
up  blood-stained  secretions  after  the  tube  has  been  changed.     Withdrawal 


Granulations  in  the  trachea  after  tracheotomy. 
(Parker.) 


826  COMPLICATIONS  AFTER  TRACHEOTOMY. 

of  the  tube  aud  inspection  of  the  wound  will  often  disclose  the  presence  of 
granulations  attached  to  the  edges  of  the  tracheal  wound  or  growing  from 
the  trachea  in  the  region  of  the  wound.  (Fig.  711.)  The  treatment  con- 
sists in  the  removal  of  the  tube  and  in  the  application  of  a  thirty-grain 
solution,  or  the  solid  stick  of  nitrate  of  silver,  or  the  granulations  may  be 
removed  with  forceps  and  scissors.  Ulceration. — This  may  arise  from 
improperly  shaped  or  badly  fitting  tracheotomy-tubes  ;  it  may  be  suspected 
when  the  tube,  if  a  silver  one,  becomes  blackened  and  there  are  fetor  of  the 
breath  and  expectoration  of  purulent  and  blood-stained  discharge.  The 
treatment  consists  in  removing  the  badly  fitting  tube  and  replacing  it  by  a 
proper  one,  and  applying  to  the  ulcerated  surface  a  ten-grain  solution  of 
nitrate  of  silver. 

Difficulty  in  the  Permanent  Removal  of  the  Tracheotomy-Tube. 
— This  is  due  in  some  cases  to  mechanical  causes,  such  as  the  growth  of 
granulations  in  the  tracheal  wound,  or  in  the  larynx,  inflammatory  hyper- 
trophy of  the  vocal  cords,  adhesion  between  the  cords,  paralysis  of  the 
posterior  cricoarytenoid  muscles,  spasm  of  the  glottis,  or  stenosis  of  the 
trachea  above  the  seat  of  operation.  In  other  cases  the  operation  seems 
to  produce  irritability  and  disordered  action  of  the  muscles  of  the  glottis, 
interrupting  their  usual  rhythm,  the  patient  being  somewhat  in  the  position 
of  one  with  paralysis  of  the  vocal  cords.  In  many  cases  mental  agitation 
plays  an  imj)ortant  part  in  preventing  the  removal  of  the  tube.  We  have 
often  seen  children  who  could  breathe  comfortably  through  the  larynx  when 
the  tube  was  plugged,  who,  when  it  had  been  removed  and  the  tracheal 
wound  had  been  closed  with  a  pad  or  an  obturator,  exhibited  great  mental 
agitation,  and  developed  such  alarming  symptoms  of  dyspnoea  that  the  rein- 
troduction  of  the  tube  became  necessary.  The  permanent  removal  of  the 
tracheotomy-tube,  even  when  much  delayed,  should  not  be  despaired  of. 
The  tube  should  be  removed  at  intei'vals  and  replaced  as  soon  as  symijtoms 
of  dyspnoea  appear  ;  a  most  satisfactory  method  of  removing  the  tube  in 
these  cases  consists  in  introducing  an  intubation-tube  into  the  larynx,  which 
is  worn  until  the  wound  in  the  trachea  has  healed. 

Laryngotomy. — In  this  operation  an  opening  is  made  into  the  larynx 
through  the  crico-thyroid  membrane.  It  is  a  simple  operation,  and  can 
therefore  be  performed  much  more  rapidly  and  safely  in  urgent  cases  than 
tracheotomy.  The  patient  being  placed  in  the  recumbent  posture,  with  the 
shoulders  slightly  elevated  and  the  head  thrown  back  to  make  the  neck  as 
X^rominent  as  possible,  the  surgeon  feels  for  the  prominence  of  the  thyroid 
cartilage,  and,  steadying  the  larynx  with  the  finger  and  thumb  of  the  left 
hand,  he  makes  an  incision  in  the  median  line  from  the  centre  of  the  thyroid 
cartilage,  extending  downward  for  an  inch  or  an  inch  and  a  half;  the  skin 
and  superficial  fascia  being  divided,  tlie  fascia  between  the  sterno-hyoid 
muscles  and  the  areolar  tissues  should  be  severed,  and  the  cricothyroid 
membrane  is  exposed.  The  knife  is  then  passed  transversely  through  the 
membrane  into  the  larynx,  care  being  taken  that  both  this  membrane  and 
the  mucous  membrane  which  covers  its  inner  surface  are  divided  at  the  same 
time.  As  soon  as  the  knife  enters  the  cavity  of  the  larynx,  blood  and  mucus 
will  be  forcibly  expelled.    The  only  bleeding  which  is  likely  to  occur  is  from 


INTUBATION  OF  THE  LARYNX.  827 

the  crico-thyroid  arteries  or  veins ;  if  these  cannot  be  avoided,  and  are 
divided,  they  should  be  temporarily  secured  by  haemostatic  forceps  or 
ligated,  and,  if  the  case  is  not  extremely  urgent,  all  hemorrhage  should  be 
arrested  before  the  crico-thyroid  membrane  is  incised.  If  the  operation  is 
done  for  a  foreign  body  impacted  in  the  larynx,  the  wound  should  be  dilated, 
and  the  foreign  body  removed  with  forceps ;  if  done  for  the  relief  of  an 
inflammatory  condition  of  the  larynx,  it  may  be  necessary  to  introduce  a 
tube  into  the  wound  for  a  few  days.  The  tube  employed  in  laryngotomy 
differs  from  the  ordinary  tracheotomy-tube  in  being  slightly  flattened.  The 
after-treatment  of  cases  of  laryngotomy  is  similar  to  that  of  cases  of 
tracheotomy. 

LaryngO- Tracheotomy. — This  operation  consists  in  making  an  inci- 
sion which  divides  one  or  two  of  the  upper  rings  of  the  trachea,  the  crico- 
tracheal  membrane,  the  cricoid  cartilage,  and  the  crico-thyroid  membrane. 
It  may  be  employed  in  cases  in  which,  from  the  age  of  the  patient,  the  crico- 
thyroid space  is  too  small  to  admit  of  a  sufiicient  opening,  or  in  those  in 
which  for  any  reason  the  surgeon  does  not  deem  it  advisable  to  attempt  to 
open  the  trachea  lower  down.  It  is  not  often  practised,  as  it  is  liable  to 
involve  injury  of  the  cords  and  change  in  the  voice.  The  incision  in  the 
skin  and  the  superficial  fascia  of  the  neck  is  made  in  the  same  manner  as  in 
the  operation  of  laryngotomy,  but  is  carried  a  little  farther  downward.  It 
may  also  be  necessary  to  displace  the  isthmus  of  the  thyroid  gland  down- 
ward as  the  wound  is  deepened,  to  expose  the  upper  portion  of  the  trachea. 
When  the  trachea  has  been  exposed,  it  should  be  opened  by  making  an 
incision  through  it  and  the  cricoid  cartilage  from  below  upward,  and  a 
tracheotomy-tube  should  be  introduced  ;  the  after-care  of  the  case  is  similar 
t(j  that  of  tracheotomy. 

Fistula  of  the  Larynx  or  Trachea. — This  is  more  common  in 
connection  with  the  larynx  than  with  the  trachea,  and  may  be  congenital  or 
result  from  wounds,  chondritis  followed  by  abscess,  and  from  foreign  bodies 
or  tumors.  The  fistula  remaining  after  tracheotomy  usually  heals  promptly 
unless  there  is  stenosis  of  the  larynx  above.  Symptoms.— These  are  the 
passage  of  air  from  the  fistula  on  expiration  and  the  escape  of  mucus  and 
pus,  and  change  in  the  voice  or  loss  of  phonation  if  the  fistulous  opening  is 
large.  Treatment. — Fistula;  of  small  diameter  may  be  closed  by  the  a]p- 
plication  of  caustics  or  the  galvano-cautery,  but  larger  ones,  and  those  of 
congenital  origin,  are  often  difficult  to  close.  If  stenosis  of  the  larynx  exists, 
this  condition  should  be  relieved  before  any  operation  is  undertaken.  Oper- 
ative treatment  consists  in  dissecting  out  the  fistulous  tract  and  bringing 
the  edges  together  with  sutures,  or  in  exposing  the  ojiening  in  the  larynx  or 
trachea,  and,  after  freshening  and  aiDproximating  its  edges,  closing  the 
external  wound  by  sliding  a  flaj)  of  skin  to  fill  the  gap. 

Intubation  of  the  Larynx. — In  this  operation,  introduced  by 
O'Dwyer,  a  metallic  or  hard  lubbei-  tube  is  passed  through  the  mouth  into 
the  larj'ux  and  allowed  to  remain  there  for  a  certain  pei'iod,  for  the  relief 
of  dyspnoea.  Intubation  of  the  larynx  has  been  practised  in  the  treatment 
of  inflammatory  affections  of  the  larynx  as  a  substitute  for  tracheotomy, 
and  is  generally  emploj^ed  to  relieve  dyspnoea  in  diphtheritic  croup,  in 


828 


INSTRUMENTS  EEQUIRED  FOR  INTUBATION. 


stricture  of  the  larynx,  and  occasionally  in  oedema  of  the  glottis.  Intuba- 
tion has  been  recommended  in  cases  of  foreign  bodies  in  the  larynx  or  in 
the  trachea,  but  in  such  cases  tracheotomy  should  be  preferred.  The  indi- 
cations for  intvibation  of  the  larynx  are  similar  to  those  for  tracheotomy. 

Instruments  required  for  Intubation. — The  instruments  required  for 
intubation   are  :     Intubation-Tubes. — The    intubation-tubes   for  children 


Introducer  and  tubes. 

are  usually  six  in  number,  of  different  sizes,  adapted  to  children  from  one 
to  twelve  years  of  age.     The  tube  now  generally  employed  consists  of  a 

metal  cylinder  which  bulges  near  its 
Fig-  713.  centre  and  is  provided  with  a  collar  or 

head  to  rest  upon  the  false  vocal  cords. 
The  tubes  are  gold-plated  or  hard  rub- 
ber with  a  metallic  lining,  and  each 
is  provided  with  an  obturator  which 
has  a  blunt  extremity,  and  through 
the  edge  of  the  collar  on  each  tube 
Mouth-gag.  there  is  a  small  perforation,  into  which 

a  strand  of  fine  braided  silk  is  passed  : 
this  serves  to  remove  the  tube  if  in  its  introduction  it  should  be  passed  into 
the  pharynx  or  the  oesophagus  instead  of  the  larynx,  or  if  owing  to  sudden 

Fig.  714. 


obstruction  it  has  to  be  hurriedly  withdrawn.  The  Introducer. — This 
instrument  consists  of  a  handle  and  a  staff,  curved  to  a  right  angle  at  its 
extremity,  which  has  a  screw  that  attaches  it  to  the  obturator,  and  a  sliding 
gear  for  detaching  the  obturator  from  the  tube  when  it  is  placed  in  the 


INTUBATION  OF  THE  LARYNX. 


829 


larynx.  (Fig.  712.)  Mouth-Gags. — Mouth-gags  of  various  kinds  may  be 
used ;  the  one  generally  used  is  a  self- retaining  instrument.  (Fig.  713.) 
The  Extractor. — The  extractor  is  also  curved  on  a  right  angle,  and  has  at 
its  extremity  a  small  forceps  with  duckbill  blades,  which  are  made  to  sepa- 
rate and  apply  themselves  to  the  interior  surface  of  the  tube  with  sufficient 
firmness  to  withdraw  it.     (Fig.  714.) 

Preparation  for  Intubation. — It  should  be  remembered  that  when  an 
intubation -tube  enters  the  larynx  breathing  is  arrested  until  the  obturator  is 
removed,  and  therefore  all  manipulations  should  be  as  rapid  as  is  consistent 
with  accuracy.  The  surgeon  should  select  a  tube  of  suitable  size  for  the  age 
of  the  patient,  and  jjass  a  strand  of  fine  braided  silk,  about  two  feet  In 
length,  through  the  opening  in  the  collar  of  the  tube,  and  after  knotting  the 
ends  together  the  tube  is  attached  by  means  of  the  obturator  to  the  intro- 
ducer. He  next  protects  the  index  finger  of  the  left  hand,  in  the  region  of 
the  second  joint,  by  wrapping  it  with  a  piece  of  rubber  plaster  or  by  slipping 
over  it  a  metal  shield.  This  is  an  important  precaution  to  prevent  the 
patient  from  biting  the  finger  in  case  the  mouth-gag  should  slip. 

Operation. — The  child  should  be  placed  in  a  sitting  position  uiion  the 
lap  of  the  nurse  or  assistant,  and  covered  by  a  blanket  loosely  thrown 
around  it.    The  nurse  grasps 

the  child's  elbows  outside  of  ^''^-  ''^^■ 

the  blanket  and  holds  them 
firmly,  but  should  not  press 
tliem  against  the  chest  in 
such  a  way  as  to  embarrass 
the  respiratory  movements ; 
at  the  same  time  the  legs  of 
the  patient  should  be  se- 
cured by  being  held  between 
the  knees  of  the  nurse.  The 
head  of  the  patient  is  next 
secured  by  being  held  be- 
tween the  open  hands  of  an 
assistant  placed  upon  each 
side  of  the  head  and  cheeks ; 
the  left  hand  of  the  assistant 
may  also  be  used  in  steady- 
ing the  mouth-gag  after  it 
has  been  introduced.  (Fig. 
715.)  It  is  possible  to  in- 
troduce the  tube  with  the 

child  in  the  recumbent  posture ;  this  we  have  done  on  several  occasions  when 
from  the  condition  of  the  circulation  we  did  not  think  it  advisable  to  lift 
the  patient  to  the  sitting  posture. 

The  mouth  is  opened  and  the  blades  of  the  mouth-gag  introduced  between 
the  molar  teeth  upon  the  left  side,  and  the  mouth  opened  as  widely  as 
possible.  The  surgeon  passes  the  index  finger  of  the  left  hand  into  the 
pharynx  and  feels  for  the  epiglottis,  which  is  hooked  forward  by  the  end  of 


830  INTUBATION   OF  THE  LARYNX. 

the  finger.  The  tube  attached  to  the  introducer,  held  in  the  right  hand,  is 
next  i^assed  into  the  mouth  and  carried  back  to  the  pharynx,  the  operator 
being  careful  to  see  that  it  hugs  the  base  of  the  tongue  in  the  middle  line, 
that  the  handle  is  depressed  well  upon  the  child's  chest,  and  that  the  silken 
thread  is  free.  When  the  extremity  of  the  tube  comes  in  contact  with  the 
end  of  the  finger  resting  upon  the  epiglottis,  the  handle  should  be  raised  as 
it  engages  in  the  larynx  and  descends  into  that  organ  ;  and  as  it  Is  pushed 
downward  into  place,  the  finger  is  placed  upon  the  head  of  the  tube  to  fix  it 
and  prevent  its  being  withdrawn  with  the  obturator.  The  trigger  is  next 
pressed,  the  introducer  and  obturator  are  drawn  from  the  mouth  by  depress- 
ing the  handle  upon  the  chest,  and  before  removing  the  finger  it  is  well  to 
push  the  tube  well  into  the  larynx. 

As  soon  as  the  obturator  is  removed  there  is  generally  a  violent  expira- 
tory effort,  with  coughing,  accompanied  by  a  gush  of  muco-puruleut  matter 
or  membrane  from  the  tube,  and  after  this  escapes  the  breathing  is  usually 
satisfactorily  established.  If  the  operator  has  passed  the  tube  into  the 
pharynx  or  the  oesophagus,  no  improvement  in  the  respiration  takes  place, 
and  it  should  then  be  withdrawn  by  the  silk  loop  and  attached  to  the  obtu- 
rator, and  another  attempt  made  to  introduce  it  into  the  larynx. 

The  mistake  which  inexperienced  operators  make  in  attempting  to  intro- 
duce the  intubation-tube  consists  in  not  hugging  the  posterior  surface  of 
the  tongue  closely,  so  that  they  pass  the  tube  over  the  epiglottis  into  the 
pharynx.  The  most  serious  comijlication  which  is  apt  to  occur  during  the 
introduction  of  the  intubation-tube  is  the  detachment  and  pushing  of  a  mass 
of  membrane  in  front  of  the  tube  into  the  trachea.  If  this  is  too  large  to  be 
expelled  through  the  tube,  the  breathing  is  suddenly  arrested ;  the  tube 
should  then  be  removed  at  once,  and  if  the  mass  of  membrane  does  not 
escape  upon  the  expiratory  efforts  of  the  patient,  the  trachea  should  be 
rapidly  opened.  So  much  do  we  dread  this  accident,  which  has  occurred 
to  us  in  one  case  only,  that  we  never  introduce  an  intubation-tube  without 
having  at  hand  the  necessary  instruments  to  do  a  tracheotomy. 

Some  operators  keep  the  loop  attached  to  the  tube  during  the  time  it  is 
retained  in  the  larynx,  so  that  by  drawing  upon  it  the  nurse  or  attendant  is 
able  to  withdraw  the  tube  instantly  if  it  should  become  obstructed  with 
membrane,  or  be  coughed  up,  and  pass  into  the  pharynx  or  the  oesophagus. 
If  it  is  decided  to  allow  the  silk  loop  to  remain  in  jjlace,  it  is  well  to  sink 
the  strands  well  down  to  the  gum  between  the  first  molar  and  premolar  teeth 
of  the  lower  jaw,  to  prevent  the  silk  from  being  bitten  in  two  by  the  child, 
which  often  occurs  if  it  is  left  free  in  the  mouth.  As  the  presence  of  the 
silk  string  usually  causes  much  irritation  of  the  pharynx,  we  prefer  to  with- 
draw it  as  soon  as  the  tube  is  securely  placed  in  the  larynx,  and  remove  the 
tube  by  means  of  the  extracting  instrument  when  its  removal  is  required. 
We  generally  allow  the  string  to  remain  in  jilace  for  ten  or  fifteen  minutes, 
and  at  the  end  of  this  time  we  introduce  the  finger  into  the  mouth  and  feel 
that  the  tube  is  in  its  proper  place,  and  theu,  while  the  tip  of  the  finger 
rests  upon  the  edge  of  the  tube,  divide  the  silk  loop  and  withdraw  it. 

After-Treatment. — After  intubation  the  patient  should  be  kept  in  a 
warm  room  in  which  a  certain  amount  of  moisture  is  maintained  by  the 


AFTER-TREATMENT   OF  INTUBATION.  831 

use  of  boiling  water  or  by  a  steam  spray.  If  there  is  little  tendency  to 
exiDectoration  tbrough  the  tube,  the  soda  solution  previously  mentioned 
may  be  emi^loyed  with  advantage.  One  of  the  greatest  troubles  after 
intubation  of  the  larynx  is  the  satisfactory  feeding  of  the  patient  and  the 
administration  of  liquid  medicines.  Liquids,  as  a  rule,  are  not  swallowed 
well,  a  portion  of  them  escaping  into  the  tube  and  producing  violent 
coughing,  although  cases  are  occasionally  met  with  in  which  the  swallow- 
ing of  liquids  does  not  seem  to  be  seriously  interfered  with  by  the  presence 
of  the  intubation-tube.  We  iisually  order  a  diet  of  semisolids,  such  as  corn- 
starch, soft-boiled  eggs,  mush,  and  junket.  The  taking  of  a  sufflcient 
quantity  of  water  often  causes  trouble,  and  in  such  cases  the  child  luay  be 
allowed  to  swallow  small  pieces  of  ice,  or  water  may  be  regularly  admin- 
istered by  the  rectum.  In  cases  where  there  is  difficulty  ia  swallowing  even 
this  form  of  diet,  it  may  be  necessary  to  resort  to  nutritious  enemata  or  the 
use  of  the  stomach-tube  for  a  few  days.  In  young  patients,  in  whom  a 
liquid  or  milk  diet  is  essential,  if  the  head  is  dropi^ed  a  little  lower  than  the 
body  during  the  act  of  deglutition  it  will  often  be  found  that  the  fluids  are 
swallowed  without  difdculty.     (Fig.  716.) 


Feeding  a  ease  of  intubation. 

Removal  of  Intubation-Tubes. — The  intubation-tube  usually  remains 
in  place  about  a  week,  but  may  be  coughed  out  sooner  if  the  swelling  of  the 
laryngeal  tissues  subsides  before  this  time.  We  usually  remove  the  tube 
within  three  or  four  days,  and  if  the  breathing  is  satisfactorily  carried  on 
for  half  an  hour  and  no  dyspnoea  appears,  its  reintroduction  may  not  be 
necessary.  If,  however,  after  the  tube  has  been  out  a  few  minutes  dyspnoea 
returns,  the  tube  should  be  promptly  reintroduced,  and  its  removal  should 
not  be  attempted  again  for  three  or  four  days.  In  many  cases  the  tube  is 
coughed  out  within  one  week  from  its  introduction,  and  its  reintroduction 
is  not  often  required  in  these  cases.  The  tube  can  usually  be  permanentlj' 
dispensed  with  in  from  five  to  ten  days,  although  we  have  had  cases  in  which 


832  INTUBATION  IN   CICATRICIAL  STENOSIS. 

it  could  not  be  permanently  removed  until  the  fifteentli  day.  Cases  have 
been  reported  in  which  the  tube  had  to  be  worn  for  many  months.  After 
an  intubation-tube  has  been  coughed  up  or  removed,  the  patient  should  be 
carefully  watched  for  from  twelve  to  twenty-four  hours,  for  the  dyspnoea  may 
recur  at  any  time  within  this  period  and  require  replacement  of  the  tube. 
After  intubation  of  the  larynx  very  decided  hoarseness  often  persists  for 
several  weeks,  but  after  this  time  usually  entirely  passes  away. 

Retained  Intubation-Tubes. — If  an  intubation-tube  has  been  worn 
for  a  long  time  there  is  sometimes  great  difficulty  in  removing  it  perma- 
nently, as  in  the  case  of  tracheotomy  tubes.  It  may  often  be  accomplished 
by  introducing  tubes  of  gradually  increasing  size. 

Comparative  Value  of  Tracheotomy  and  Intubation.— A  con- 
siderable experience  with  both  of  these  operations  has  led  us  to  believe  that 
intubation  possesses  certain  advantages  over  tracheotomy  in  cases  of  diph- 
theritic laryngitis  in  which  there  is  no  marked  swelling  of  the  tonsils ; 
whereas  in  cases  in  which  this  condition  exists,  causing  obstruction,  trache- 
otomy should  be  performed.  As  intubation  is  not  a  cutting  operation,  con- 
sent for  its  performance  is  more  readily  obtained  than  for  tracheotomy. 

Intubation  in  Cicatricial  Stenosis  of  the  Larynx. — The  introduc- 
tion of  an  intubation-tube  in  cases  of  stenosis  of  the  larynx  resulting  from 
cicatrization  following  wounds  or  injuries,  or  following  the  pressure  of 
growths  upon  the  larynx,  or  in  eases  where  there  is  difficulty  in  the  removal 
of  the  tracheotomy -tube,  may  often  be  employed  with  advantage.  When 
intubation-tubes  are  introduced  for  stenosis  of  the  larynx,  they  are  em- 
ployed not  only  to  relieve  the  dyspnoea,  but  also  as  dilators,  and,  therefore, 
the  tubes  should  be  removed  at  intervals  and  replaced  by  larger  ones.  In 
such  cases  the  larynx  seems  to  bear  the  presence  of  the  tube  remarkably 
well,  and  it  may  be  allowed  to  remain  for  a  week  or  ten  days  without  removal. 
It  should  be  removed,  however,  at  this  time,  and  replaced  by  a  tube  of 
greater  size  if  there  is  evidence  that  its  further  use  is  required. 


CHAPTEE   XXXIII. 

SURGERY  OF  THE  CHEST. 
By  Heney  E.  Wharton,  M.D. 

Contusions  of  the  Chest. — Contusions  of  the  chest  unaccompanied 
by  wounds  of  the  thoracic  viscera  are  usually  not  serious  injuries.  The 
most  prominent  symptom  is  painful  respiration,  and  there  may  develop 
later  ecchj^mosis  from  injury  of  the  blood-vessels.  It  is  probable  that  many 
cases  of  severe  contusion  of  the  chest  have  associated  with  them  fracture  of 
the  ribs,  which  is  often  a  more  difficult  injury  to  diagnose  than  would  be 
sujpposed,  from  the  fact  that  displacement  of  the  fragments  is  prevented  by 
the  attachment  of  the  intercostal  muscles.  The  pectoral  muscles  may  be 
partially  torn  from  their  insertions  and  a  hsematoma  may  be  present. 

Treatment. — This  consists  in  preventing  motion  upon  the  side  of  the 
injury  by  the  application  of  strips  of  adhesive  plaster.  These  should  be 
applied  as  for  cases  of  fracture  of  the  ribs.  Abscess  may  result  from  con- 
tusion of  the  soft  ijarts  or  from  the  breaking  down  of  a  hrematoma,  and 
when  present  should  be  promptly  opened  and  drained,  with  full  aseptic 
precautions. 

Contusions  of  the  Chest  with  Rupture  of  the  Thoracic  Vis- 
cera.— Laceration  of  the  lung  without  fracture  of  the  ribs  is  a  rare  acci- 
dent, which  may  result  from  the  chest  being  squeezed  between  heavy  bodies 
or  from  the  passage  of  the  wheels  of  wagons  over  it.  Although  the  injury 
may  occur  in  adults,  it  is  most  commonly  observed  in  children,  in  whom 
the  elasticity  of  the  ribs  saves  them  from  fracture.  The  symptoms  of  this 
injury  are  shock,  dyspnoea,  htemoptysis,  ijneumothorax,  subcutaneous 
emphysema,  and  dulness  on  percussion  if  there  has  been  free  hemorrhage. 
If  the  patient  survives  for  a  few  days,  pleurisy  will  be  present,  and  a  puru- 
lent collection  may  also  develop  in  the  chest  at  a  later  period.  The  prognosis 
in  this  injury  is  always  grave,  the  majority  of  patients  dying  within  a  few 
days.  We  have  recently  had  under  our  observation  three  cases  of  contusion 
of  the  chest  with  rupture  of  the  lung,  all  in  children  ;  two  of  them  died 
within  five  days,  the  third  recovered  after  a  protracted  illness. 

Treatment. — In  these  cases  the  condition  of  shock,  which  is  usually 
very  marked,  should  be  treated  by  the  application  of  external  warmth,  and 
the  use  of  cardiac  stimulants.  If,  after  reaction  has  occurred,  the  respira- 
tory movements  are  painful  the  chest  should  be  strapped  and  opium  admin- 
istered freely,  and,  if  there  is  evidence  of  hemorrhage,  ergot  should  also 
be  employed.  Pleurisy,  or  a  purulent  collection  in  the  pleural  cavity,  call 
for  appropriate  treatment. 

Concussion  of  the  Chest. — In  addition  to  the  previously  described 
injury,  there  occasionally  occurs  as  the  result  of  force  applied  to  the  chest 
a  condition  which  has  been  described  as  concussion  of  the  lung,  or  commotio 

833 


834  PENETRATING   WOUNDS   OF  THE   CHEST. 

thoracicce,  a  condition  analogous  to  concussion  of  the  brain,  in  which  there  is 
serious  functional  derangement  without  appreciable  organic  lesion.  The 
symptoms  of  this  injury  are  collapse,  great  dyspncea,  and  diminished  respi- 
ratory murmur.  These  symptoms  may  disappear  in  a  few  hours  and  leave 
no  trace  of  serious  injury  of  the  lung.  Death,  on  the  other  hand,  may  occur 
soon  after  the  reception  of  the  injury,  and  post-mortem  examination  of  such 
cases  has  failed  to  reveal  any  distinct  lesion,  the  fatal  result  being  probably 
due  to  disturbance  of  the  cardiac  ganglia  and  sympathetic  i)lexus. 

Treatment. — The  treatment  consists  in  lowering  the  head,  administer- 
ing cardiac  stimulants,  ammonia,  alcohol,  or  strychnine,  and  the  employ- 
ment of  artificial  respiration,  preferably  by  Laborde's  method. 

WOUNDS  OP  THE  CHEST. 

Wounds  of  the  chest  may  be  non-i^enetrating  or  penetrating. 

Non-Penetrating  Wounds  of  the  Chest. — Wounds  involving  this 
region  may  be  incised  or  lacerated  or  gunshot ;  they  may  be  slight  or  exten- 
sive, involving  the  skin  and  cellular  tissue  only,  or  penetrating  the  deep 
fascia  and  the  muscles.  They  may  be  attended  with  free  hemorrhage,  par- 
ticularly if  the  intercostal  or  the  internal  mammary  arteries  have  been 
injured.  In  examining  these  wounds  the  surgeon  should  be  careful  that  he 
does  not  convert  the  wound  into  a  penetrating  one. 

Treatment. — In  dressing  these  wounds  the  surgeon  should  be  careful  to 
sterilize  the  wound  and  keep  it  aseptic,  for  septic  wounds  of  the  chest  are 
not  infrequently  followed  by  septic  infection  of  the  intrathoracic  viscera. 
Incised  wounds  of  the  chest  should  be  approximated  by  deep  sutures,  passed 
to  the  depth  of  the  wound,  or  the  muscles  and  deep  fascia  may  be  united  by 
buried  sutures,  and  the  skin  and  suiierficial  fascia  approximated  by  a  sepa- 
rate layer  of  sutures.  In  lacerated  wounds  a  few  sutures  may  be  introduced 
to  hold  the  parts  in  place,  but  if  they  cause  any  tension  they  should  not  be 
used.  The  wounds  should  be  dressed  with  an  antiseptic  or  sterilized  gauze 
dressing.  Healing  in  these  cases  is  usually  slow,  on  account  of  the  constant 
motion  of  the  parts  in  the  movements  of  respiration,  but  it  may  be  facili- 
tated by  the  application  of  strips  of  adhesive  plaster,  limiting  the  motion  of 
the  chest  on  the  injured  side. 

Penetrating  Wounds  of  the  Chest.— These  may  consist  of  small 
or  extensive  punctured,  incised,  lacerated,  or  gunshot  wounds  with  or  with- 
out injury  to  the  thoi-acic  viscera.  The  jDrincipal  dangers  in  penetrating- 
wounds  of  the  chest  arise  from  hemorrhage,  if  the  intercostal  or  internal 
mammary  arteries,  the  heart  or  great  vessels,  or  the  lung  have  been  injured, 
and  from  septic  infection,  for  it  is  almost  impossible  to  disinfect  the  pleural 
cavity  if  infective  material  has  once  been  introduced  through  the  wound. 

Penetrating  Wounds  of  the  Chest  without  Injury  of  the  Vis- 
cera.— The  chest  wall  and  costal  pleura  may  be  penetrated  in  incised 
wounds  and  the  viscera  may  escape  injury.  The  symptoms  in  such  an 
injury  will  depend  somewhat  upon  the  extent  of  the  wound.  Air  may  be 
drawn  in  and  pass  out  of  the  wound  with  the  movements  of  respiration 
(fraumatopncea).  Emphysema  of  the  cellular  tissue  in  the  region  of  the 
wound  is  also  likely  to  be  present.     If  the  wound  is  extensive,  the  lung 


PENETRATING  AVOUNDS  OF  THE  CHEST.  835 

upon  the  side  of  the  injury  may  collapse.  Hernia  of  the  lung  may  be 
observed.  The  treatment  of  these  cases  consists  in  controlling  the  bleeding 
and  in  sterilizing  and  closing  the  external  wound  and  applying  over  it  an 
antiseptic  dressing. 

Penetrating  Wounds  of  the  Chest  with  Injury  of  the  Viscera. — 
Penetrating  wounds  involving  the  viscera,  either  jjunctured,  incised,  lacer- 
ated, or  gunshot,  are  always  most  serious  injuries.  When  the  lung  has  been 
injured,  the  patient  expectorates  blood  or  bloody  mucus ;  if  the  wound  in 
the  chest  wall  be  of  considerable  size,  air  mixed  with  blood  may  escape  from 
the  wound  ;  the  lung  may  also  be  collapsed,  in  which  case  dyspnoea  will  be 
marked  and  pneumothorax  can  be  clearly  demonstrated.  Collapse  of  the 
lung  occurs  from  air  passing  into  the  pleura  with  each  inspiration,  and  when 
there  is  a  wound  of  the  lung,  from  air  passing  from  it  with  each  expiration, 
so  that  it  rapidly  accumulates  in  the  pleural  cavity  and  the  lung  collapses. 
We  have  had  recently  under  our  care  a  young  man  who  had  a  pick  driven 
into  the  right  side  of  his  chest,  producing  a  lacerated  penetrating  wound 
about  two  and  a  half  inches  in  length,  which  separated  two  ribs  from  their 
costal  cartilages  and  also  lacerated  the  lung.  In  this  case  there  were  marked 
dyspnoea,  expectoration  of  bloody,  frothy  mucus,  escape  of  air  and  blood 
from  the  external  wound,  and  collapse  of  the  right  lung,  and  the  heart  and 
pericardium  were  displaced  to  the  right  side  so  that  they  could  be  seen  and 
felt  at  the  bottom  of  the  wound.  Emphysema  of  the  tissues  surrounding  the 
wound  may  also  be  present.  Prolapse  of  the  lung  may  be  observed,  and  is 
most  apt  to  occur  in  extensive  wounds  of  the  pleural  sac ;  the  protrusion 
taking  place  during  expiration  or  a  forced  expiratory  effort,  owing  to  the 
fact  that  during  expiration  the  air  in  the  lung  is  under  pressure,  and  when 
the  support  of  the  chest  wall  is  removed  a  part  of  the  lung  may  yield  to  the 
pressure  of  the  contained  air  and  be  forced  through  the  wound.  Hemor- 
rhage from  the  external  wound  is  probably  one  of  the  earliest  and  most  fatal 
complications  of  these  wounds,  and  may  arise  from  injury  to  the  heart,  the 
great  vessels,  or  the  intercostal  or  internal  mammary  arteries,  or  from 
wounds  of  the  azygos  veins. 

Treatment. — This  will  depend  upon  the  nature  of  the  wound  and  the 
extent  of  injury  of  the  viscera.  If  hemorrhage  be  present,  it  should  receive 
the  flj'St  attention  ;  if  from  the  position  of  the  wound  it  is  probable  that  the 
bleeding  arises  from  the  intercostal  or  internal  mammary  arteries,  the  wound 
should  be  enlarged  and  the  tissues  ligated  en  masse,  or  the  vessels  sought  for 
and  ligated.  Difaculty  may  be  experienced  in  exposing  an  intercostal 
artery,  in  which  case  a  portion  of  the  rib  may  be  excised,  or  a  ligatu]-e  may 
be  carried  around  the  rib,  by  which  procedure  the  vessel  may  be  secured. 
If  it  is  found  that  the  bleeding  arises  from  a  wound  of  the  great  vessels, 
it  is  not  probable  that  surgical  interference  can  avert  the  fatal  issue.  If 
the  bleeding  has  been  arrested  before  the  surgeon  sees  the  case,  and  the 
cavity  of  the  chest  is  found  partially  filled  with  blood-clot,  it  is  wiser 
not  to  turn  out  the  blood-clot  and  search  for  the  source  of  the  bleeding, 
but  to  close  the  wound  and  trust  to  the  absorption  and  organization  of 
the  blood-clot ;  or,  later,  if  the  clot  breaks  down  the  resulting  fluid  may  be 
removed  by  aspiration  or  incision.     If  the  hemorrhage  is  severe,  it  has  been 


836  ■  PNEUMOTHORAX. 

recommended  to  open  the  chest  and  introduce  a  drainage-tube  so  as  to  bring 
about  a  condition  of  pneumothorax  and  by  pressure  of  air  upon  the  lung  to 
favor  its  collapse  and  thus  check  the  bleeding.  This  method  provides 
drainage,  diminishes  the  chance  of  pyothorax  and  prevents  subsequent 
binding  down  of  the  lung  by  adhesions  from  the  organization  of  the  clotted 
blood.  If  hemorrhage  is  not  a  prominent  symptom,  the  external  wound 
should  be  closed  with  sutures,  a  dressing  of  sterilized  or  antiseptic  gauze 
applied,  and  the  respiratory  movements  of  the  chest  upon  the  injured  side 
limited  by  the  application  of  adhesive  straps.  Extensive  exploration  of  the 
wound  in  such  cases  is  injudicious ;  it  is  much  better  after  cleansing  the 
external  wound  to  apply  an  antiseptic  dressing  and  depend  upon  aseptic 
occlusion.  If  hernia  of  the  lung  exists,  which  is  rare  as  a  primary  com- 
plication of  penetrating  wounds,  and  the  vitality  of  the  protruding  portion 
of  the  viscus  is  unimpaired,  this  should  be  carefully  sterilized  and  returned 
within  the  chest ;  if,  however,  the  protruding  portion  of  the  lung  has  been 
lacerated  or  incised,  and  its  vitality  has  been  impaired,  it  should  be  ligated 
as  close  to  the  ribs  as  possible,  and  the  portion  in  advance  of  the  ligature 
excised,  the  stump  being  returned  within  the  chest,  or  secured  in  the  wound 
by  a  few  sutures,  and  the  external  portion  of  the  wound  closed  by  sutures 
and  covered  with  an  aseptic  or  antiseptic  dressing.  Hernia  of  the  lung 
occurring  after  the  external  wouud  has  healed  should  be  treated  by  the 
application  of  a  compress  held  in  position  by  a  belt. 

Hseraothorax. — This  consists  in  an  accumulation  of  blood  in  the 
pleural  cavity.  We  have  seen  a  stab  wound  of  the  chest  inflicted  by  a 
small  knife,  wounding  the  azygos  veins,  cause  death  from  hemorrhage. 

The  constitutional  treatment  of  cases  of  penetrating  wounds  of  the  chest 
consists  in  the  use  of  opium,  the  patient  being  kept  absolutely  at  rest.  If 
pneumonia  or  pleurisy  develops  it  should  be  treated  as  if  arising  inde- 
pendently of  traumatism. 

Emphysema. — This  consists  in  an  infiltration  of  air  into  the  cellular 
tissue,  and  is  usually  manifested  by  swelling  in  the  region  of  the  wound ; 
it  may  be  recognized  by  tlie  elastic  character  of  the  swelling  and  by  the 
fact  that  it  crepitates  upon  pressure.  Emphysema  may  be  limited  to  the 
region  of  the  wound,  or  may  extend  widely  through  the  tissues,  even  involv- 
ing the  whole  body,  giving  the  patient  a  bloated  appearance.  A  form  of 
emphysema  occurring  after  punctured  wounds,  particularly  of  the  anterior 
region  of  the  chest,  known  as  mediastinal  emphysema,  caused  by  air  passing 
back  under  the  pleura  to  the  connective  tissue  at  the  root  of  the  lung,  may 
give  rise  to  marked  dyspnoea  and  embarrassment  of  the  circulation  and  lead 
to  a  fatal  termination.  Treatment. — Emphysema  usually  requires  no  sur- 
gical treatment,  the  air  ceasing  to  spread  and  disappearing  as  soon  as  the 
wound  in  the  chest  wall  is  closed. 

Pneumothorax. — This  consists  in  an  accumulation  of  air  in  the  pleural 
cavity  ;  it  may  cause  marked  dyspnoea  and  be  recognized  by  hyper-resonance 
over  the  seat  of  injury,  with  absence  of  respiratory  murmur,  amphoric 
breathing,  and  occasionally  metallic  tinkling.  These  conditions  may  result 
from  penetrating  wounds  of  the  chest.  Pneumothorax  may  be  avoided, 
when  there  is  fear  of  causing  it  during  oijerations,  by  filling  the  wound  with 


GUNSHOT  WOUNDS  OF  THE  CHEST.  837 

normal  salt  solution  or  packing  it  with  wet  sponges  or  ganze.  Pneumo- 
thorax, if  extensive  and  involving  both  sides  of  the  chest,  may  produce  so 
much  dyspnosa  that  life  will  be  threatened.  We  have  seen  unilateral  pneu- 
mothoi-ax  result  in  death,  the  other  lung  being  crippled  by  adhesions. 
Treatment. — In  this  condition  aspiration  of  the  air  fi-om  the  cavitj^  may 
be  employed,  or,  better,  the  pleural  sac  may  be  filled  with  salt  solution,  the 
wound  tightly  closed,  and  the  fluid  subsequently  aspirated. 

Hydrothorax  and  Empyema. — Serous  or  purulent  effusions  in  the 
pleural  cavity  may  exist  as  complications  of  penetrating  wounds  of  the 
chest,  and  their  presence  may  be  diagnosed  by  the  time  of  develoijment  of 
the  symptoms  of  dulness  upon  i^ercussion  and  the  absence  or  feebleness  of 
vocal  and  respiratory  sounds  over  the  seat  of  injury.  The  treatment  of 
these  conditions  will  be  considered  under  Operations  ujiou  the  Chest. 

Gunshot  Wounds  of  the  Chest.— These  injuries  may  be  inflicted  by 
balls,  bullets,  or  small  shot ;  if  iutlicted  by  the  latter  at  close  range,  exten- 
sive laceration  of  the  chest  wall  and  viscera  may  result.  Gunshot  wounds 
of  the  chest  may  be  penetrating  or  non-penetrating  ;  the  former  are  always 
serious  injuries,  the  records  of  military  surgery  showing  a  heavy  mortality. 
Conner  states  that  from  one-half  to  one-third  of  those  killed  outright  in 
action  have  been  found  to  have  died  fi'om  gunshot  wounds  of  the  chest. 

Non-Penetrating  Gunshot  Wounds. — These  injuries  are  not  usually 
serious  unless  they  occur  in  the  axillary  or  the  subclavicular  region,  involv- 
ing injuries  of  the  vessels,  in  which  case  they  are  often  quickly  fatal  from 
hemorrhage.  Balls  not  infrequently  strike  a  rib  and  are  deflected,  passing 
around  the  rib  to  the  spine,  and  either  escape  through  a  wound  of  exit  or 
remain  embedded  in  the  tissues.  Treatment. — If  in  these  iujui-ies  only  a 
wound  of  entrance  exists,  and  the  ball  cannot  be  easily  located,  it  is  unwise 
to  make  extensive  explorations  witli  a  probe  to  locate  the  ball,  or  free 
incisions  to  remove  it,  as  by  so  doing  the  wo;ind  may  be  converted  into  a 
penetrating  one.  It  is  better  to  disinfect  the  wound  and  apply  an  autiseiDtic 
dressing,  repair  usually  taking  place  promptly,  and  the  ball,  if  it  causes 
trouble,  may  be  located  and  removed  at  a  later  period.  If  the  missile  has 
j)assed  through  the  soft  parts  and  escaped,  the  wound  should  be  treated  as  a 
non-penetrating  wound  produced  by  other  causes. 

Penetrating  Gunshot  Wounds. — These  wounds,  as  previously  stated, 
are  most  serious  injuries  ;  the  missile  may  lodge  in  the  viscera  or  may  injiire 
the  heart  or  the  great  vessels.  The  latter  injury  is  almost  always  fatal, 
but  penetrating  wounds  involving  the  lung  are  not  so  serious,  and  a  fair 
proportion  of  such  cases  recovers.  The  modern  ball  used  in  warfare  is  apt 
to  perforate  the  chest  and  escape,  and  is  not  likelj'  to  lodge  in  the  viscera. 
Penetrating  pistol-ball  wounds  of  the  chest  occurring  in  civil  practice, 
unless  the  heart  or  the  great  vessels  be  involved,  although  grave  injuries, 
are  not  often  fatal.  Treatment. — If  the  ball  has  penetrated  the  chest  and 
escaped,  or  has  penetrated  the  chest  and  remains  embedded  in  the  viscera, 
no  informatiou  can  be  obtained  by  probing ;  hence  this  should  be  avoided, 
and  attempts  to  locate  the  ball  and  remove  it  by  operation  should  not  be  un- 
dertaken. If,  however,  the  ball  has  i)euetrated  both  the  chest  ^^•al]s  and  the 
lung,  and  is  arrested  undei-  the  skin  and  can  be  located,  it  should  be  removed, 

54 


838  WOUNDS   OF  THE   HEART  AIS'D   PERICARDIUM. 

aud  the  wounds  sterilized  and  dressed  antiseptically.  In  peneti-atiug  gunshot 
wounds  caused  by  small  shot  at  short  range,  or  by  fragments  of  wood  or 
stone  from  blasting  accidents  or  explosions,  when  a  portion  of  the  chest  wall 
is  torn  away,  exposing  the  lung  or  even  lacerating  or  tearing  away  a  por- 
tion, a  most  serious  injury  is  presented.  Such  cases  should  be  treated  by 
first  disinfecting  the  wound  as  far  as  possible,  removing  foreign  bodies 
which  may  be  present,  packing  the  wound  loosely  with  sterilized  gauze,  and 
covering  the  region  with  a  large  gauze  dressing.  Under  this  method  of 
treatment  it  is  not  unusual  to  have  recovery  follow,  even  when  there  has 
been  extensive  destruction  of  both  the  chest  wall  and  the  lung. 

Wounds  of  the  Mediastinum. — The  mediastinal  space  is  occupied 
by  the  heart  suiTOunded  by  the  pericardium,  the  great  vessels,  the  descend- 
ing aorta,  the  oesoi)hagus,  and  the  x^neumogastric  nerves. 

Wounds  of  the  Heart  and  Pericardium. — Eupture  of  the  heart  and 
pericardium  may  occur  as  the  result  of  contusion  of  the  chest  without  frac- 
ture of  the  ribs.  Traumatic  ruptiu'es  of  the  heart  and  pericardium  are 
invariably  followed  by  a  rapidly  fatal  result,  but  in  a  few  cases  life  has  been 
prolonged  for  a  few  hours.  The  heart,  pericardium,  and  great  vessels  may 
be  injured  by  incised,  punctured,  lacerated,  and  gunshot  wounds,  and, 
although  the  prognosis  in  these  wounds  is  always  grave,  death  in  many  cases 
occurring  promptly,  in  a  number  of  instances  recovery  has  followed.  Several 
cases  of  successful  suturing  of  wounds  of  the  heart  have  been  recorded. 
Wounds  of  the  coronary  arteries  ai'e  quickly  fatal.  Death  may  result  from 
shock  and  pulmonary  anfemia,  from  pressure  upon  the  heart  of  the  blood  in 
the  pericardium,  or  from  direct  injiuy  of  the  cardiac  muscle  preventing  its 
contraction.  Symptoms. — These  are  sharp  pain,  cardiac  syncope,  feeble- 
ness of  heart-sounds,  dxilness  upon  percussion,  and  enlargement  of  the  nor- 
mal area  of  dulness,  caused  by  hemorrhage  into  the  pericardium.  Treat- 
ment.— The  patient's  head  should  be  lowered,  to  prevent  syncope  from 
cerebral  anaemia,  external  warmth  should  be  applied,  and  opium  given  to 
relieve  pain,  and,  if  reaction  occurs,  cardiac  sedatives  shoiild  be  adminis- 
tered. If  the  wound  in  the  heart  can  be  exposed,  sutures  should  be  applied, 
the  bleeding  being  controlled  by  digital  pressure  while  the  sutures  are  being 
introduced. 

In  exposing  the  heart  to  control  hemorrhage  various  methods  of  osteo- 
plastic resection  of  the  sternum  and  ribs  have  been  practised,  care  being- 
taken  to  avoid  opening  the  pleural  cavity.  Podi-ez  resected  the  left  half  of 
the  sternum  and  turned  it  to  the  left  side,  saving  the  periosteum  on  its  under 
surface.  Wehr  recommends  an  incision  beginning  at  the  right  border  of 
the  sternum  in  the  third  interspace,  which  crosses  the  sternum  to  a  point 
two  fingers'  breadth  to  the  left  of  the  sternum,  curves  downward  over  the 
fourth,  fifth,  sixth,  and  seventh  ribs,  and  thence  back  across  the  bone  at  the 
base  of  the  xiphoid  cartilage.  He  saws  thi-ough  the  bone,  preserving  the 
periosteum  on  the  posterior  sm-face,  and,  to  avoid  wounding  the  left  pleura, 
cuts  the  costal  cartilages  very  obliquely  with  a  probe-pointed  knife. 

Foreign  Bodies. — These  may  penetrate  and  become  lodged  in  the  heart, 
and  their  removal  should  be  attempted  if  their  position  can  be  located  and 
their  presence  causes  marked  disturbance.     Patients  have  recovered  with 


MEDIASTINAL  ABSCESS.  839 

foreign  bodies  remaiuiug  in  the  organ,  and  a  few  cases  have  been  recorded 
of  the  successful  removal  of  foreign  bodies  from  the  heart.  Wounds  of  the 
great  vessels  at  the  base  of  the  heart  and  of  the  descending  aorta  are  usually 
rapidly  fatal  and  are  beyond  the  reach  of  surgical  treatment. 

Wounds  of  the  Diaphragm.— The  position  of  the  diaphragm  varies 
with  the  respiratory  movements,  and  ]nay  be  markedly  changed  by  distention 
of  the  abdominal  contents  or  cavity,  or  by  thoracic  tumors  or  pleuritic 
effusions  ;  hence  it  may  be  injured  by  wounds  out  of  its  ordinary  situation. 

Rupture  of  the  Diaphragm. — This  may  result  from  contusion  of  the 
chest,  as  well  as  from  a  similar  injury  to  the  abdomen,  and  is  more  commoil 
on  the  left  than  on  the  right  side,  the  liver  upou  the  right  side  protecting  it 
to  a  certain  extent.  Eupture  of  the  diaphragm  is  a  serious  injury,  and  may 
be  associated  with  injury  of  the  thoracic  or  abdominal  viscera,  or  with 
hernia  of  the  intestines  or  stomach  through  the  rent ;  strangulation  of  the 
latter  organs  may  lead  to  a  fatal  result. 

Wounds  of  the  Diaphragm. — These  are  generally  associated  with 
penetrating  wounds  of  the  chest  or  abdomen ;  the  sharp  extremity  of  a 
fractured  rib  may  also  cause  a  wound  of  the  diaphragm.  If  the  wound  is 
small  and  hernia  does  not  occur,  and  if  the  adjacent  viscera  are  not  severely 
injured,  the  prognosis  as  regards  recovery  is  good.  The  symjjtoms  of  rup- 
ture or  of  wounds  of  the  diaphragm  are  a  rapid  and  irregular  pulse,  dis- 
turbed respiratory  action  (diaphragmatic  action  being  diminished,  and  that 
of  the  accessory  muscles  of  respiration  being  increased),  pain,  dyspnoea, 
coughing,  and  in  some  cases  hiccough.  If  a  hernia  exists  there  may  be  a 
peculiar  resonance  at  the  seat  of  injury,  and  auscultation  may  disclose  the 
presence  of  fluid  in  the  intestines  or  the  stomach  as  they  rest  in  the  thoracic 
cavity.  Treatment. — Small  wounds  of  the  diaphragm  in  which  no  hernia 
has  occurred  heal  promjitly,  and  it  is  often  impossible  to  diagnose  these 
lesions.  In  a  case,  however,  of  contusion  or  wound  of  the  chest  or  abdomen 
where  the  presence  of  a  rupture  or  wound  of  the  diaphragm  with  hernia  of 
either  the  stomach  or  the  intestines  can  be  made  out,  it  is  justifiable  to  oi^eu 
the  abdomen  and  search  for  the  wound  in  the  diaphragm,  reduce  the  pro- 
lapsed viscus,  and  close  the  rent  with  sutures.  A  few  successful  cases  in 
which  this  procedure  was  adopted  have  been  reported. 

Congenital  Defects  of  the  Diaphragm. — A  congenital  defect  is 
sometimes  observed  in  the  diaphragm  ;  a  considerable  portion  may  be  want- 
ing, or  there  aiay  be  a  congenital  fissure  which  permits  some  of  the  abdom- 
inal organs  to  escape  into  the  thoracic  cavity.  This  condition  is  not  likely 
to  be  recognized  during  life  unless  strangulation  of  the  hernia  occurs,  in 
which  event  a  laparotomy  should  be  performed  and  an  attempt  made  to 
reduce  the  hernia  and  close  the  fissure. 

Mediastinal  Abscess. — Abscess  of  the  mediastinum  may  result  from 
traumatism,  such  as  contusions,  fractures,  gunshot  wounds,  or  punctured 
wounds  of  the  anterior  region  of  the  chest.  This  form  of  abscess  may  have 
its  origin  in  abscess  of  the  neck,  in  which  case  the  pus  burrows  down  behind 
the  deep  cervical  fascia,  or  may  result  from  suppuration  of  tubercular  medi- 
astinal glands,  or  from  osteomyelitis  of  the  sternum.  The  symptoms  of 
mediastinal  abscess  are  fever,  deep-seated  pain  which  is  increased  upou 


840  PLEURAL  EFFUSIONS. 

coughing  or  swallowing,  dyspnoea,  oedema  of  tlie  tissues  over  the  sternum, 
and  dilatation  of  the  superficial  veins.  The  abscess  may  point  at  the  lateral 
aspect  of  the  sternum  or  at  the  eusiform  cartilage.  Treatment. — If  there 
is  evidence  of  pointing  at  the  sides  of  the  sternum  or  at  the  eusiform  carti- 
lage, an  incision  should  be  made,  the  pus  evacuated,  and  the  cavity  drained. 
If,  however,  there  is  no  evidence  of  pointing  in  these  situations,  the  sternum 
should  be  trephined  and  the  abscess  opened  and  drained. 

Tumors  of  the  Mediastinum. — Tumors  of  the  mediastinum  may 
be  benign,  such  as  lipoma,  fibroma,  dermoid  or  hydatid  cysts,  or  enlarge- 
ments of  the  thymus  or  mediastinal  glands.  Aortic  aneurism  may  also 
present  in  this  region.  Malignant  growths  of  the  mediastinum  are  either 
sarcomata  or  carcinomata,  and  may  occui'  either  as  primary  or  as  secondary 
aifections.  Sarcoma  is  the  form  of  disease  most  commonly  met  with,  aud 
usually  involves  the  anterior  mediastinum.  Carcinoma  of  the  mediastinum 
occurs  next  in  point  of  frequency.  Symptoms. — The  principal  symj)toms 
of  mediastinal  tumor  are  pain,  dyspuoea,  cough,  oedema  of  the  neck  from 
obstruction  of  the  venous  retirrn,  dilated  veins,  displacement  of  the  heart, 
and  in  some  cases  disturbance  of  function  of  the  pneumogastric  nerves,  if 
they  are  included  in  the  gi'owth.  Treatment. — The  removal  of  mediastinal 
tumors  is  an  operation  attended  with  great  danger,  and  can  be  accomplished 
with  safety  to  the  patient  in  rare  cases  only.  The  operation  necessitates  the 
removal  of  a  portion  of  the  sternum  and  ribs,  or  Milton's  operation,  anterior 
thoracotomy,  may  be  employed  (page  846),  aud  when  the  tumor  is  exjiosed 
it  is  often  found  that  it  is  so  firmly  attached  to  important  structures  in  the 
thorax  that  its  removal  cannot  be  safely  accomplished. 

Hydatid  Cyst  of  the  Lung. — This  affection  is  not  common  in  this 
country,  but  is  occasionally  observed.  Its  treatment  consists  in  exposing  the 
wall  of  the  cyst  by  excising  a  portion  of  several  ribs  and  incising  and  drain- 
ing it.  Aspiration  is  dangerous,  as  the  cyst  may  rupture  internally.  The 
mortality  in  cases  operated  uxjon  was  sixteen  per  cent.,  while  in  unoj)erated 
cases  it  was  sixty-six  per  cent. 

Pleural  Effusions. —  Collections  of  fluid  in  the  pleural  cavity  may 
occui"  from  injurj^  of  the  chest,  or  from  acute  or  chronic  inflammatory  affec- 
tions of  the  pleura  or  lungs  ;  pleural  effusions  may  also  result  from  tumors 
of  the  pleura,  causing  obstruction  of  the  venous  circulation.  Acute  pleural 
effusions,  to  which  the  name  hydrothorax  is  applied,  are  serous  unless 
they  result  from  injury  to  the  chest  or  thoracic  viscera,  in  which  case  they 
ofteu  contain  a  certain  amount  of  blood.  Chronic  pleural  effusions  are 
usually  purulent,  and  may  arise  fi-om  the  infection  of  acute  effusions  by 
staphylococci,  streptococci,  or  diplococci,  or  may  be  caused  by  tubercular 
pleurisy.  Pleural  effusions  may  form  rapidly  or  slowly ;  as  a  rule,  the 
effusions  following  acute  pleurisy  accumulate  very  rapidly,  and  the  pleural 
sac  is  ofteu  almost  filled  with  fluid  in  twenty-four  or  thirty-six  hours. 
Slowly  forming  effusions,  on  the  other  hand,  generally  result  from  the 
presence  of  tumors  or  from  tubercular  jjleurisy  ;  in  the  latter  case  there  is 
usually  marked  thickening  of  the  pleura.  A  serous  effusion  may  become 
purulent  fi-om  infection  by  pyogenic  organisms  or  from  the  bursting  of  an 
adjacent  abscess  into  the  pleural  sac. 


PURULENT  PLEURAL  EFFUSION.  841 

Symptoms. — The  prominent  symptoms  of  pleural  eifusions,  whether 
serous  or  purulent,  are  dyspnoea,  rapidity  and  feebleness  of  the  pulse,  eleva- 
tion of  the  temperature,  and  bulging  of  the  intercostal  spaces  on  the  affected 
side,  as  well  as  dnluess  upon  percussion,  most  marked  at  the  base  of  the 
chest,  the  line  of  dulness  varying  with  the  position  of  the  patient.  The 
patient  generally  rests  upon  the  affected  side.  The  apex  beat  of  the  heart 
is  usually  displaced  to  one  side,  according  to  the  position  and  amount  of  the 
effusion ;  displacement  of  the  aj^es  beat  to  the  right  side  is  always  more 
marked  than  displacement  to  the  left.  Eespii-atory  murmur  is  weak  or 
absent  over  the  portion  of  the  chest  occupied  by  the  effusion,  and  vocal 
fremitus  is  absent,  while  over  the  lung  compressed  by  the  effusion  bronchial 
breathing  may  be  heard.  Although  in  most  cases  the  presence  of  effusion 
can  be  clearly  made  out  by  the  physical  signs,  yet  it  is  often  well  to  verify 
the  diagnosis  by  the  use  of  the  aspirating  needle.  This  instrument  should 
be  carefully  sterilized  before  being  used,  as  a  serous  effusion  may  easily  be 
converted  into  a  purulent  one  by  neglect  of  this  precaution. 

Treatment. — A  small  acute  pleural  effusion  is  often  absorbed,  but  if  the 
effusion  be  extensive,  as  soon  as  it  interferes  with  the  function  of  respiration 
its  removal  should  be  accomplished  by  surgical  means.  A  diseased  pleura 
cannot  be  depended  upon  to  absorb  a  large  amount  of  pleural  effusion ;  the 
long-continued  pressure  of  such  an  effusion  upon  the  lung  may  seriously 
interfere  with  its  subsequent  expansion,  and  reaccumulation  of  the  effusion 
is  more  apt  to  occur  in  cases  where  the  operation  is  delajed  than  in  cases  in 
which  the  effusion  is  promptly  removed. 

Purulent  Pleural  Effusion.— Empyema. — The  term  empyema  is 
generally  used  to  indicate  a  collection  of  pus  in  the  pleural  cavity,  although 
it  may  also  be  used  to  designate  a  collection  of  pus  in  any  cavity  of  the 
body.  Purulent  pleural  effusion  may  result  from  an  acute  serous  effusion 
develoijing  in  the  course  of  pleurisy,  tubercular  pleurisy,  or  pneumonia, 
which  has  been  contaminated  by  specific  or  pyogenic  organisms,  or  from  the 
infection  of  blood  or  serum  in  the  pleural  cavity  after  penetrating  wounds 
of  the  chest  or  lung.  We  may  have  in  these  cases  tubercle  bacilli  and  diiDlo- 
cocci  pneumonite  as  well  as  streptococci  and  staphylococci.  In  recent  puru- 
lent pleural  effusion  the  pleura  is  not  much  thickened,  but  in  cases  of  some 
duration  the  pleura  is  always  thickened,  and  may  be  from  half  an  inch  to  an 
inch  in  thickness. 

A  small  purulent  pleui-al  effusion  may  in  the  course  of  time  largely  dis- 
appear, the  fluid  portions  being  absorbed,  and  the  more  consistent  portions 
undergoing  caseation  and  absorption  or  becoming  encysted.  The  jjurulent 
matter  in  the  chest  may  penetrate  the  lung  and  enter  a  bronchial  tube  and 
escape  by  the  mouth,  or  may  burrow  through  the  pleura  and  intercostal 
muscles  and  point  upon  the  surface  of  the  chest,  or  may  perforate  the  dia- 
phragm, giving  rise  to  a  subdiaphragmatic  abscess,  or  may  pass  into  the 
abdomen  or  behind  or  in  front  of  the  peritoneum,  giving  rise  to  an  extra- 
peritoneal abscess.  Symptoms. — The  physical  signs  of  imrulent  pleural 
effusion  are  the  same  as  those  of  serous  pleural  effusion,  with  the  addition 
that  in  the  former  there  are  symptoms  which  indicate  the  presence  of  pus, 
chills,    sweating,    irregular  temperature,  and  emaciation.     Treatment. — 


842 


PARACENTESIS  THOEACIS. 


When  it  is  evident  that  a  i^leiiral  effusion  is  purulent,  in  view  of  the  very 
slight  chance  of  its  undergoing  absorption,  as  well  as  of  the  danger  that  its 
presence  causes  the  patient,  it  should  be  promptly  removed,  either  by 
aspiration,  which  only  in  exceptional  cases  is  followed  by  a  cure,  or  by 
incision  and  drainage ;  the  latter  should  always  be  preferred,  as  it  is  most 
likely  to  be  followed  by  a  satisfactory  result. 


OPERATIONS   UPON   THE   CHEST  AND   ITS   CONTENTS. 

Paracentesis  Thoracis. — This  consists  in  perforating  the  walls  of 
the  chest  to  remove  an  effusion  from  the  pleural  cavity.  The  most  conve- 
nient instrument  for  this  i^urpose  is  the  aspirator.  If  an  aspirator  is  not  at 
hand,  a  trocar  and  canula  may  be  used,  or  a  puncture  may  be  made  witli  a 
narrow-bladed  knife,  and  the  puncture  kept  open  by  the  introduction  of  a 
grooved  director.  Whichever  instrument  be  used,  it  is  essential  that  it  be 
thoroughly  sterilized  before  being  introduced  in  the  pleural  cavity. 

In  performing  j)aracentesis  thoracis  it  is  not  usually  necessary  to  give  an 
anaesthetic,  as  the  operation  is  not  painful ;  but,  if  desired,  local  anaes- 
thesia may  be  produced  by  a  spray  of  rhigoleue,  or  by  the  subcutaneous 
injection  of  cocaine.  The  patient  should  be  in  a  semirecumbeut  posture, 
and  the  skin  surrounding  the  seat  of  the  proposed  puncture  should  be  care- 
fully sterilized.  The  part  usually  selected  is  the  mid-asillary  line,  between 
the  seventh  and  eighth  or  the  eighth  and  ninth  ribs.     (Fig.  717. )    The  skin 

is  drawn  upward  or  downward  with  the 
finger,  and  the  needle  of  the  aspirator  is 
introduced  with  a  quick  thrust ;  when  it 
has  penetrated  the  pleura  the  trocar  is 
removed  and  the  iiuid  is  allowed  to  escape 
into  the  vacuum-bottle.  If  the  patient 
presents  no  unfavorable  symptoms,  as 
much  fluid  as  possible  should  be  removed, 
but  if  he  shows  symptoms  of  syncope  after 
a  considerable  quantity  of  fluid  has  been 
removed,  the  head  should  be  lowered  and 
the  needle  withdrawn.  If  the  patient 
coughs,  and  blood  escapes  from  the  canula, 
showing  that  the  lung  has  been  punctured,  the  instrument  should  be  with- 
drawn. When  it  is  removed  the  small  puncture  should  be  closed  with  gauze 
and  collodion.  In  simple  serous  effusions  one  or  two  tappings  will  often 
effect  a  cure,  but  in  purulent  effusions  aspiration  gives  only  temporary  relief, 
and  a  cure  results  only  after  an  incision  has  been  made  and  thorough  drain- 
age establislied. 

Thoracotomy. — Purulent  pleural  effusions  may  be  removed  by  a 
simple  incision  between  the  ribs,  from  an  inch  to  one  and  a  half  inches  in 
length,  which  should  be  made  in  a  dependent  portion  of  the  chest  and  in 
the  mid-axillary  line.  Simf)le  incision  without  the  introduction  of  a  drain- 
age-tube is  not  often  ijractised.  The  procedures  usually  adopted  in  acute 
purulent  effusions  are  incision  and  the  introduction  of  drainage-tubes,  or 
the  excision  of  a  portion  of  a  rib  to  secure  an  opening  sufficiently  large  to 


A,  position  at  whioli  to  open  the  pleural 
cavity.    (After  Dennis.) 


THORACOTOMY.  843 

secure  free  drainage.  In  acute  emijyema  iu  children  we  liave  rarely  found 
it  necessary  to  resort  to  the  excision  of  a  portion  of  a  rib,  but  have  found 
the  introduction  of  drainage-tubes  satisfactory.  In  adults,  however,  and  in 
purulent  pleural  effusions  in  children  which  have  existed  for  some  time  the 
resection  of  a  portion  of  a  rib  and  the  introduction  of  draiuage  through  this 
opening  secures  free  drainage  and  is  followed  by  the  best  results. 

When  draiuage  by  tubes  is  employed  the  skiu  of  the  chest  upon  the  side 
of  the  operation  should  be  carefully  sterilized  ;  after  mapping  out  the  area 
of  dulness,  an  incision  about  one  aud  a  half  inches  iu  length  should  be  made 
through  the  tissues  at  a  dependent  portion  of  this  region.  The  sixth  inter- 
costal space  in  the  mid-axillary  line  is  the  position  preferred.  The  tissues  are 
carefully  divided  until  the  pleura  is  exposed  ;  this  should  be  opened  with  a 
knife  or  a  director,  when  purulent  matter  will  escape  from  the  opening.  A 
stout  flexible  metallic  probe  with  an  eye  in  its  point  is  bent  and  passed  into 
the  wound,  and  is  made  to  project  at  a  jjoint  more  posterior  in  the  inter- 
costal space  between  the  eighth  and  ninth  ribs.  This  is  cut  down  upon, 
and,  when  exijosed,  is  pushed  out  of  the  lower  wound  ;  it  is  then  attached  to 
a  large-sized  rubber  di-ainage-tube  and  withdrawn,  and  as  this  is  done  the 
tube  is  carried  through  the  pleural  cavity.  The  ends  of  the  tube  are  then 
transfixed  with  safety-pins  and  cut  off  flush  with  the  skin.  It  is  often  well 
to  introduce  also  a  short  draiuage-tube  several  inches  in  length  into  the 
lower  wound,  to  secure  additional  drainage. 

Irrigation  of  the  pleural  cavity  shoirld  be  avoided,  as  sudden  death  has 
occurred  from  this  jirocedure.  The  skin  surrounding  the  opening  of  the 
drainage-tube  should  be  washed  with  bichloride  solution,  aud  the  tubes 
should  be  covered  by  a  piece  of  iirotective  or  rubber  tissue,  which  often  acts 
as  a  valve  over  the  mouth  of  the  tubes,  allowing  the  discharge  to  escape, 
but  preventing  the  entrance  of  air ;  a  coijious  dressing  of  sterilized  or 
bichloride  gauze  aud  cotton  is  placed  over  the  opening  of  the  tube  and  held 
in  position  by  a  bandage.  The  dressings  should  be  renewed  as  soon  as  they 
become  soaked,  usually  within  twelve  or  twenty-four  hours,  and  subsequent 
dressings  will  be  required  less  frequently.  At  the  end  of  a  week  or  ten 
days,  if  the  amount  of  discharge  is  diminishing,  the  tubes  may  be  shortened, 
or  one  may  be  removed  ;  aud  at  the  end  of  two  or  three  weeks,  if  there  is 
only  a  little  thin  discharge  from  the  remaining  tube,  it  may  be  removed,  and 
the  wound  then  usually  closes  in  a  few  days.  Strips  of  sterilized  gauze  maj^ 
be  employed  in  the  place  of  drainage-tubes,  or  used  to  replace  the  tubes  in  a 
few  days.  To  secure  the  best  results  from  this  method  of  treatment,  the  largest- 
sized  drainage-tube  which  can  be  passed  between  the  ribs  should  be  employed. 
In  these  cases  there  is  often  a  certain  amount  of  deformity  of  the  chest  by  the 
falling  in  of  the  wall  towards  the  lung  to  obliterate  the  pleural  cavity. 

When  it  is  considered  desirable  to  resect  a  portion  of  a  rib,  the  latter  is 
exposed  for  an  inch  and  a  half  by  an  incision,  and  with  an  elevator  the 
periosteum  is  separated  from  it  from  above  downward  ;  it  is  then  divided  at 
the  extremities  of  the  incision  with  a  saw  or  bone-cutting  forceps,  the  boue 
not  being  entirely  divided  at  its  lower  portion  ;  the  section  of  bone  is  then 
grasped  with  forceps  and  wrenched  loose ;  by  this  means  it  is  possible  iu 
many  cases  to  avoid  division  of  the  intercostal  artery.     If  the  pleural  cavity 


844 


THORACOPLASTY. 


has  not  been  opened  in  the  manij)ulations,  it  should  be  freely  opened  and 
drainage-tubes  or  gauze  drainage  introduced. 

Thoracoplasty. — Estlander's  Operation. — This  operation  consists 
in  exposing  and  removing  several  inches  of  several  contiguous  ribs,  so  that 
the  chest  walls  can  fall  inward  and  come  in  contact  with  the  j)ulmonary 
pleura,  thus  obliterating  the  cavity.  This  procedure  has  proved  a  most 
valuable  one  in  cases  of  long-standing  emj)yema  with  great  thickening  of 
the  pleura  or  in  those  which  have  ruptured  spontaneously  at  some  point  of 
the  chest  wall  and  have  resulted  in  a  thoracic  fistula,  also  in  cases  in  which 
the  lung  is  so  bound  down  by  adhesions  that  incision  and  drainage  have 
failed  to  bring  about  a  core. 

An  oval  flap  six  inches  in  length  and  four  inches  in  breadth,  with  its 
base  near  the  mid-axillary  line,  is  dissected  up  from  the  chest  so  as  to 
exi30se  three  or  four  ribs,  or  an  incision  six  inches  in  length  may  be  made 
over  the  fifth,  sixth,  seventh,  and  eighth  ribs  in  the  mid-axillary  line,  and 
two  rectangular  flaps  may  be  dissected  up,  one  backward  and  one  forward, 
from  this  incision,  so  as  to  expose  from  four  to  six  inches  of  two  or  three 
contiguous  ribs.  The  ribs  are  next  divided  at  the  extremities  of  these 
incisions  with  a  narrow  saw  or  bone-pliers,  and  removed.  Hemorrhage 
from  the  intercostal  arteries  is  not  usually  troublesome,  but  if  they  bleed 
they  can  be  secured  by  ligatures.  The  costal  pleura  should  next  be  freely 
excised  to  the  length  of  the  incision,  making  an  opening  in  the  chest  as 
large  as  the  removal  of  bone  will  permit.  The  number  and  extent  of  the 
ribs  to  be  excised  will  depend  upon  the  size  of  the  cavity  exposed.  The 
exposed  cavity  should  be  irrigated  with  sterilized  water,  the  surfaces  of  the 
costal  and  the  pulmonary  pleura  curetted,  and  a  few  strips  of  gauze  loosely 
l^acked  into  the  cavity.     The  flaps  should  then  be  laid  over  the  cavity,  but 

need  not  be  secured  by  sutures.  A  large 
sterilized  or  antiseptic  gauze  dressing- 
should  be  applied  and  held  in  place  by 
a  bandage.  As  healing  progresses,  the 
soft  parts  are  drawn  inward  and  become 
attached  to  the  pulmonary  pleura,  and 
the  cavity  is  obliterated. 

Schede's  Operation. — This  consists 

in  exposing  and  excising  a  large  portion 

of  the  chest  wall  over  the  cavity  in  cases 

of  thoracic  fistula  in  which  there  is  great 

thickening  of  the  pleura.     An  incision  is 

made,  and  a  large  oval  flap  of  skin  and 

muscles  is  dissected  up,  exposing  the  ribs 

from  the  second  to  the  ninth  and  from 

the  costal  cartilages  to  their  angles.    The 

chest  wall  over  the  cavity,  composed  of 

the  exposed  ribs,  intercostal  muscles,  and 

costal  pleura,  is  then  cut  away  with  strong  bone-shears,  and,  after  curetting 

and  washing  out  the  cavity,  the  skin-flap  is  applied  to  the  pulmonary  pleura. 

This  operation  is  attended  with  considerable  danger  from  shock  and  hemor- 


FiG.  718. 


Eesult  of  Schede's  operation  i 
of  chest. 


PNEUMONOTOMY.  845 

rhage,  and  produces  great  deformity  of  the  cliest  at  the  seat  of  operation ; 
it  should  therefore  be  employed  only  when  a  less  heroic  procedure  has  failed 
to  bring  about  a  cure.     (Fig.  718.) 

Decortication  of  the  Lung. — This  term  is  applied  to  an  operation 
devised  by  Fowler  to  free  the  lung  and  render  its  expansion  possible  in  case 
of  old  empytema  in  which  the  lung  is  bound  down  by  thick  layers  of  mem- 
brane. The  operation  is  performed  by  making  an  elliptical  incision  over 
the  seat  of  cavity  in  the  chest  and  removing  three  or  four  inches  of  two  or 
three  contiguous  ribs,  or  a  larger  opening  may  be  made ;  the  thickened 
costal,  diaphragmatic,  and  jjulmonary  pleura  are  then  carefully  separated 
by  a  blunt  dissection  and  removed,  and  the  external  wound  closed  to  permit 
of  expansion  of  the  lung.  The  removal  should  be  as  complete  as  possible, 
but  if  it  is  found  impossible  to  perform  a  comj)lete  operation  the  pulmonary 
l^leura  should  be  removed.  The  mortality  following  the  operation  has  not 
been  great, — three  deaths  in  forty-one  cases.  According  to  Fowler  it  is 
applicable  to  all  cases  of  old  emxjysema  in  which  tuberculous  lesions  in  the 
lungs  are  not  present,  and  is  to  be  preferred  to  Estlander's  or  Schede's 
operation,  as  it  is  followed  by  a  more  complete  restoration  of  the  functions 

of  the  lung. 

OPERATIONS  UPON  THE  LUNGS. 

Pneumonotomy. — This  opei'ation,  which  consists  in  making  an  inci- 
sion into  the  tissue  of  the  lung,  may  be  employed  for  the  drainage  of 
abscesses  or  cysts,  in  the  treatment  of  gangrene  of  the  lung,  for  the  removal 
of  foreign  bodies,  in  cases  of  bronchiectasis  from  foreign  bodies,  and  for  the 
exposure  and  treatment  of  tubercular  cavities. 

The  most  favorable  cases  for  pneumonotomy  are  those  of  abscess  or  gan- 
grene of  the  lung,  in  which  the  pulmonary  tissue  overlying  and  surrounding 
the  abscess  or  the  gangrenous  area  is  adherent  to  the  costal  pleura.  When 
the  operation  is  performed  for  the  relief  of  bronchiectasis,  following  the 
lodgement  of  a  foreign  body,  the  cavity  may  be  opened  and  drained  and  the 
foreign  body  removed.  Bronchiectasis  if  it  involves  one  tube  only  is  much 
more  favorable  for  operation  'than  when  a  number  of  tubes  are  affected. 
The  operation  of  pneumonotomy  in  the  treatment  of  tuberculous  cavities 
should,  according  to  Godlee,  be  restricted  to  cases  in  which  there  is  a  single 
cavity  in  a  favorable  location  and  the  patient  is  being  worn  out  by  the 
harassing  cough. 

The  patient  being  anesthetized  and  the  position  of  the  cavity  accurately 
located,  an  incision  two  inches  in  length  should  be  made  at  its  most  depend- 
ent portion  through  an  intercostal  space  ;  when  the  lung  is  exposed,  if  this 
is  not  adherent  to  the  chest  wall,  it  may  be  fixed  to  the  chest  by  the  appli- 
cation of  a  few  sutures,  and  attempts  to  open  the  cavity  should  be  postponed 
for  a  few  days  until  adhesions  shall  have  formed.  If  the  lung  is  adherent 
to  the  chest  wall,  an  exploring  trocar  may  be  passed  through  the  lung-tissue 
to  verify  the  diagnosis.  If  the  lung  becomes  collapsed,  dyspnoea  may  be  so 
marked  that,  artificial  respiration  will  have  to  be  resorted  to,  or  forced 
respiration  may  be  employed  through  a  tracheal  canula.  It  may  also  be 
necessary  to  resect  a  portion  of  several  ribs  to  expose  the  cavity  sufficiently. 
When  the  cavity  is  located,  the  superimposed  lung-tissue  may  be  divided 


846  INTRATHORACIC  TUMORS. 

with  a  knife,  or  the  cavity  may  be  opeued  with  the  knife  of  Paquelin's 
cautery.  The  cavity  should  be  explored  with  the  tiuger,  and  if  a  foreign 
body  can  be  located  it  should  be  removed  with  forceps.  If  gangrenous 
tissue  is  present,  it  should  be  gently  removed  with  the  curette.  The  cavity 
should  then  be  irrigated  with  some  non-irritating  antiseptic  solution,  and  a 
large  draiuage-tube  introduced.  The  after-treatment  consists  in  washing 
out  the  cavity  and  retaining  the  drainage-tube  until  exi^ectoration,  and  dis- 
chai'ge  from  the  wound,  have  entirely  ceased. 

Pneuraonectomy. — This  operation  consists  in  the  excision  of  a  por- 
tion of  the  lung,  and  may  be  rec[uired  for  the  removal  of  tumors  of  the  lung, 
or  of  tumors  of  the  chest  which  have  involved  the  lung,  or  in  the  treatment 
of  recent  or  old  irreducible  hernise  of  the  lung  following  injuries.  It  has  also 
been  employed  for  the  removal  of  tuberculous  portions  of  the  lung.  Experi- 
mental research  has  shown  that  in  animals  a  considerable  portion  of  the  lung- 
may  be  removed  with  comparative  safety.  The  steps  of  the  operation  are 
similar  to  those  for  pneumonotomy.  The  lung-tissue  should  be  divided 
with  a  knife,  or  with  a  cautery  knife  to  avoid  hemorrhage.  The  results  of 
this  ojjeration  in  human  beings  have  not  been  sufficiently  encouraging  to 
justify  its  employment  save  in  exceptional  cases. 

Intrathoracic  Tumors. — These  growths  may  spring  from  the  walls 
of  the  chest  or  from  the  thoracic  viscera.  Those  arising  from  the  thoracic 
viscera  are  not  cases  for  sui'gical  treatment,  except  in  cases  of  hydatid  cysts. 
Tumors  springing  from  the  chest  wall  are  usually  carcinomata,  and  if  not 
too  intimately  connected  with  the  thoracic  viscera  can  often  be  removed 
with  safety  ;  in  some  cases  they  may  be  removed  subperiosteally  ;  in  others 
it  is  necessary  to  open  the  pleural  cavity.  The  operation  for  the  removal  of 
intrathoracic  tumors  is  always  attended  with  great  risk,  and  the  surgeon 
should  be  guided  in  his  oj)inion  as  to  the  advisability  of  their  removal  by 
the  size  of  the  growth  and  the  presence  of  healthy  skin  over  the  tumor,  for 
if  the  wound  cannot  be  covered  by  skin  the  operation  should  not  be  attempted. 
The  attachment  of  the  growth  to  the  viscera  is  also  a  condition  which  should 
decide  the  surgeon  for  or  against  operation.  In  operating  upon  these  growths 
a  free  incision  should  be  made,  and  it  will  often  be  found  necessary  to  divide 
several  ribs  and  remove  portions  of  them  with  the  growth. 

Anterior  Thoracotomy. — Milton's  Operation. — This  operation  has 
been  employed  for  the  removal  of  tumors  from,  and  exploration  of,  the 
anterior  mediastinum.  An  incision  is  made  in  the  median  line  of  the  neck 
from  the  thyroid  cartilage  and  carried  downward  over  the  sternum  to  the 
ensiform  cartilage.  The  trachea  is  exposed  opposite  the  episternal  notch  and 
the  fascia  is  detached  outward  to  the  insertion  of  the  sterno-mastoid  mus- 
cles, separated  with  the  finger,  and  displaced  downward,  with  the  structures 
lying  beneath  the  upi^er  end  of  the  sternum.  The  sternum  is  then  divided 
nearly  through  with  a  saw  in  the  line  of  the  skin  incision,  and  the  ensiform 
cartilage  is  separated  from  the  sternum  with  bone-forceps.  A  spatula  is 
introduced  beneath  the  sternum  from  below  and  the  divided  surfaces  of  the 
bone  are  separated  with  a  chisel  and  by  traction  with  strong  curved  reti-actors. 
In  this  manner  a  sejtaration  of  the  bones  for  two  inches  can  be  obtained  for 
exijloration  of  the  anterior  mediastinum. 


PARACENTESIS  PERICARDII. 


847 


Posterior  Thoracotomy. — Bryant's  Operation. — Thi.s  operation 
may  be  practised  for  the  removal  of  foreign  bodies  from  the  oesophagus  or 
bronchi,  posterior  mediastinal  tumois,  and  for  the  relief  of  pressure  from 
enlarged  glands.  The  jiatient  should  be  placed  obliquely  upon  the  abdomen 
with  the  side  to  be  operated  upon  upi^ermost.  A  flap  three  iuches  square 
with  its  base  over  the  spinous  processes  of  the  vertebriTe  is  formed,  including 
all  of  the  tissues  down  to  the  ribs.  Three  ribs  should  be  exposed  ;  the  mid- 
dle rib  is  then  separated  from  the  tissues  beneath  and  removed  and  a  corre- 
sponding x^ortion  of  the  ribs  above  and  below  are  separated  from  the  pleura 
and  divided  at  their  vertebral  attachments  and  at  their  other  extremities, 
their  intercostal  attachments  not  being  separated.  The  bronchus  or  cesopha- 
gus  is  then  exxjosed  and  incised  and  the  foreign  body  removed.  The  wound 
is  closed  by  replacing  the  upper  and  lower  ribs  and  suturing  them  with  silk- 
worm-gut or  wire,  and  the  flap  is  secured  in  jjosition  by  sutures. 

Paracentesis  Pericardii. — This  operation  may  be  required  for  the 
relief  of  distention  of  the  sac  from  pericardial  effusion  following  injuries  or 
resulting  from  acute  or  chronic  pericarditis.  The  heart  extends  from  the 
third  to  the  sixth  costal  cartilage  and  from  half  an  inch  to  the  right  of  the 
right  border  of  the  sternum  to  a  point  half  an  inch  to  the  right  of  the  left 
nipple.  The  symx^toms  of  pericardial  effusion  are  j^nshiug  ux^ward  or  loss 
of  the  apex  beat,  dysxmoea,  prsecordial  ox^XJi'^ssion,  feeble,  irregular  pulse, 
difSculty  in  deglutition,  dilatation  of  the  cervical  veins,  increased  area  of 
cardiac  dulness,  which  is  triangular  in 
shax^e,  and  muffling  of  the  heart-sounds. 
These  symptoms  may  arise  from  a  serous 
or  purulent  effusion  in  the  x^ericardium. 

Operation. — The  removal  of  serous 
effusion  from  the  pericardium  is  usually  / 
accomplished  by  introducing  the  needle 
of  the  aspirator  into  the  fifth  intercostal 
sx^ace  at  a  point  two  inches  to  the  left 
of  the  left  border  of  the  sternum,  ex- 
ternal to  the  internal  mammary  arterj^ 
(Fig.  719.)  The  needle  should  be  thrust 
directly  through  the  chest  wall,  and  the 

fluid-  allowed  to  escax^e  very  slowly.  If  it  is  found  that  the  effusion  is  xiuru- 
lent,  although  temporary  relief  may  be  afforded  by  asx^iratioir,  it  will  subse- 
quently be  necessary  to  incise  and  drain  the  XJCricardium.  An  incision 
should  be  made  at  the  same  x^oint  as  for  tax^x^ing  the  pericardium,  a  soft 
rubber-tube  or  gauze  drain  introduced,  and  a  cox^ious  antisex)tic  dressing 
XJlaced  over  the  wound. 


,  position  at  whicli  to  open  tlie  pericardium. 
(After  Dennis.) 


CHAPTEK    XXXIV. 

SURGERY   OF  THE  VERTEBRA  AND   SPINAL  CORD. 
By  B.   Faequhar  Curtis,   M.D. 

Injuries  of  the  Back.— Incised  and  contused  wounds  of  the  back  do 
not  differ  from  those  in  other  situations,  excejDt  that  a  very  severe  injury  may 
affect  the  spinal  cord  or  the  kidneys.  Sprains  of  the  muscles  of  the  back 
can  be  distinguished  from  the  deeper  sprains  involving  the  spinal  column 
by  the  lesser  severity  of  the  symptoms.  The  sprained  muscle  is  generally 
tender  to  the  touch,  and  sometimes  is  more  or  less  contracted,  although  more 
frequently  the  surrounding  muscles  are  in  a  state  of  spasm  in  order  to  avoid 
any  motion  of  the  injured  one.  Rest,  massage,  and  counterirritation  are  the 
best  methods  of  treatment.  A  broad  strapping  of  plaster  similar  to  that  for 
fracture  of  the  ribs  is  also  useful. 

Dislocation  of  the  Spine. — In  the  vertebral  column  fracture  and 
dislocation  are  almost  invariably  combined,  the  interlocking  of  the  bony 
processes  making  it  difficult  for  a  dislocation  to  occur  without  fracture,  and 
the  dislocation  is  usually  the  more  important  part  of  the  injury.  To  distin- 
guish the  tvro  is  often  impossible.  Simple  dislocation  is  rare  except  in  the 
cervical  region,  but  there  it  presents  a  definite  clinical  picture. 

In  simple  dislocation  of  the  spine  there  is  most  frequently  a  forward  dis- 
placement of  the  upper  vertebra  at  the  point  of  injury.  This  is  called 
an  anterior  bilateral  dislocation  when  it  affects  both  lateral  articulations, 
and  when  it  is  confined  to  one  side  it  is  called  a  rotatory  dislocation.  The 
bilateral  form  is  the  more  common  and  also  the  more  dangerous.  Backward 
dislocation  is  rare,  except  that  in  rotatory  dislocations  a  partial  backward 
displacement  is  found  in  the  joint  of  the  opposite  side.  The  edges  of  the 
articular  processes  become  caught  upon  each  other  so  that  the  bones  are  held 
in  the  abnormal  j)osition.  It  is  sometimes  possible  to  distinguish  dislocation 
from  fracture  by  the  greater  rigidity  and  the  frequent  occurrence  of  con- 
tractions of  the  muscles  supplied  by  nerves  above  the  point  of  injury  in  the 
dislocation.  Eeduction  of  the  deformity  is  also  more  difficult  than  in  the 
case  of  fracture,  but  the  cord  is  less  likely  to  be  injured.  The  deformity  and 
rigidity  of  a  dislocation  are  sometimes  simulated  by  the  stiffness  of  the  spine 
seen  in  simple  sprains,  but  in  such  cases  the  deformity  is  not  so  well  marked. 
The  prognosis  as  to  life  is  naturally  better  in  dislocation  than  in  fracture, 
particularly  in  the  rotatory  form. 

Symptoms. — In  anterior  bilateral  dislocations  of  the  vertebrse  the  ver- 
tebra just  below  the  joint  affected  will  be  prominent  at  the  back,  and  the 
one  above,  being  displaced  forward,  will  project  in  front.  This  can  be  ascer- 
tained in  the  cervical  region  by  inserting  the  finger  into  the  ijharynx  where 
the  body  of  the  atlas  lies  on  a  level  with  the  posterior  nares.  In  these  dis- 
placements in  the  neck  the  head  is  usually  bent  forward  and  fixed  in  this 


FRACTURES  OF  THE  SPINE.  849 

position,  but  occasionally  it  is  straight,  or  even  bent  backward.  In  rotatoi-y 
dislocations  the  head  and  face  are  rotated,  towards  the  shoulder  of  the  side 
opposite  to  the  injury,  and  the  head  is  also  inclined  laterally  to  that  side. 
(Pig.  720.)  The  chin  may  be  turned  to  the  same  side  as  the  injury.  The 
neck  is  convex  on  the  inj  ured  side,  „ 

and  the  muscles  are  tense,  the  tips 
of  the  spines  making  a  convex 
curve  in  that  direction.  Occa- 
sionally one  of  the  spines  is  felt  to 
be  displaced  laterally  towards  the 
convex  side,  and  sometimes  a 
greater  prominence  is  perceptible 
in  the  pharynx  upon  the  injured 
side. 

AttemjDts  to  move  the  head 
are  painful,  the  muscles  may  be 
spasmodically  contracted  and 
there  may  be  continuous  paiu. 
Tenderness  is  found  on  jjressure     , 

UDOn  the  spine  of  the  affected  unilateral  dislocation  of  cervical  vertebrte.  (Case  of  Dr. 
1  Ii,        T   1         i.    -,     ■    ■  \  G.L.Walton.) 

bone,  over  the  dislocated  joint, 

and  especially  over  the  opposite  joint  in  unilateral  dislocations.  Deglutition 
may  be  diilicult.  Injury  to  the  cord  is  often  absent,  and  when  present  will 
resemble  that  occurring  in  the  more  severe  injuries  described  below.  Exam- 
ination with  the  Rontgen  ray  may  assist  in  determining  the  deformity. 

Treatment. — Eeduction  of  the  unilateral  dislocations  is  effected  by 
making  strong  traction  on  the  head,  slightly  exaggerating  the  faulty  position 
in  order  to  disengage  the  edges  of  the  articular  processes  which  resist 
replacement,  then  rotating  towards  the  injured  side  and  inclining  the  head 
towards  that  side.  By  jiressure  on  the  neck  one  should  endeavor  to  make 
the  lower  vertebrae  follow  the  movements  of  the  head.  In  the  bilateral 
dislocation  traction  on  the  head  with  slight  rotary  and  lateral  rocking  move- 
ments must  be  depended  upon.  Extensive  motion,  especially  flexion,  is  to 
be  avoided  on  account  of  the  danger  to  the  cord.  When  the  dislocation  has 
been  reduced,  the  head  and  shoulders  are  to  be  fixed  by  a  wire  gutter  splint 
or  plaster-of- Paris  dressing. 

Fractures  and  Fracture-Dislocations  of  the  Spine.— Fractures 
of  the  spine  may  occur  in  any  part  of  the  column,  but  are  most  common  in 
the  dorsal  region,  especially  affecting  the  lower  dorsal  and  first  lumbar  ver- 
tebrse.  Fracture  of  the  spinous  processes  or  of  the  laminre  alone  is  rare, 
the  articular  processes  being  usually  broken  or  the  bodies  of  the  vertebrie 
crushed.  Crushing  of  the  bodies  shortens  the  column,  and  is  generally 
accompanied  by  some  bending  at  the  point  of  injury,  the  concavity  being 
directed  forward  and  the  spinous  process  projecting  behind.  There  may 
also  be  forward,  backward,  or  rotatory  displacements  in  these  fractures. 

The  injury  is  usually  caused  by  falls  upon  the  head  or  buttocks  or  on 
the  feet  in  the  erect  position.  It  may  also  be  caused  by  a  fall  upon  a  beam 
so  that  the  spine  is  bent  backward,  by  being  carried  on  a  vehicle  under  a 


850  FEACTUEES  AND  DISLOCATIONS   OF  THE   SPINE. 

low  doorway,  by  falls  while  carrying  a  heavy  weight  on  the  back,  or  by 
gunshot  injui-ies.  Fractures  of  the  spinous  processes  and  laminje  are  usually 
due  to  a  direct  blow.     These  accidents  are  rare  iu  children. 

The  displacement  of  the  broken  bone  inward  across  the  si^inal  canal 
generally  injures  the  spinal  cord  and  often  divides  it  completely.  A  gun- 
shot injury  to  the  spine  is  very  liable  to  involve  the  cord,  even  if  the  bone 
is  not  much  damaged. 

Symptoms. — As  in  fractures  of  the  skull  the  most  important  symptoms 
are  due  to  the  brain  lesion,  so  in  these  injuries  the  chief  symptoms  depend 
on  the  damage  inflicted  on  the  spinal  cord  and  the  nerve-roots.  The  local 
symptoms  found  in  the  spine  itself  are  :  (1)  Deformity,  which  may  show 
itself  by  the  backward  j)rojection  of  the  spinous  processes  if  the  bodies  are 
crushed,  and  by  a  lateral  displacement  of  the  tij)S  of  the  processes  if  the  injury 
has  been  upon  one  side  or  if  a  rotatory  dislocation  exists.  The  deformity  may 
not  be  evident  until  the  patient  is  able  to  stand.  The  Eontgen  ray  exami- 
nation is  of  the  greatest  assistance  in  determining  deformity.  (2)  Altered 
Mobility.  The  mobility  of  the  spine  may  be  imxiaired,  and  the  rigidity 
may  be  associated  with  curvature  or  rotation.  Abnormal  mobility  at  the 
point  of  the  fracture  is  very  seldom  found,  although  in  some  cases  motion 
may  be  felt  in  the  fragments.  (3)  Pain  and  Tenderness.  Pain  may  or 
may  not  be  present,  and  it  is  often  due  rather  to  pressure  upon  or  injury  of 
the  nerves  than  to  the  injury  of  the  bones.  Local  tenderness  is  a  very 
common  symptom,  and  is  useful  in  locating  the  exact  site  of  the  lesion. 
(4)  Crepitation  can  seldom  be  obtained  with  the  slight  amount  of  motion 
which  it  is  safe  to  make  in  the  examination.  (5)  Loss  of  Function.  In 
some  cases  the  patient  may  be  able  to  stand  and  walk,  but,  as  a  rule,  this  is 
impossible  from  pain  or  paralysis. 

Spinal  Cord  Symptoms. — The  canal  containing  the  cord  is  so  narrow 
that  even  a  slight  displacement  of  the  bones  causes  pressure  upon  that 
organ,  the  amount  of  injury  to  the  latter  depending  upon  the  degree  of 
the  pressure.  The  cord  may  be  crushed  and  entirely  divided  or  it  may  be 
slightly  compressed  by  the  displaced  bones.  In  the  first  case  a  complete 
paralysis  results,  and  its  extent  depends  upon  the  situation  of  the  injury 
to  the  cord,  varying  from  a  complete  paralysis  from  the  neck  downward 
to  a  paralysis  of  the  lower  extremities  only.  In  the  more  localized  and 
partial  injuries,  and  especially  if  the  nerve-roots  only  are  compressed,  the 
paralysis  may  be  confined  to  a  single  group  of  muscles  or  to  a  single 
extremity.  The  injury  to  the  cord  is  frequently  out  of  proportion  to  the 
disijlacement  of  the  bone,  as  the  latter  partly  returns  to  its  proper  position, 
and  the  compression  is  partially  relieved  in  at  least  two-thirds  of  the  cases. 
When  the  laminae  have  been  driven  into  the  spinal  canal  by  a  direct  blow, 
the  injury  to  the  cord  is  often  sharply  limited  and  may  cause  the  typical 
lateral  paralysis  of  Brown -Sequard.  Besides  actual  destruction  or  com- 
pression of  the  cord  by  the  displaced  bone,  the  injury  may  cause  the  for- 
mation of  a  hsematoma  in  the  caual  or  in  the  substance  of  the  cord  which 
will  cause  symptoms  of  gradually  increasing  pressure.  In  any  case  of 
fracture  or  dislocation  of  the  spine,  besides  the  immediate  injury  inflicted 
on  the  spinal  cord  a  secondary  descending  myelitis  with  degeneration  is 


TBEATMENT  OF  FRACTURES  AND  DISLOCATIONS  OF  TPIE  SPINE.     851 

quite  common.  In  injuries  of  the  upper  four  or  five  cervical  vertebne, 
although  the  cord  is  less  likely  to  be  injured,  because  that  is  the  widest  part 
of  the  canal,  there  is  great  danger  of  sudden  death  from  injury  to  the 
phrenic  nerve.  Paralysis  of  the  intercostal  muscles  may  be  produced  by 
injury  at  this  point  or  even  in  the  dorsal  region.  Paralysis  of  the  bladder 
and  of  the  intestine  may  be  pioduced  by  injury  in  any  part  of  the  cord. 
Priapism  is  a  common  symptom  of  injury  in  the  cervical  region.  The 
reflexes  may  be  present  or  they  may  be  lost.  (For  the  localization  of  the 
injury  to  the  cord,  see  page  857.)  Pressure  sores  form  over  the  sacrum  and 
over  any  of  the  bony  points  on  the  paralyzed  limbs,  and  even  on  the  penis 
where  it  rests  constantly  on  the  edge  of  a  urinal  on  account  of  dribbling  of 
urine.  The  pressure  sores  may  become  very  extensive,  covering-  the  entire 
back,  and  add  considerably  to  the  exhaustion  of  the  patient. 

Prognosis. — In  estimating  the  prognosis  in  injuries  of  the  spinal 
column  we  must  distinguish  between  the  effect  upon  the  column  itself  and 
that  upon  the  nervous  structures.  Fractures  in  the  cervical  region  are 
almost  invariably  fatal,  and  the  large  majority  of  the  j^atients  die  within 
three  or  four  days,  while  if  recovery  takes  place  a  permanent  paralysis 
usually  remains.  In  the  dorsal  region  the  jirognosis  is  better,  and  death  is 
generally  postponed  for  several  weeks.  In  the  lumbar  region  less  than  one- 
half  of  the  ijatients  die ;  if  death  occurs  it  comes  later,  and  the  paralysis 
may  entirely  disappear  if  recovery  takes  place.  The  bony  deformity  may  be 
permanent,  leaving  a  rigid  spine  bent  or  rotated  at  the  point  of  injury.  The 
prognosis  of  the  nerve  injury  will  depend  on  the  extent  of  the  lesion.  If 
there  is  progressive  paralysis  of  the  respiratory  muscles,  death  will  soon 
take  place.  Extensive  paralysis  with  paralysis  of  the  bladder  will  also  be 
fatal.     Partial  paralysis  maj^  be  recovered  from. 

Treatment. — When  a  severe  injury  has  been  sustained  which  has  prob- 
ably resulted  in  fracture  or  dislocation  of  the  spine,  the  greatest  care  and 
gentleness  must  be  exercised  in  handling  the  patient,  lest  fatal  injury  be 
inflicted  on  the  cord.  In  rare  cases  the  patient  may  be  able  to  walk  and 
may  ha^-e  no  severe  symptoms  for  days,  and  may  then  suddenly  die  from 
accidental  displacement  of  the  bones.  Usually,  however,  he  will  be  found 
lying  down,  often  in  collapse,  and  a  stretcher,  a  board,  or  a  sheet  should  be 
slipped  under  him,  his  neck  and  head  being  moved  as  little  as  possible,  in 
order  to  transport  him. 

These  injuries  may  be  treated  by  three  methods.  First,  by  the  expect- 
ant plan,  in  which  the  patient  is  simply  kept  at  rest  on  a  water-bed,  the 
head  and  body  being  xjroperly  supported  by  sand-bags  or  jjillows  on  each 
side,  or  by  a  plaster  jacket  or  spinal  brace.  In  the  second  method  some 
effort  is  made  to  reduce  the  displacement,  which  is  most  readily  accom- 
plished when  the  injury  is  in  the  cervical  region,  because  here  the  bones  are 
small  and  easily  accessible,  and  strong  extension  with  rotation  or  flexion  of 
the  head  is  often  successful.  The  reduction  should  be  attempted  only  with 
the  full  understanding  of  the  patient  that  it  is  dangerous,  for  the  control  over 
the  bones  is  so  slight  that  a  fatal  injury  to  the  cord  might  be  produced.  These 
manipulations  should  be  limited  to  forcible  extension  of  the  parts,  since 
attempts  at  flexion  are  more  likely  to  increase  the  injury.     If  simple  exten-- 


852  INFLAMMATIONS  AND  TUMORS   OF  THE   BACK. 

sion  is  insufflcient  for  reduction,  the  suspension  apparatus  employed  in 
applying  the  plaster-of-Paris  jacket  for  Pott's  disease  may  be  applied  and 
the  patient  suspended.  Finally,  there  is  the  operative  method.  The  bones 
being  exposed  by  an  incision  along  the  spine,  as  in  laminectomy,  the 
depressed  bone  may  be  removed  or  elevated,  or  a  dislocation  reduced  by 
proper  manipulation  under  the  control  of  the  finger  and  the  eye.  In  some 
cases  a  silver  wire  twisted  around  the  spinous  processes  has  retained  the 
bones  in  place.  If  the  patient  be  seen  early  enough,  and  if  the  injury  to  the 
cord  be  not  too  extensive,  good  results  can  undoubtedly  be  obtained  by 
oijera.tious  of  this  nature.  After  i-eduction  the  head  and  body  should  be 
encased  in  a  plaster-of-Paris  jacket,  but  this  must  be  removed  if  pressure 
sores  develop  beneath  it.  An  extension  apparatus  fixed  to  the  head  and 
legs,  as  in  Pott' s  disease  (page  550),  may  also  be  employed.  In  some  cases 
the  reduction  occurs  spontaneously,  but  symptoms  of  injury  to  the  cord  are 
present  and  may  require  operation.  Some  surgeons  prefer  to  wait  several 
weeks  before  operation,  arguing  that  the  hopeless  cases  and  the  cases  with 
lesions  capable  of  spontaneous  recovery  will  thus  be  spared  the  great  risk  of 
operation. 

In  the  after-treatment  the  principal  attention  must  be  given  to  the  paraly- 
sis of  the  bladder  and  bowels  and  to  the  pressure  sores.  The  regular  use  of 
the  catheter  must  be  begun,  with  every  precaution  against  cystitis,  which  is 
almost  certain  to  develop  sooner  or  later.  If  cystitis  occurs,  irrigation  of  the 
bladder  must  be  systematically  carried  out.  It  has  been  suggested  by  some 
to  allow  the  bladder  to  fill  up  without  the  use  of  the  catheter  and  to  estab- 
lish "incontinence  by  overflow,"  so  as  to  avoid  infection  from  instruments, 
but  this  method  involves  certain  dangers  of  its  own.  The  bowels  should 
be  evacuated  by  the  use  of  softening  enemata  and  laxatives,  and  properly 
regulated  by  the  diet,  food  being  given  which  will  produce  as  little  fecal 
matter  as  possible.  Pressure  sores  are  to  be  a^'oided  by  the  use  of  the  water- 
bed  or  air  mattress,  by  changing  the  position  of  the  patient,  by  employing 
small  pillows,  by  careful  washing  of  the  back,  by  hardening  the  skin  with 
alcohol  or  an  iclithyol  solution,  and  by  painting  the  doubtful-looking  s^jots 
with  iodoform  collodion.  Even  with  the  greatest  care  pressure  sores  are 
prone  to  develop  after  several  weeks  or  nionths'  confinement  in  bed.  When 
pressure  sores  develop  they  must  be  kept  as  aseptic  as  possible,  sinuses 
drained,  and  sloughs  removed.  The  permanent  bath  will  add  to  the  patient's 
comfort. 

Inflammations  and  Tumors  of  the  Back. — Cellulitis  and  car- 
buncle are  found,  but  do  not  differ  from  the  ordinary  varieties  of  these 
affections.  Syphilitic  eruptions  are  also  very  frecpient.  Bursitis  of  the 
gluteal  bursse  occurs,  and  less  frequently  the  bursse  about  the  scapula  are 
inflamed.  They  present  the  usual  symjitoms,  and  are  treated  along  the  lines 
laid  down  elsewhere.  Both  benign  and  malignant  tumors  occur  on  the 
back,  the  most  frequent  being  sebaceous  cysts  and  lipomata.  Sarcoma  is 
found  in  the  deep  muscles  of  the  back,  and  epithelioma  occurs,  although 
very  rarely,  in  the  skin. 

Spina  Bifida. — Spina  bifida  (also  called  hydrorrhachis)  is  a  congenital 
tumor,  originating  from  the  spinal  canal,  from  the  same  causes  that  lead  to 


SPINA   BIFIDA. 


853 


cephalic  meningoceles  (page  726).  Owing  to  imijroper  development  of  the 
spinal  column,  its  canal  is  not  closed  posteriorly,  and  protrusion  of  the 
membranes,  and  even  some  of  the  nervous  structures,  takes  place  through 
the  Oldening  in  the  bones,  from  the  pressure  of  the  cerebro-spinal  fluid. 
This  jDrotrusion  may  be  situated  in  any  part  of  the  spine,  but  is  most 
common  in  the  lumbar  and  sacral  regions.  The  skin  covering  the  sac  may 
be  normal,  but  it  is  usually  thin  and  translucent,  and  may  be  very  vascular. 
In  some  cases  the  sac  consists  only  of  the  membranes  of  the  cord,  but  the 
dura  is  almost  invariably  deficient  to  the  same  extent  as  the  bone.  The 
communication  with  the  spinal  canal  may  be  very  narrow  or  may  involve 
many  vertebral  arches.  ^Nerves  are  frequently  seen  running  in  the  walls  of 
the  sac  and  returning  at  the  lower  margin  to  their  normal  course,  or  cross- 
ing the  cavity  from  side  to  side,  like  tense  bands.  The  substance  of  the 
spinal  cord  is  occasionally  expanded  over  the  walls  of  the  sac.  The  cord 
and  nerves  are  involved  in  two-thirds  of  the  cases,  and  paralysis  is  a  fre- 
quent comijlication.  When  the  protrusion  consists  of  the  membranes  only 
it  is  called  a  spinal  meningocele  (Fig.  721).  This  is  a  very  rare  form,  most 
cases  so  called  being  myelocystoceles.  In  some  cases  the  sac  is  formed  of 
the  cord  itself,  the  cavity  being  the  dilated  central  canal  of  the  cord,  a  con- 
dition known  as  myelocystocele  (Fig.  722). 

Fig.  721.  Fig.  722. 


Section  of  spinal  meningocele. 
Fig.  723. 


Section  of  myelocystocele. 
Fig.  724.  Fig. 


Diagrams  and  section  showing  formation  of  myelocele. 

In  some  cases  the  atrophic  cord  is  exposed  at  the  bottom  of  the  defect 
{racMscMsis),  or  lifted  up  on  the  surface  of  a  cyst  by  fluid  collected  between 
'the  cord  and  the  anterior  wall  of  the  spinal  canal  (myelocele).  Fig.  723 
shows  a  diagrammatic  transverse  section  through  a  spinal  cord  in  which  the 
central  canal  has  remained  open  posteriorly.     Fig.  724  shows  the  effect  of 


854 


SYMPTOMS   OF  SPINA  BIFIDA. 


fluid  accumulating  iu  the  vertebral  canal  in  front  of  such  a  cord,  inverting 
it  and  turning  the  anterior  nerve-roots  into  the  interior.  Fig.  725  shows  a 
section  through  such  a  spina  bifida  (myelocele)  with  the  inverted  cord  lying- 
flattened  out  along  the  apex  of  the  sac,  the  fluid  having  accumulated  in  the 
subarachnoid  space.  The  dura  does  not  enter  into  the  sac.  The  remains 
of  the  cord  in  these  cases  form  a  reddish  area  with  a  dej)ression  at  each  end 
where  the  central  canal  is  obliterated,  and  this  is  surrounded  by  a  thin  scar- 
like zone  where  the  serous  membrane  and  the  external  epidermis  come  in 
contact.  When  the  cord  is  atrophic  the  paralysis  is  serious  and  the  cases  are 
not  suitable  for  oijeration. 

Symptoms. — The  sac  forms  a  projection  upon  the  back  over  the  spine 
(Pig.  726),  covered  by  normal  skin,  or  thin  scar  tissue  with  remains  of  the 

cord.     The  swelling  fluctuates  and  is 
Fig.  726.  often  translucent.     If  the  oijening  in 

Fig.  727. 


Spina  bifida.  Spontaneous  cure  of  spina  biiida. 

the  spinal  canal  is  large,  the  sac  sometimes  swells  up  with  strong  respiratory 
efforts  in  crying  or  coughing,  but  pulsation  is  rare.  Strong  pressure  on  the 
sac  sometimes  increases  the  tension  of  the  fontanelle,  and  may  cause  convul- 
sions and  signs  of  cerebral  compression.  These  tumors  tend  to  increase  in 
size,  the  coverings  becoming  thinner,  until  finally  they  slough.  This  acci- 
dent results  in  death,  either  from  the  loss  of  the  cerebro-spinal  fluid  or  by 
infection  of  the  membranes  and  meningitis.  A  spontaneous  cure  occurs  in 
rare  instances  (Fig.  727),  the  tumor  gradually  growing  smaller  and  the  cov- 
erings over  the  sac  thickening. 

In  the  condition  known  as  spina  bifida  occulta  the  arrest  of  develop- 
ment is  limited  to  the  bone,  and  there  is  no  protrusion  of  the  membranes. 
In  these  cases  there  is  apt  to  be  a  fatty  tumor  over  the  opening  in  the  canal, 
with  a  local  overgrowth  of  hair,  and  thickening  of  the  skin.  In  spina 
bifida  occulta  and  in  cases  of  spontaneous  cure,  symptoms  sometimes  develop 


SURGICAL  DISEASES   OF  THE  SPINAL  CORD.  855 

indicatiug  pressure  upou  the  cord  or  cauda  equina,  siich  as  paralysis,  anaes- 
thesia, aud  trophic  disturbances,  and  the  pressure  has  been  successfully 
relieved  by  operation  in  a  few  cases  of  this  kind.  Certain  rare  congenital 
cysts  and  fatty  tumors  of  the  spinal  canal  may  i^rotrude  and  resemble 
spina  bifida,  but  the  cysts  are  usually  lobulated  and  the  lipomata  are  not 
translucent.  Spina  bifida  is  frequently  associated  with  other  deformities, 
such  as  clubfoot,  and  also  with  hydrocephalus.  The  prognosis  is  bad,  nearly 
all  of  the  patients  dying  before  five  years  of  age  if  left  without  treatment. 
Treatment  is  useless  if  there  is  extensive  paralysis  or  hydrocephalus. 

Treatment. — The  treatment  by  injection — drawing  off  a  drachm  or  two 
of  the  fluid  and  injecting  from  one-half  to  one  drachm  of  tincture  of  iodine 
or  iodine  glycerin  solution  (iodine,  10  grains  ;  potassium  iodide,  30  grains ; 
glycerin,  1  ounce) — has  been  successful  in  about  one-half  of  the  cases.  The 
puncture  is  made  obliquely  through  the  sound  skin  at  the  side  of  the  tumor 
with  a  hypodermic  needle,  full  aseptic  precautions  being  observed.  In  this 
method  there  is  danger  of  paralysis  when  the  nerves  are  involved,  of  septic 
complications  and  meningitis,  and  of  subsequent  leakage  of  cerebrospinal 
fliiid.  Operative  removal  of  the  tumor  has  also  given  fair  results,  which 
are  constantly  improving.  The  dangers  of  operation  are  three-fold  :  first, 
the  shock  and  loss  of  blood  at  the  time  of  operation  ;  secondly,  septic  infec- 
tion ;  and.  thirdly,  leakage  of  the  cerebro-spiual  fluid.  There  is  also  danger 
of  injury  and  permanent  paralysis  of  the  nerves  which  are  included  in  the 
sac.  The  operation  is  most  successful  in  pure  meningoceles  having  a  small 
communication  with  the  spinal  canal.  It  is  begun  by  dissecting  back  the 
skin  from  the  tumor.  If  the  pedicle  of  the  sac  is  small,  it  is  simply  ligated  ; 
if  large,  the  opening  must  be  sutured,  but  the  sac  should  be  opened  to  ascer- 
tain whether  any  nerves  are  involved.  If  large  nerve-trunks  or  the  cord 
itself  be  included  in  the  sac  wall,  as  proved  by  palpation,  by  seeing  them 
through  a  thin  sac,  or  by  the  presence  of  paralysis,  no  operation  is  allow- 
able. Operation  should  not  be  undertaken  before  the  child  is  three  months 
of  age.  In  some  cases  successful  attempts  have  been  made  to  close  the 
opening  by  making  bone  or  periosteal  flaps  from  the  vertebral  arches  or  the 
sacrum,  or  by  grafting  the  periosteum  of  a  rabbit  on  the  sutured  sac. 

Surgical  Diseases  of  the  Spinal  Cord  and.  its  Membranes.— 
Inflammation. — Inflammation  of  the  spinal  meninges  may  follow  similar 
affections  of  the  head,  or  may  arise  from  direct  infection  through  an  external 
wound,  and  the  symptoms  are  spinal  irritation,  convulsions,  aud,  finally, 
paralysis,  together  with  a  high  fever.  Purulent  meningitis  is  rare,  but 
when  it  has  once  set  in  treatment  appears  to  be  powerless,  and  a  fatal  end 
may  be  exi^ected.  In  case  of  external  infection  the  only  available  method 
of  treatment  is  a  free  opening  and  drainage  of  the  wound. 

Tumors  of  the  spinal  cord  are  usually  gliomata  or  tuberculous  nodules, 
but  they  are  rare.  The  tumors  which  chiefly  occupy  the  surgeon  are  those 
which  develop  in  the  meninges,  especially  the  dura,  or  in  the  bone,  aud 
compress  the  cord  or  involve  it  secondarily.  These  tumors  are  generally 
fibromata,  sarcomata,  or  gummata.  A  tumor  affecting  the  spinal  cord  may 
be  suspected  when  localized  motor  and  sensory  paralysis  develops  without 
known  cause,  especially  if  it  be  preceded  by  symptoms  of  irritation,  such  as 


856  LACERATION  AND  CONTUSION   OF  THE  SPINAL  CORD. 

increased  reflexes,  muscular  sijasm,  spinal  rigidity,  and  pain.  Intense  pain, 
often  limited  to  certain  nerves,  is  a  common  symptom,  and  sometimes  local 
tenderness  of  the  spine  is  observed.  (For  localization  of  spinal  cord  lesions, 
see  page  857. )  Tumors  in  tlie  spinal  canal  whicli  compressed  the  cord,  but 
did  not  originate  from  it,  have  been  successfully  removed  by  the  operation  of 
laminectomy  (page  859). 

Injuries  of  the  Spinal  Cord. — Concussion. — The  symptoms  recog- 
nized under  the  name  of  concussion  of  the  si^inal  cord  are  due  to  slight 
lesions,  such  as  very  small  lacerations,  hemorrhages,  or  contusions.  This 
condition  has  been  known  by  the  name  of  "railway  spine,"  on  account  of 
its  frequent  production  by  railroad  accidents.  It  is  most  marked  in  persons 
of  a  neurotic  temperament,  and  depends  largely  upon  the  fright  and  cere- 
bral shock  received  at  the  time  of  injury.  The  symptoms  occasionally  dis- 
appear as  suddenly  as  hysterical  affections. 

Symptoms. — The  fact  that  these  cases  are  often  comjilicated  with  law- 
suits for  the  recovery  of  damages  renders  the  interpretation  of  the  reality 
of  the  symptoms  still  more  difiBcult.  The  ijrevailing  opinion  at  the  present 
time  is  that  such  patients  do  not  feign  the  symptoms  they  present,  but  that 
they  are  the  subjects  of  a  real  nervous  affection,  although  it  is  probable  that 
the  mind  is  affected  as  much  as  the  spinal  cord. 

There  are  three  types  distinguishable  among  these  cases,  the  picture  pre- 
sented being  respectively  that  of  neurasthenia,  neuralgia,  or  paralysis,  and 
in  some  cases  any  or  all  of  the  groups  of  "symptoms  may  be  combined.  The 
neurasthenic  patients,  who  are  the  most  numerous,  show  a  loss  of  memory 
and  of  will-power  and  have  some  pain  in  the  back  and  a  feeling  of  weak- 
ness, with  congestion  of  the  conjunctiva  and  more  or  less  disturbance  of  all 
the  bodily  functions.  The  neuralgic  patients  suffer  from  severe  shooting 
pains  in  various  nerves,  but  particularly  in  the  back  and  in  the  lower 
extremities.  Thirdly,  the  paralytic  type  of  patients  have  a  marked  loss  of 
power  or  even  complete  paralysis  of  one  or  more  groups  of  muscles,  espe- 
cially of  the  lower  extremities,  and  localized  patches  of  ansesthesia.  In  all 
cases  there  is  an  exaggeration  of  the  reflexes.  These  symptoms  do  not,  as  a 
rule,  begin  until  some  hours  or  days  after  the  accident  which  causes  them. 
It  cannot  be  said  that  any  one  of  these  types  is  more  diflicult  to  cure  or 
more  likely  to  result  in  permanent  disability  than  the  others.  In  some  cases 
the  symptoms  disappear  suddenly  and  completely  without  any  adequate 
explanation,  and  if  this  disappearance  happens  to  coincide  with  the  winning 
of  large  damages  in  a  lawsuit,  great  discredit  may  be  thrown  upon  the 
patient  and  the  experts,  but  unjustly,  for  many  cases  are  on  record  in  which 
even  the  winning  of  the  suit  has  not  succeeded  in  effecting  a  cure.  Law- 
suits, whether  successful  or  not,  are  a  detriment  to  a  patient  in  this  condi- 
tion, for  what  he  most  needs  is  rest  and  freedom  from  responsibility  and  care. 

Treatment. — Complete  rest  is  the  only  method  of  treatment,  except  the 
administration  of  the  usual  tonics,  hot  and  cold  baths,  massage,  and  gentle 
exercise,  with  a  free  out-door  life.  Occasionally  some  counterirritation  by 
a  thorough  cauterization  over  the  spine  is  of  advantage. 

Laceration  and  Contusion. — Laceration  and  contusion  of  the  spinal 
cord,  if  extensive,  are  marked  by  paralysis  corresponding  to  the  portion  of 


AVOUNDS   OF  THE  SPINAL   CORD. 


857 


the  cord  iuvolved,  and  are  usually  associated  with  severe  fractures  or  dislo- 
cations of  the  spiual  column.  A  comijlete  recovery  may  take  place  even  in 
sevei'e  cases,  although  this  is  usually  slow. 

Compression. — Compression  of  the  spinal  cord  may  be  caused  by  dis- 
placed bone  (from  fracture  or  si^iual  caries),  by  a  foreign  body,  such  as  a 
rifle-ball  lodging  in  the  canal  (Fig.  728),  and  by  bloodclot,  inflammatory 
exudate,  or  tumors  in  the  canal. 

Wounds  of  the  Spinal  Cord. — The  cord  may  be  completely  divided 
by  fractured  or  dislocated  bones  of  the  spiual  column,  and  also  by  pene- 
trating wounds  by  a  knife,  gunshot,  or  other  missile.  In  the  later  cases 
cerebro-spinal  fluid  may  escajje  from  the  wouud. 

Symptoms  and  Diagnosis  of  Lesions  of  the  Spinal  Cord. — The 
symptoms  of  complete  compression  or  destruction  of  the  spinal  cord  are  the 
same,  whatever  their  cause  may 

be,  but  usually  they  begin  sud-  ^'g.  728. 

denly  in  the  traumatic  cases.  f~ 

There  is  complete  motor  and 
sensory  paralysis  below  the  level 
of  the  lesion,  but  the  muscles  do 
not  atrophy  or  contract.  The 
tendou  reflexes  are  completely 
lost,  although  the  skin  reflexes 
may  remain.  The  total  loss  of 
tendon  reflex  is  a  probable  but 
not  absolute  indication  of  a  com- 
plete destruction  of  the  cord. 
There  is  retention  of  urine  and 
faeces  owing  to  loss  of  the  ex- 
pulsive power,  but  later  the  anal 
sphincter  becomes  jjaralyzed. 
Cystitis  is  common  from  infec- 
tion due  to  the  use  of  the  catheter.  If  the  catheter  is  not  employed  the 
accumulating  urine  finally  overpowers  the  sphincter  and  the  surplus  dribbles 
away,  establishing  an  incontinence  from  overflow,  the  bladder  remaining 
distended.  Sometimes  symptoms  of  intestinal  obstruction  or  stenosis  of  the 
pylorus  appear  from  paralysis  of  the  peristaltic  movements,  with  great  dis- 
tention.    Pressure  sores  form  upon  the  sacrum  and  other  prominent  parts. 

When  only  one  lateral  half  of  the  cord  is  affected,  the  characteristic 
Brown-Sequard  symptoms  are  produced.  There  is  complete  motor  paralysis 
on  the  injured  side,  but  the  reflexes  remain  and  the  muscles  do  not  atrophy. 
If,  however,  there  is  much  destruction  of  the  ganglion  cells  at  the  seat  of  the 
lesion  there  will  be  immediate  atrophy  of  the  muscles  they  innervate,  while 
the  muscles  lower  down  do  not  degenerate.  There  is  hypertesthesia  of  the 
injured  side.  On  the  opposite  side  will  be  found  loss  of  the  sense  of  pain 
and  temperature,  but  the  sense  of  touch  remains  normal.  The  bladder  and 
rectum  are  generally  not  affected.  The  symptoms  soon  show  improvement, 
which  must  be  due  to  other  fibres  taking  on  the  function  of  those  which 
have  been  destroyed,  for  the  fibres  of  the  cord  do  not  regenerate.     Partial 


Gunshot  fracture  of  cervical  vertebra,  showing  ball  en- 
croaching on  spinal  canal. 


858  WOUNDS   OF  THE  SPINAL  CORD. 

lesions  of  less  extent  have  their  own  pecnliar  symptoms,  which  may  allow 
of  their  exact  localization.  In  all  partial  traumatic  lesions  the  hemorrhage 
and  oedema  immediately  after  the  injury  may  j)roduce  symptoms  of  complete 
destruction  of  the  cord,  which  pass  off  leaving  the  minor  symptoms. 

Lesions  which  xjroduce  moderate  local  compression  of  the  cord,  such  as 
inflammatory  exudate,  subdural  blood-clot,  and  tumors,  cause  pain,  a  band- 
like feeling  around  the  waist,  localized  muscular  twitching,  exaggerated 
reflexes,  and  other  signs  of  nerve  irritation.  As  the  pressure  increases  these 
symj)toms  give  way  to  those  of  paralysis,  partial  or  complete. 

Hemorrhages  taking  place  in  the  tissues  of  the  cord  may  directly  involve 
and  destroy  the  ganglionic  centres,  causing  permanent  paralysis  and 
muscular  atrophy.  Large  focal  hemorrhages  are  very  common  in  the 
cervical  cord  as  the  result  of  injury,  and  may  produce  motor  and  sensory 
paralysis  of  all  the  extremities.  The  ganglionic  centres  of  the  arms  are 
l^aralyzed  directly,  but  the  clot  also  presses  upon  the  nerve-libres  which  j)ass 
down  the  pyramidal  tracts,  and  thus  paralyzes  the  parts  below.  In  both 
cases  the  paralysis  is  flaccid,  but  in  the  legs  it  soon  becomes  spastic,  and 
then  begins  to  improve.  The  knee-jerk  at  first  may  be  normal,  exaggerated, 
or  completely  lost  (Bailey) ;  later  it  becomes  exaggerated.  The  arms  are 
much  slower  in  recoverj%  and  there  may  be  a  permanent  atrophic  paralysis 
from  the  destruction  of  the  ganglia.  The  ansesthesia  in  these  cases  is  pecu- 
liar, the  sense  of  touch  being  preserved,  but  the  sense  of  heat  and  pain 
being  lost,  and  it  may  be  as  extensive  as  in  complete  compression  of  the 
cord.  Pain,  j)aralysis  of  the  sphincters,  and  bed-sores  may  or  may  not  be 
present. 

Small  focal  hemorrhages  cause  similar  symptoms,  but  of  less  extent, 
and  sometimes  only  very  limited  areas  of  heat  and  pain  anaesthesia,  with 
exaggerated  reflexes,  are  found.  The  general  prognosis  of  simple  hemor- 
rhage into  the  cord  is  not  hoj)eless,  the  tendency  being  towards  recovery, 
and  improvement  of  the  jjaralysis  begins  quite  early.  But  the  patients  are 
apt  to  present  symptoms  of  spinal  neurasthenia  for  a  long  time. 

The  diagnosis  of  the  situation  and  extent  of  the  lesions  of  the  spinal  cord 
depends  upon  the  nerve-symptoms.  In  interpreting  the  symptoms  we  can 
generally  neglect  the  oblique  passage  of  the  nerve-roots  downward  in  the 
spinal  canal  before  emerging.  Experience  shows  that  if  local  pressure  is 
exerted  at  any  point  in  the  canal  the  cord  is  more  liable  to  damage  than  the 
tougher  nerve-roots  at  its  sides.  But  we  must  know  accurately  the  relative 
position  of  each  vertebral  body  and  its  corresponding  spinous  process,  in 
order  to  locate  the  segments  of  the  cord.  The  anaesthesia  prodiiced  by  the 
lesions  of  the  cord  is  usually  limited  by  horizontal  lines,  not  by  the  areas  of 
distribution  of  the  spinal  nerves,  for  the  fibres  from  any  one  centre  are  not 
grouped  together  but  pass  out  in  several  adjoining  nerves.  The  motor 
paralysis  is  often  indistinct  in  its  limits,  because  each  motor  root  takes  its 
origin  from  several  segments  of  the  cord  and  the  origins  of  several  roots 
overlap  each  other.  A  lesion  of  one  segment  may  cut  off  only  part  of  the 
supply  of  the  roots  affected  and  produce  only  j)artial  paralj'sis  of  certain 
muscles.  Muscular  atrophy  is  generally  absent,  even  in  comiilete  paralysis 
due  to  lesions  of  the  cord,  because  the  ganglia  below  the  lesion  are  sufficient 


OPERATIONS   ON  THE  SPINAL  CORD.  859 

to  keep  up  the  muscular  nutritiou,  but  atrophy  occurs  if  the  focal  gauglia 
of  the  part  are  desti'oyed,  as  has  been  described  above,  by  a  heraorrhage. 
The  lesion  is  at  a  higher  level  than  would  be  indicated  by  a  strict  anatomical 
interpretation  of  the  symptoms,  and  its  upper  limit  will  be  found  to  coi- 
respond  more  nearly  with  the  area  of  spinal-cord  irritation,  as  shown  by 
hypera^sthesia,  etc.  On  the  other  hand,  immediately  after  an  injury,  the 
symptoms  may  indicate  a  much  more  extensive  damage  to  the  cord  than 
really  exists,  and  it  may  be  necessary  to  wait  for  some  improvement  before 
making  a  diagnosis. 

Treatment. — Open  wounds  involving  the  spinal  cord  are  seldom  infected, 
and  they  should  not  be  examined  by  the  probe  or  finger  for  fear  of  infecting 
them.  The  surrounding  parts  should  be  rendered  aseptic,  large  wounds 
partly  sutured,  a  small  drain  being  inserted  through  the  skin  and  fascia, 
and  an  aseptic  dressing  applied.  If  symptoms  of  injury  to  the  cord  are 
present,  the  question  of  operation  requires  discussion.  Incised  wounds  of 
the  cord  cannot  be  dealt  with  surgically,  for  the  fibres  will  not  regenerate. 
Gunshot  wounds  demand  interference  if  there  are  indications  of  compression, 
but  not  otherwise.  Operations  are  of  no  value  for  the  relief  of  hemorrhage 
into  the  substance  of  the  cord.  We  have  already  given  the  indications  for 
interference  in  fractures.  The  other  details  of  treatment  have  also  been 
given,  page  851. 

Operations  on  the  Spinal  Cord. — Surgical  operations  on  the  spinal 
cord  are  as  yet  limited  to  the  relief  of  compression,  depressed  bone  being- 
elevated,  dislocations  reduced,  and  tumors  removed.  It  is  difdeult  to 
explain  why  wounds  of  the  cord  should  not  heal  by  primary  union  as  well 
as  those  of  nervous  tissue  elsewhere,  but  all  experiments  made  in  this  direc- 
tion have  failed.  This  does  not  apply,  however,  to  the  nerve-roots, 
which  may  be  united  like  the  perij;)heral  nerves  with  good  results. 

Laminectomy. — Laminectomy  is  the  operation  of  oiiening  the  spinal 
canal  by  cutting  away  the  vertebral  arches.  An  H-incisiou  is  often  used, 
flaps  being  turned  upward  and  downward,  including  the  skin,  muscles,  and 
spinous  processes,  the  arches  being  divided  in  the  same  lines  on  each  side. 
A  better  method  is  the  formation  of  a  lateral  flaiD  by  an  incision  over  the 
arches  upon  one  side,  the  periosteum  and  muscles  being  reflected  to  the 
bases  of  the  spinous  processes,  the  latter  then  being  divided  with  bone- 
forceps  or  chisel  and  lifted  up  in  the  flap,  the  dissection  of  which  is 
continued  towards  the  other  side  until  the  arches  are  exposed  from  end  to 
end.  The  latter  are  then  cut  away.  In  operating  for  fracture,  the  bone 
must  be  removed  with  great  care  to  avoid  increase  of  the  injury  by  the 
displaced  loose  bone.  Aftet  recovery  a  fibrous  cicatricial  membrane  closes 
the  gap  in  the  spine  as  efficiently  as  the  original  bone,  but  occasionally  some 
weakness  has  resulted.  By  this  operation  depressed  bone  may  be  elevated 
or  cut  away,  an  abscess  or  a  hematoma  evacuated,  tuberculous  foci  curetted, 
and  tumors  of  the  cord  or  surrounding  parts  extirpated.  In  severe'  neural- 
gia of  the  spinal  nerves,  especially  when  associated  with  muscular  spasm, 
laminectomy  has  been  performed  and  the  posterior  roots  of  the  nerves 
divided  within  the  canal.  The  mortality  of  laminectomy  is  less  than  twenty 
per  cent. ,  in  spite  of  the  serious  conditions  for  which  it  is  undertaken. 


CHAPTER    XXXV. 


SURGERY  OF  THE  BREAST. 


By  B.  Paequhae  Curtis,  M.D. 


ANOMALIES  AND  MALFORMATIONS. 

Anomalies. — Anomalies  of  tie  breast  are  of  very  freqneat  occurrence, 
the  most  common  being  tbe  presence  of  supernumerary  breasts  or  poly- 
mazia. Absence  of  the  breast,  or  amazia,  is  a  very  rare  condition.  Super- 
numerary breasts  are  usually  found  in  the  line  of  the  mammary  and  epigas- 
tric arteries,  extending  down  on  the  abdomen,  often  symmetrically,  from  two 
to  four  extra  breasts  being  ijresent.  They  are  occasionally  found  in  men.  It 
is  not  infrecxuent  for  supernumerary  breasts  to  occur  in  the  axillary  line  just 
under  the  fold  of  the  jDectoralis  major  or  high  up  in  the  axilla.  The  supernu- 
merary breasts  are  generally  provided  with  a  rudimentary  nipple.  They  vary 
in  size,  some  being  merely  a  little  deposit  of  gland-tissue  in  the  skin,  while 
others  are  well  developed.  The  nipple  may  be  absent  even  when  the  breast 
is  of  good  size,  and  in  the  case  of  axillary  mammae  without  a  nipple  a  con- 
nection sufficient  to  allow  the  escape  of  secretion  has  sometimes  been  found 
between  the  supernumerary  and  the  normal  gland.  Except  for  the  possi- 
bility that  tumors  may  develoiJ  in  them,  supernumerary  breasts  are  of  very 
little  significance.  Occasionally  they  are  congested  during  lactation,  and, 
especially  if  there  is  no  nipple,  the  distention  may  be  very  painful. 

The  nipple  of  the  normal  breast  also  presents  anomalies,  being  sometimes 
multiple  and  very  rarely  entirely  absent.  It  is  very  frequently  so  badly 
developed  that  it  is  of  little  use  for  nursing,  and  a  plastic  operation  has 

been  suggested,  consisting  in  the  excision 
of  elliptical  pieces  of  skin  on  three  or  four 
sides,  the  long  axis  of  the  ellipses  being  on 
lines  radiating  from  the  nipxjle,  and  the 
widest  part  corresponding  with  the  base 
of  the  nipple.  The  edges  of  the  wounds 
are  aj^proximated  bj^  sutures,  and  a  buried 
suture,  introduced  subcutaneously  so  as  to 
cross  the  widest  part  of  every  ellipse  and 
entirely  surround  the  nipple,  is  tied  loosely 
so  as  to  gather  in  the  skin  at  the  proper 
place  for  the  base  of  the  nipple. 

Hypertrophy. — Atrophy  of  the  breast 
is  a  verj^  common  condition,  but  is  of  no 
clinical   significance.      Hypertrophy,    how- 
ever, j)roduces  very  large  tumors,  which 
may  be  a  great  burden.     (Fig.  729.)     The  structure  of  the  gland  is  usually 
that  of  the  normal  breast,  but  in  some  cases  there  is  a  marked  increase  of 
860 


Hypertrophy  of  one  mamma  in  a  airl  aged 
fifteen. 


ACUTE  MASTITIS.  861 

the  fibrous  stroma.  There  is  very  little  or  no  milk-producing  power.  The 
hypertrophy  may  be  limited  to  one  breast,  but  both  are  generally  involved. 
It  most  commonly  begins  about  puberty  or  during  pregnancy,  and  the  breast 
may  attain  an  enormous  size,  reaching  to  the  groin  and  weighing  as  much  as 
sixty  pounds.  The  nipple  is  normal  in  most  cases,  though  occasionally  it  is 
stretched  out,  and  the  areola  is  apt  to  be  somewhat  larger  than  normal. 

Treatment. — Tlie  radical  treatment  of  this  condition  is  removal, 
although  when  the  breasts  are  not  too  large  some  relief  can  be  obtained 
by  a  ijroperly  fitting  supx)ort  for  the  heavy  glands.  The  glands  are  very 
vascular,  and  an  operation  for  this  condition  involves  vessels  of  very  large 
size.  Occasionally  greatly  dilated  veins  are  to  be  seen  over  the  surface  of 
the  tumor. 

INJURIES. 

Injuries  of  the  breast  consist  of  wounds  and  contusions.  In  wounds 
of  the  breast  the  hemorrhage  is  likely  to  be  severe,  but  the  wounds  unite 
readily.  In  lactation  there  may  be  an  escape  of  milk  from  the  wound  for  a 
few  hours.  Contusions  of  the  breast  may  result  in  the  production  of  a 
large  swelling  caused  by  blood-clot  and  tedema,  and  it  is  claimed  that  blows 
upon  the  breast  may  be  the  origin  of  a  chronic  mastitis  or  even  of  malig- 
nant disease ;  but  in  only  ten  or  twelve  per  cent,  of  the  cases  of  cancer  is 
there  any  history  of  such  an  injury.  The  treatment  of  wounds  of  the 
breast  does  not  differ  from  that  of  similar  wounds  elsewliere.  Contusions 
are  treated  by  the  application  of  cold  compresses,  the  ice  bag,  or  by  com- 
pression with  a  thick  cotton  dressing. 

INFLAMMATION. 

The  Nipple. — The  nipple  and  the  areola  are  subject  to  inflammations 
resulting  from  pyogenic  and  specific  infection.  The  j)rimary  lesion  of  syph- 
ilis is  often  found  here,  a  healthy  woman  having  been  infected  by  nursing  a 
syphilitic  child.  Erosions  and  suj^erficial  ulcers  of  the  nipple  are  not 
uncommon  from  nursing,  and  are  a  frequent  cause  of  deeper  inflammation 
in  the  breast.  The  treatment  of  these  small  lesions  consists  in  absolute 
cleanliness  of  the  parts  and  also  of  the  infant's  mouth,  in  suspending  nursing 
or  permitting  it  only  at  long  intervals,  and  in  touching  the  flssure  with 
solid  nitrate  of  silver.  Proper  attention  to  the  development  of  the  nipple 
before  the  child  is  born  and  to  cleanliness  afterwards  will  prevent  fissures. 
No  strong  antiseptics  can  be  used,  for  fear  of  poisoning  the  infant.  An 
abscess  may  be  limited  to  the  nipple  and  areola,  distending  the  nipple 
immensely,  and  sometimes  discharging  through  one  of  the  lacteal  ducts. 
Obstruction  of  the  ducts  in  the  nipple  may  produce  cysts,  without  any  over- 
distention  of  the  breast  proj)er,  and  these  may  suppurate. 

Acute  Mastitis. — Mastitis,  as  inflammation  of  the  breast  is  called,  may 
be  acute  or  chronic.  The  acute  form  is  due  to  bacterial  iul'ection,  which  may 
take  place  through  the  milk-ducts,  or  through  the  lymphatic  channels  from 
an  infection  starting  in  some  wound  or  erosion  of  the  nipple  or  the  skin. 
The  inflammation  may  be  limited  to  one  lobe  or  may  extend  througliout  the 
breast.  It  is  most  common  during  the  activity  of  the  gland  in  the  puerperal 
state,  but  is  also  found  at  other  periods. 


862  PUERPERAL  MASTITIS. 

Puerperal  Mastitis.— In  the  puerperal  condition  the  infection  generally 
arises  from  some  erosion  or  wound  of  the  nipple  occasioned  by  suckling. 
The  usual  type  of  puerperal  mastitis  is  oue  in  which  only  one  or  two  of  the 
main  lobes  of  the  gland  are  involved.  The  breast  presents  a  tender  swelling, 
limited  to  a  part  or  involving  the  entire  mamma,  for  even  if  the  abscess  is 
limited  to  one  lobe  the  congestion  is  liable  to  extend  through  the  entire 
gland.  There  are  pain  and  tenderness,  oedema  and  redness  of  the  skin, 
fever,  and,  possibly,  a  chill ;  in  fact,  the  symptoms  of  acute  inflammation. 
The  diagnosis  is  to  be  made  between  mastitis  and  a  simple  congestion  or 
retention  of  milk  in  the  gland,  or  some  of  the  acute  varieties  of  neoplasm. 
The  symptoms  of  simple  congestion  of  the  gland  or  of  retention  of  milk 
caused  by  obstruction  of  the  nipple  closely  resemble  those  of  the  early  stages 
of  inflammation ;  but,  fortunatelj^,  the  treatment  is  the  same  in  the  three 
conditions.  The  diagnosis  of  acute  mastitis  from  a  rapidly  growing  tumor 
may  be  exceedingly  difficult,  for  a  sarcoma  may  occasion  a  rise  of  tempera- 
ture. Occasionally  a  fibroadenoma  of  the  gland  increases  suddeiily  with 
inflammatory  symptoms  during  lactation,  and  then  subsides  to  its  original 
size  and  form.  A  delay  of  a  few  days  ought  to  be  sufficient  to  make  the 
distinction  between  these  conditions,  as  pus  will  soon  appear  in  mastitis. 

Prognosis. — The  j)rognosis  of  puerperal  mastitis  is  not  bad.  The  inflam- 
mation in  some  cases  will  resolve  ;  in  most  cases  under  prompt  treatment 
it  forms  only  a  limited  abscess,  which  lieals  when  incised,  leaving  a  small 
scar  as  the  only  result  of  the  affection.  Under  bad  treatment  or  in  very 
virulent  cases  the  inflammation  may  involve  several  lobes,  each  forming  an 
abscess  by  itself,  the  cavities  of  which  may  or  may  not  communicate,  and 
great  destruction  of  the  tissues  of  the  breast  may  result.  Yet  even  in  these 
cases  recovery  may  take  place  under  j)rompt  treatment,  and,  in  spite  of  the 
apparent  destruction  of  its  tissues,  the  breast  is  often  quite  as  active  in  milk- 
production  afterwards  as  one  which  has  never  been  inflamed. 

Treatment. — The  treatment  of  mastitis  in  the  first  stages  consists  in  the 
application  of  an  ice-bag,  or  simple  compi'ession  with  a  thick  cotton  di-essing 
and  a  firm  bandage.  If  nursing  with  the  other  breast  is  continued,  the  niii- 
ple  of  the  breast  under  compression  should  be  left  uncovered,  so  that  milk 
can  escai^e  from  it,  but  no  nursing  should  be  done  upon  that  side.  It  is  recom- 
mended by  good  authority  that  in  the  very  earliest  stages  gentle  massage  of 
the  breast  should  be  made,  and  this  treatment  will  often  relieve  an  obstructed 
nipple,  or  cause  resolution  in  the  early  stages  of  inflammation.  If  there  is 
evidence  of  active  infection,  however,  massage  should  never  be  employed. 
If  there  is  an  ulcer  or  abrasion  of  the  nipple,  it  must  be  carefully  cleansed 
and  dressed  in  an  aseptic  manner.  If  an  abscess  forms,  incision  is  necessary, 
and  should  be  made  as  early  as  possible.  Pus  will  form  in  two  or  three  days, 
and  should  be  immediately  evsicuated  in  order  to  prevent  burrowing  and 
further  destruction  of  the  tissues.  The  incisions  for  abscess  should  be  made 
in  radiating  lines  from  the  nipple,  aud  if  there  is  more  than  one  cavity, 
every  one  should  be  opened,  thin  seista  between  them  being  broken  down 
with  the  finger  so  as  to  allow  of  the  freest  drainage.  If  it  is  found  that  the 
first  incision  does  not  drain  properly,  another  incision  at  the  most  dependent 
part  of  the  abscess- cavity  should  be  added.     Gentle  use  of  the  curette  to 


NON-PUERPERAL  IMASTITIS.  863 

remove  sloughs  from  the  iuterior  of  the  abscess  is  advisable  if  the  case  is  one 
of  long  standing.  These  incisions  are  preferably  made  under  general  anes- 
thesia, although,  if  the  abscesses  are  small  and  superficial,  cocaine  may 
answer.  In  neglected  cases  in  which  the  breast  is  extensively  involved,  with 
numerous  sinuses  through  which  the  pus  has  escaped,  the  sinuses  should  be 
thoroughly  explored,  and  enlarged  so  as  to  admit  of  thorough  curetting  of 
their  walls,  and  all  the  cavities  should  be  well  drained  at  the  most  dependent 
part.  As  soon  as  the  inflammation  subsides,  strong  comj)ression  of  the  entire 
organ  should  be  made  against  the  chest,  so  as  to  hasten  the  closing  of  the 
cavities.  A  wet  dressing  is  allowable  in  the  early  stages  of  abscess,  but  the 
use  of  poultices  should  not  be  encouraged,  because  they  may  favor  too  great 
destruction  of  the  gland-tissue.  It  is  seldom  that  abscess  of  the  breast  is 
followed  by  suppuration  of  the  axillary  lymph-nodes,  although  the  latter 
frequentlj'  become  swollen  and  tender. 

Non-Puerperal  Mastitis. — Mastitis  may  occur  in  the  infant  at  birth  or 
soon  after,  in  virgins  about  the  time  of  puberty,  and  even  in  the  male.  Cor- 
responding with  the  smaller  size  and  less  vascularity  of  the  breast,  the 
symptoms  are  less  acute,  but  abscess  may  form.  Bryant  suggests  that  some 
of  the  retracted  and  imperfect  nipples  so  frequently  seen  may  be  the  result 
of  abscesses  in  infancy.  It  is  a  common  thing  for  the  breast  of  the  new-born 
to  be  distended  and  to  contain  a  little  secretion,  and  it  is  not  improbable 
that  the  formation  of  abscesses  may  be  caused  by  the  injudicious  rubbing  of 
tlie  nurse  or  mother  to  dissipate  this  swelling.  At  or  before  puberty  a  sub- 
acute mastitis  may  closely  simulate  sarcoma.  Treatment. — Congestive 
swelling  can  be  cured  by  compression  and  a  belladonna  plaster.  Abscesses 
require  incision  as  described  above. 

Sloughing  Mastitis. — In  some  cases  there  is  a  very  acute  and  virulent 
infection  causing  a  general  inflammation  of  the  entire  gland,  with  great  pain 
and  induration,  and  resulting  in  acute  sloughing  of  all  its  tissues  and  severe 
septic  poisoning.  These  cases  are  fortunately  very  rare.  The  treatment 
demanded  consists  in  two  or  three  very  free  incisions  extending  from  the 
nipple  to  the  margin  of  the  breast.  The  incisions  should  be  made  before 
pus  forms,  in  order  that  tension  may  be  relieved  at  once  and  some  of  the 
breast-tissue  saved  if  possible. 

Chronic  Sinuses. — Chronic  sinuses  are  not  infrequent  as  a  result  of 
abscess  of  the  breast,  especially  when  neglected,  and  sometimes  milk  is  dis- 
charged from  them,  owing  to  the  wound  of  a  lacteal  duct.  Treatment  con- 
sists in  thorough  curetting  and  drainage,  or  in  complete  section  of  the  over- 
lying tissues  and  packing  the  wound.  According  to  Bryant,  a  cure  can  be 
obtained  in  obstinate  cases  by  confining  the  patient's  arm  to  her  side. 

Subcutaneous  and  Retromammary  Abscess. — In  connection  with 
mastitis  we  may  speak  of  subcutaneous  and  retromammary  abscesses.  The 
subcutaneous  tissue  over  the  breast  is  liable  to  suppurative  inflammation 
just  as  elsewhere,  and  not  infrequently  abscesses  also  form  between  the  gland 
and  the  pectoral  muscle.  These  may  be  acute  or  chronic,  tuberculous  abscess 
being  quite  common  behind  the  breast  as  a  result  of  caries  of  the  ribs.  The 
retromammary  abscess  usually  forms  a  rather  flat  swelling,  extending  to 
the  margin  of  the  breast  and  pushing  the  gland  forward  in  front  of  it.     The 


864  TUBERCULOSIS   OF  THE  BREAST. 

diagnosis  cau  generally  be  made  by  the  great  thickness  of  tissue  which 
exists  between  the  pus  and  the  skin,  and  the  even  distention  apparently 
affecting  the  whole  region  of  the  gland.  In  tuberculous  abscess  there  will 
be  an  absence  of  acute  symirtoms.  Treatment.- — It  is  important  to  make 
the  diagnosis  in  these  cases  in  order  that  the  abscess  may  be  opened  without 
cutting  through  the  glandular  tissue,  a  semilunar  incision  being  made  at  the 
margin  of  the  breast.  The  cavity  should  be  drained.  Tuberculous  abscesses 
can  sometimes  be  cui'cd  by  aspiration,  followed  by  injection  of  iodoform 
emulsion. 

Chronic  Mastitis. — Chronic  mastitis  may  be  either  a  slight  infection 
of  low  grade,  resulting  in  very  slow  suppuration,  or  a  non-suppurative 
inflammation,  affecting  mainly  the  interstitial  tissues  of  the  breast. 

Suppurative  Form. — Small  dei^osits  of  pus  may  occur  in  the  gland 
and  persist  for  months  or  years  with  few  or  no  symj)toms.  They  may  be 
mistaken  for  malignant  tumors,  the  nipple  often  being  retracted  and  the 
skin  adherent,  and  the  abscesses  usually  being  surrounded  by  indiirated 
tissue.  They  may  involve  one  lobe  or  the  entire  organ.  It  is  not  improb- 
able that  a  large  majority  of  these  cases  are  instances  of  tuberculosis. 

Interstitial  Form. — Intei'stitial  chronic  mastitis  may  involve  a  single 
lobe  or  the  entire  breast.  It  produces  thickening  of  the  fibrous  stroma,  and 
microscopical  examination  reveals  congestion  of  the  tissues,  with  some 
round-cell  infiltration  and  new  production  of  fibrous  tissue.  The  process 
may  remain  stationary  or  may  slowly  extend.  It  is  frequently  associated 
with  the  production  of  cysts,  caused  by  obstruction  of  the  milk-ducts  or  of 
the  lymj)hatics,  and  the  contents  of  these  cysts— blood,  milk,  or  serum — are 
apt  to  become  very  dark  with  age.  The  breast  feels  firmer  than  normal,  and 
the  fingers  can  recognize  small,  hard  nodules  and  bands  passing  through  it 
in  different  directions.  In  some  cases  the  gland  seems  distended  almost  as 
if  a  diffuse  tumor  were  present  or  as  if  it  were  injected  with  wax.  The 
diagnosis  from  diffuse  cystoadenoma  of  the  mamma  may  be  imjjossible. 

Treatment. — There  is  no  treatment  for  chronic  mastitis  except  removal 
of  the  organ,  and,  as  the  condition  sometimes  results  in  the  development  of 
malignant  disease,  amputation  is  to  be  recommended  when  it  is  well  marked. 
We  have  a  specimen  from  a  case  of  chronic  mastitis  which  involved  the 
whole  breast  and  contained  several  cysts,  showing  on  the  margin  of  one  of 
these  cysts  a  minute  patch  of  begiuning  carcinoma,  which  was  the  only 
particle  of  malignant  disease  in  the  gland.  The  patient  remained  free  from 
recurrence  after  the  removal  of  the  breast,  but  twelve  years  later  she 
developed  carcinoma  in  the  other  breast. 

Tuberctllosis  of  the  Breast. — Tuberculosis  of  the  breast,  except  as 
a  result  of  extension  from  tuberculous  glands  in  the  axilla  or  from  tubercu- 
lous disease  in  the  chest  or  ribs,  is  rare.  In  the  primary  form  the  disease 
may  occur  at  any  age,  although  the  great  majority  of  the  patients  are 
between  the  thirtieth  and  fiftieth  years.  It  seems  to  be  equally  common  in 
male  and  female,  and  it  has  no  connection  with  pregnancy  or  lactation.  The 
disease  may  be  diffused  through  the  entire  breast  or  limited  to  one  lobe.  It 
appears  in  the  shape  of  a  tuberculous  infiltration  with  the  formation  of 
granulation-tissue  and  hard  masses,  or  it  may  form  cold  abscesses,  and 


SYPHILIS   OF  THE   BREAST.  865 

sinuses  fi-equeutly  remain  when  the  abscesses  have  discharged.  In  the 
nodular  form  the  breast  appears  occupied  by  a  tumor  under  normal  skin, 
the  gland  not  being  adherent  to  the  chest  wall,  and  the  nipple  not  retracted. 
The  surface  of  the  breast  is  apt  to  be  nodular.  The  glands  in  the  axilla  are 
seldom  involved  when  the  disease  begins  in  the  breast,  but,  as  Konig  has 
remarked,  the  great  majority  of  the  cases  begin  in  the  glands  of  the  axilla 
and  involve  the  breast  secondarily.  If  the  disease  is  seen  in  this  stage 
before  the  sinuses  form,  the  resemblance  to  a  tumor  is  veiy  close.  The 
progress  of  the  disease  is  very  slow,  and  like  that  of  tuberculosis  of  the 
soft  parts  elsewhere.  The  general  health  is  not  seriously  affected,  and  the 
patient  may  have  no  trace  of  disease  elsewhere,  even  when  the  mamma  is 
reduced  to  a  mass  of  indurated  tuberculous  tissue,  containing  many  small 
abscesses.  In  the  great  majority  of  cases,  however,  there  are  tuberculous 
lesions  in  other  parts.  The  diagnosis  of  tuberculosis  of  the  breast  is  easy  if 
sinuses  exist,  but  otherwise  it  may  be  impossible  to  distinguish  between  the 
nodular  form  and  a  malignant  tumor,  or  between  a  cold  abscess  and  a  cyst. 
The  presence  of  tuberculosis  elsewhere  will  give  a  clue. 

Treatment. — The  best  treatment  is  thorough  removal  of  the  diseased 
tissue,  amputation  being  done,  and  the  glands  in  the  axilla  removed  also  if 
they  are  involved.  In  the  majority  of  cases  the  patient  ultimately  succumbs 
to  pulmonary  tuberculosis. 

Syphilis  of  the  Breast. — Syphilis  of  the  breast  appears  cxuite  often 
in  the  primary  form,  infection  taking  place  from  nursing.  Various 
secondary  lesions  of  the  skin  appear  about  the  breast  as  elsewhere.  In 
the  late  stages  gumma  is  found,  and  sometimes  produces  extensive  destruc- 
tion of  the  gland-tissue.  Gumma  may  form  in  the  gland  itself,  in  the  sub- 
cutaneous tissue,  involving  the  gland  secondarily  by  ulceration,  or  in  the 
retromammary  tissue.  In  some  cases  the  condition  resembles  a  malignant 
tumor,  hard  or  soft  swellings  being  present,  covered  by  healthy  skin ;  but 
this  error  is  rarely  made,  for,  as  a  rule,  a  gumma  spreads  rapidly  and  soon 
ulcerates,  producing  the  characteristic  excavated  iilcer  with  a  sloughing 
centre  and  ragged  undermined  edges,  more  or  less  circular  in  shape.  In 
doubtful  cases  treatment  will  soon  settle  the  diagnosis.  The  prognosis 
is  excellent,  the  disease  generally  being  quickly  brought  under  control. 
The  treatment  is  the  usual  "mixed  treatment"  interuallj',  aided  by  clear- 
ing out  the  sloughs  and  dressing  the  cavities  with  iodoform. 

Mastodynia. — Mastodynia,  or  neuralgia  of  the  breast,  is  an  obstinate 
afifection  which  is  not  uncommon,  but  is  poorly  understood.  jSl'enralgic 
pains  in  the  breast  may  arise  from  a  great  varietj'  of  causes,  like  neuralgia 
in  general,  but  the  form  to  which  the  name  mastodynia  has  been  given  is 
usiially  found  associated  with  a  single  tender  spot  in  the  breast.  Not  infre- 
quently a  small  fibrous  nodule  can  be  found  at  this  spot.  Mastodynia  is 
often  a  symptom  of  hysteria.  The  treatment  should  be  constitutional, 
including  tonics,  change  of  air.  and  an  endeavor  to  distract  the  attention 
of  the  patient  from  the  painful  spot.  Severe  counterirritation  with  the 
cautery  will  occasionally  produce  a  good  result.  The  application  of  a  bella- 
donna plaster,  worn  for  some  time,  often  gives  relief.  In  cases  where  a 
distinct  nodule  can  be  found,  the  pain  is  relieved  by  excision  of  this  mass. 


866 


DIFFUSE  CYSTOADENOMA. 


Fig.  730. 


TUMORS  OP  THE  BEEAST. 

Lipoma,  angioma,  and  chondroma  are  occasionally  met  with  in  tlie  breast, 
but  are  of  rare  occurrence.  The  benign  tumors  ordinarily  found  are 
fibroma,  adenoma,  and  certain  cysts,  and  the  malignant  new  growths  are 
sarcoma  and  carcinoma.  Myxoma  and  endothelioma  form  an  intermediate 
class.  Over  eighty  per  cent,  of  the  tumors  of  the  breast  are  carcinomatous. 
Fibroadenoma. — A  pure  fibroma  or  a  pure  adenoma  is  a  rarity,  form- 
ing a  well-eucapsulated  tumor,  from  the  size  of  a  hazel-nut  to  that  of  an 
English  walnut,  existing  in  the  breast  without  symptoms,  and  usually 
discovered  by  accident.  The  great  majority  of  tumors  of  this  nature  are 
mixed,  containing  fibrous  and  epithelial  tissue  in  varying  j)roportions, 
although  the  latter  may  not  be  increased  in  amount,  and  is  simjjly  the 
remains  of  the  normal  gland-tissue  surrounded  by  the  fibrous  neoplasm. 

Diffuse  Oystoadenoma. — About  the  menopause  au  adenomatous 
change  is  frequently  found  which  has  no  distinct  boundaries  and  tends  to 

the  production  of  cysts.  The  epithelial 
cells  multiply  in  the  alveoli,  and  there  is 
some  increase  of  the  connective-tissue 
stroma.  (Fig.  730. )  The  epithelium  may 
form  a  solid  plug,  and  the  centre  of  the 
latter  may  break  down  and  be  the  starting- 
point  of  a  cyst  which  enlarges  by  disten- 
tion of  the  alveolus.  The  cells  do  not  pene- 
trate the  basement  substance  and  grow 
wildly  outside,  as  in  carcinoma,  but  their 
proliferation  is  very  irregular.  The  thick- 
ened connective- tissue  stroma  may  contract 
and  produce  cysts  by  drawing  apart  the 
wall  of  the  ducts,  and  in  other  places  the 
ducts  may  be  obliterated  by  its  compres- 
sion so  that  retention  cysts  develop  behind  these  strictures.  In  some  cases 
the  connective  tissue  may  contain  abundant  round  cells  as  in  chronic  inter- 
stitial mastitis,  and  the  diagnosis  between  the  two  may  be  impossible.  The 
process  is  diffuse  without  definite  boundaries,  and  may  involve  a  single  lobe, 
an  entire  gland,  or  both  breasts.     (Eeclus,  Schimmelbusch. ) 

Clinical  History. — This  disease  is  usually  found  after  the  thirtieth  yeai 
of  life,  developing  slowly  and  without  symptoms  unless  cysts  rapidly 
increase  in  size.  The  patient  generally  finds  a  small  mass  in  the  breast  acci- 
dentally, but  occasionally  there  is  pain  and  tenderness.  On  examination  an 
indurated  spot  or  a  tense  cyst  is  felt  in  the  breast,  and  all  the  tissues  of  the 
gland  may  feel  thickened,  or  other  masses  may  be  discovered.  In  one-third 
of  the  cases  both  glands  are  involved.  The  nipijle  is  seldom  retracted  and 
the  skin  is  rarely  adherent ;  we  have  observed  both  of  these  symptoms. 
The  axillary  glands  are  not  affected  unless  acute  inflammation  develops,  as 
may  occur  from  infection  entering  through  the  ducts,  and  causing  suppura- 
tion of  a  cyst,  or  of  the  gland.  The  progress  of  the  disease  is  slow,  but 
cysts  occasionally  enlarge  very  rapidly.     Some  observers  claim  that  after  a 


Oystoadenoma  of  mamma. 


ENCAPSULATED  AND   INTRACANALICULAR  FIBROADENOMA.         8G7 

certain  stage  the  progress  is  arrested  and  atrophy  of  the  gland,  softening  of 
all  the  indurated  masses,  and  absorption  of  the  cysts  take  place.  This 
recovery  would  account  for  the  cases  of  reported  spontaneous  cures  of 
cancer,  for  the  resemblance  to  malignant  disease  may  be  extremely  close.  A 
certain  proportion  of  the  cases  of  diffuse  cystoadenoma  develop  carcinoma- 
tous changes,  as  in  chronic  mastitis,  beginning  usually  in  a  minute  focus  in 
the  indurated  tissiie,  and  sometimes  involving  the  axillary  lymphatic  nodes 
at  an  early  period  when  the  original  focus  is  very  small.  In  one  case  of  the 
writer  a  careful  search  failed  to  reveal  any  trace  of  carcinoma  in  the  brea.st, 
although  the  axillary  glands  were  extensively  diseased. 

Diagnosis. — The  diagnosis  of  chronic  interstitial  mastitis  from  diffuse 
cystoadenoma  is  impossible  because  of  the  similarity  of  their  clinical  history 
and  pathological  changes.  (See  page  864.)  Diffuse  cystoadenoma  differs 
from  the  ordinary  fibroadenoma  because  the  latter  is  encapsulated,  or  at 
least  limited  in  extent,  while  the  former  often  affects  the  entire  breast.  The 
diagnosis  from  carcinoma  is  easy  if  cysts  are  present,  for  cysts  rarely  occur 
in  carcinoma,  and  the  cardinal  signs  of  malignancy,  adhesion  of  the  skin 
and  retraction  of  the  nipi)le,  are  rare  in  cj'stoadenoma.  Enlarged  lymph- 
nodes  are  not  often  found  in  cystoadenoma,  and  the  induration  of  the  breast 
is  less  marked  than  in  carcinoma.  Some  cases,  however,  show  a  verj^  per- 
plexing combination  of  symptoms  of  both  diseases.  It  is,  moreover,  impos- 
sible to  say  in  any  given  case  of  cystoadenoma  that  some  small  focus  of 
malignant  change  has  not  developed,  for  it  may  be  too  small  to  give  the 
usual  signs. 

Treatment. — Cysts  in  these  altered  breasts  can  sometimes  be  cured  by 
aspiration,  followed  by  vigorous  compression.  If  the  changes  are  far 
advanced  in  one  lobule  while  the  rest  of  the  breast  is  fairly  healthy,  the 
affected  part  may  be  excised.  But  if  the  disease  is  extensive,  progressive, 
or  characterized  by  great  induration,  the  entire  breast  should  be  removed, 
operating  as  if  for  inciijient  carcinoma,  excising  an  abundance  of  skin,  the 
pectoral  fascia,  and  the  contents  of  the  axilla.  (See  page  876.)  Cysts  that 
refill  after  aspiration  also  need  excision.  Patients  may  be  kept  under  obser- 
vation in  apparently  benign  cases,  but  if  the  least  suspicion  of  malignancy 
exists,  operation  should  not  be  delayed.  A  morbid  dread  of  cancer  also 
renders  operation  advisable. 

Encapsulated  and  Intracanalicular  Fibroadenoma. — In  the  ordi- 
nary form  of  fibroadenoma  the  stroma  of  the  breast  is  thickened  into  fibrous 
bauds,  arranged  in  concentric  layers  or  in  bundles  of  interlacing  fibres, 
enclosing  between  their  meshes  acini  and  ducts,  either  normal  or  slightly 
altered  by  pressure  or  stretching.  These  tumors  vary  in  size  from  small 
nodules  to  masses  infiltrating  a  quarter  of  the  breast.  They  are  usually  well 
encapsulated,  but  in  some  cases  there  is  no  very  distinct  limit  between  the 
diseased  tissue  and  the  surrounding  healthy  gland.  The  intermediate  por- 
tion represents  sometimes  the  changes  found  in  chronic  mastitis,  although 
with  jrather  less  cellular  infiltration.  In  the  intracanalicular  form  the  tumor 
grows  into  a  lacteal  duct  and  distends  it.  (Fig.  731.)  The  tumor  may 
project  into  the  distended  canal  as  a  smooth  hemispherical  or  lobulated 
mass,  or  like  a  true  papilloma.     In  rare  instances  these  papillomatous  out- 


868        ENCAPSULATED  AXD   INTRACANALICULAR   FIBROADENOMA. 

growths  have  been  found  projecting  through  the  ducts  at  the  nipple  without 
any  ulceration. 

Clinical  History. — Fibroadenoma  is  most  frequent  in  adult  life,  espe- 
cially from  t■^^•enty  to  thirty  years  of  age,  although  it  has  been  observed  at 


Fic   "31 


Intracaiiahcular  fibroma  of  the  breast         100     (F  C  \^ood  M  D  ) 

seven  years,  and  also  at  seventy.  The  cystic  tumors  appear  somewhat  later 
than  the  solid.  The  growth  of  the  solid  tumors  is  slow  (according  to  Gross, 
abovit  two-thirds  of  an  inch  in  diameter  in  one  year),  and  they  have  few 
symj)toms,  except  those  due  to  the  enlargement.  The  cystic  tumors  increase 
more  rapidly,  and  they  may  enlarge  steadily,  or  suddenly  increase  after  a 
period  of  very  slow  growth,  owing  to  the  rapid  development  of  cysts.  They 
have  been  known  to  reach  the  size  of  a  man's  head  in  one  year,  and  instances 
are  on  record  in  which  they  have  weighed  from  twenty  to  thirty  pounds. 
Occasionally  they  are  tender  and  painful,  but  this  is  characteristic  rather  of 
the  small  single  nodules.  In  about  one-seventh  of  the  cystic  cases  there  is  a 
serous  or  bloody  discharge  from  the  uipi^le,  but  this  is  absent  in  the  solid 
variety.  The  nipple,  as  a  rule,  is  unaltered,  but  may  appear  depressed 
relatively  if  the  tumor  develops  near  it.  The  skin  is  seldom  adherent,  brrt 
the  veins  may  be  dilated  in  large  tumors.  If  the  tumor  is  of  considerable 
size  it  generalljr  involves  the  entire  breast.  If  it  grows  from  one  quadrant 
only,  the  remainder  of  the  gland  is  spread  out  over  it  in  a  thin  layer.  In 
rare  instances  it  may  become  pedunculated  and  hang  from  the  side  of  the 
chest. 

Multiple  tumors  of  a  fibroadenomatous  character  are  not  infrequently 
found  in  the  breast.  It  is  rarely  that  ulceration  takes  place  in  fibroade- 
noma, but  the  skin  may  become  so  stretched  that  it  gives  way  and  the  mass 
of  the  tumor  j)rotrudes  through  the  skin.  When  exposed  in  this  way  the 
tumor  forms  a  papillomatous-looking  mass,  which  projects  from  the  opening 
and  is  liable  to  become  infected  and  to  ulcerate.     This  is  more  likely  to 


SARCOMA  OF  THE  BREAST. 


869 


Oj'stic  fibroadenoma  of  twenty  years'  duration. 


occur  ill  the  large  tumors,  and  especially  the  intracanalicular  ^^ariety.  (Fig. 
732.)  There  is  no  metastasis  to  the  glands  or  elsewhere,  and  the  general 
health  is  not  affected  by  these  tiimors.  As  nearly  all  the  benign  mammary 
tumors  are  fibroadeuomata,  the  chief  point  in  the  diagnosis  is  the  distinc- 
tion between  them  and  the  ordinary  ^ 
cysts  and  sarcoma,  of  both  of  which 
we  shall  speak  later. 

Treatment. — The  only  treat- 
ment possible  is  extirpation.  "When 
the  tumor  is  small  it  may  be  enu- 
cleated from  the  breast,  the  gland 
itself  being  left  untouched,  and  this 
is  easy  in  the  majority  of  cases  on 
account  of  the  encapsulation.  But 
if  the  tumor  is  large,  the  entire 
breast  should  be  removed.  If  the 
tumor  is  small,  operation  is  not 
absolutely  necessary,  for  we  may  be 
dealing  with  one  of  those  tumors 
which  will  remain  stationary  or 
increase  very  slowly ;  but  a  full 
explanation  should  be  made,  and 
the  patient  should  assume  the  re- 
sponsibility, for  many  tumors  that 
have  remained  stationarj'  for  years  have  finally  become  sarcomatous.  The 
surgeon  should  follow  the  rule  to  remove  all  tumors,  even  when  confident  of 
their  benign  character,  as  a  part  of  the  proishjdactic  treatment  of  cancer. 

Small  tumors  near  the  lower  and  outer  margin  of  the  breast  can  be 
removed  by  an  incision  in  the  fold  beneath  the  gland,  detaching  the  latter 
from  the  pectoral  fascia  if  necessary  and  cutting  out  the  tumor  fi-om  the 
posterior  aspect.     The  scar  will  be  concealed  by  the  hanging  breast. 

Sarcoma. — Pathology. — Sarcoma  occurs  in  the  breast  in  all  its  dif- 
ferent varieties,  about  two-thirds  of  the  cases  being  spindle-cell  and  one- 
quarter  of  them  round-cell  sarcoma,  the  least  frequent  being  the  giant-cell 
form.  It  is  sometimes  quite  well  encapsulated.  Cystic  degeneration  is  com- 
mon and  cartilage  is  sometimes  present  in  these  tumors.  Sarcoma  is  char- 
acterized here,  as  elsewhere,  by  its  rapid  growth,  but  it  is  occasionallj^  very 
slow,  and  in  many  cases  tumors  which  had  remained  stationary  for  years 
have  proved  to  be  sarcoma.  There  are  also  cases  in  which  a  tumor  has 
remained  stationary  for  years  and  then  suddenly  become  active,  and  exami- 
nation has  shown  it  to  be  a  sarcoma.  Many  of  these  cases  are  probably 
instances  of  malignant  degeneration  of  a  tumor  originally  a  fibroma. 

Clinical  History. — Sarcoma  generally  begins  at  from  thirty  to  fifty 
years  of  age,  the  cystic  form  rather  earlier  than  the  solid.  Sarcoma  of  the 
breast  usually  appears  as  a  tumor  near  the  nipple,  the  size  of  a  walnut  or  an 
egg  when  first  noticed,  soft  and  semifluctuating,  or  hard  and  often  nodular, 
or  varying  in  consistency  in  different  parts.  The  skin  is  unaltered  over  it 
and  not  adherent  to  the  tumor,  which  appears  more  or  less  movable  in  the 

56 


870  DIAGNOSIS  OF  SAECOMA   OF   THE  BREAST. 

breast,  and  entirely  so  on  the  tissues  beneath.  Pain  may  be  present,  espe- 
cially if  the  tiimor  increases  rapidly  in  size,  but  it  is  more  frequently  absent. 
There  may  be  a  bloody-discharge  from  the  nipple.  The  axillary  glands  are 
enlarged  and  involved  in  nearly  one-sixth  of  the  cases  (Poulsen),  but  they 
do  not  feel  so  hard  as  in  the  epithelial  growths.  The  tumor  usually  grows 
rapidly,  reaching  the  size  of  the  fist  in  a  yeai'  or  less.  It  may  remain 
limited  to  that  part  of  the  breast  in  which  it  originated  until  it  attains  a 
considerable  size.  The  nipple  is  not  retracted,  although  it  may  sometimes 
appear  to  be  so  because  it  is  suiTOuuded  by  projecting  masses  of  the  tumor. 
There  is  occasionally  a  discharge  of  bloody  serum  ft-om  the  nipple.  Tlie 
skin  over  the  tumor  is  tense,  very  seldom  adherent,  and  the  veins  are 
dilated,  but  the  dilatation  often  spoken  of  as  pathognomonic  of  sarcoma  is 
due  to  the  large  size  of  the  growths,  and  is  found  with  large  benign  tumors 
as  well.  The  skin  is  seldom  directly  invaded  (in  ten  per  cent.,  according 
to  Gross),  but  it  may  give  way  to  the  pressure  from  within,  especially  in 
cystic  tumors.  The  tumor  may  project  through  this  oj^ening,  as  in  the  case 
of  fibroadenoma,  but  this  occurs  much  more  commonly  than  in  the  latter 
growth,  taking  place  in  one-fifth  of  the  cases.  The  tumor  often  protrudes 
without  infiltrating  the  edges  of  the  opening.  In  the  later  stages  the  tumor 
may  attain  a  large  size,  invading  the  wall  of  the  chest  and  the  skin,  and 
causing  great  pain  and  severe  hemorrhages  from  the  sloughing  or  ulcerating 
surface,  but  until  this  occurs  the  general  health  usually  remains  unaffected. 
Secondary  tumors  occur  in  over  one-half  of  the  cases,  and  are  found  in 
nearly  all  the  organs  of  the  body,  but  are  most  frequent  in  the  lungs,  liver, 
and  brain.  Secondary  disease  of  the  other  breast  or  of  the  stomach  and 
uterus  has  been  noted,  but  is  very  rare.  "When  secondary  tumors  develop 
they  frequently  occur  in  many  different  organs  at  once,  and  the  patient  gen- 
erally succumbs  rapidly  to  the  symptoms  so  ijroduced  and  dies  of  cachexia. 

Diagnosis. — The  diagnosis  of  sarcoma  is  founded  on  its  rapid  growth, 
its  soft  and  varying  consistency,  and  the  occasional  infection  of  the  lymph- 
nodes,  all  of  which  distinguish  it  from  benign  tumors.  There  may  also  be 
a  slight  increase  in  the  temperature  of  the  breast.  Prom  carcinoma  it  is 
differentiated  by  the  greater  rapidity  of  its  growth,  or  the  sudden  appear- 
ance of  rapid  growth  in  a  tumor  which  had  been  previously  quiescent,  the 
indications  of  encapsulation,  the  freedom  Irom  adhesions  to  the  skin  and 
deeper  tissues,  the  normal  character  of  the  nipple,  and  the  absence  of  infec- 
tion of  the  axillary  glands  in  five-sixths  of  the  cases. 

Prognosis. — The  prognosis  is  hopeless  unless  comjilete  removal  by  oper- 
ation is  successful.  A  local  recurrence  is  frequent  even  when  all  of  the 
growth  has  apparently  been  eradicated.  If  no  operation  is  done  death  some- 
times takes  place  within  a  year,  and  generally  within  three  years  of  the 
time  the  tumor  is  noticed.  The  results  of  treatment  by  operation  are  as  yet 
in  doubt,  but  it  seems  probable  that  from  twenty-five  to  fifty  per  cent,  of  the 
cases  may  be  saved  by  timely  removal. 

Treatment. — The  proper  ti-eatment  is  removal  of  the  breast,  together 
with  the  underlying  pectoralis  major  muscle  and  the  axillary  contents.  The 
latter  should  always  be  removed,  even  when  there  is  no  visible  sign  that  the 
glands  are  involved,  for  the  same  reason  as  in  carcinoma  of  the  breast.     In 


CARCINOMA  OF  THE   BREAST.  871 

the  incurable  cases,  little  or  nothing  can  be  done  except  to  give  morphine 
and  keep  the  parts  protected  and  clean. 

Myxoma. — Pure  myxoma  is  not  often  found  in  the  breast.  It  is  a  less 
malignant  tumor  than  sarcoma,  although  it  is  to  be  noted  that  myxoma  origi- 
nating in  the  tissues  near  the  breast  may  be  very  malignant.  The  tumors 
grow  rather  more  slowly  than  sarcoma,  and  do  not  invade  the  lymphatics  or 
cause  metastatic  deposits,  but  they  not  infrequently  involve  the  skin,  and 
they  tend  to  return  after  oj)eration  in  about  one-sixth  of  the  cases  (Gross). 
Myxomata  are  painful  and  the  tumors  have  a  varying  consistency.  Clini- 
cally they  should  be  regarded  as  sarcomata,  and  should  be  treated  in  the 
same  manner. 

Endothelioma. — In  the  breast  endothelioma  may  originate  from  the 
lining  of  the  blood-  or  lymph- vessels,  or  from  that  of  the  lymph  spaces,  and 
is  commonly  known  as  angiosarcoma.  It  forms  single,  movable,  non- 
infiltrating tumors,  not  involving  the  lymph-nodes,  but  causing  general 
metastasis.  These  tumors  occur  in  women  over  fifty  years  of  age.  They 
grow  quite  rapidly,  and  may  be  hard  or  soft ;  the  skin  tends  to  become 
adherent  over  them,  but  without  the  dimpling  seen  in  carcinoma  (Schmidt). 
Recurrence  is  very  rapid,  and  from  a  clinical  stand-point  these  tumors  also 
must  be  classified  with  sarcomata  and  so  treated. 

Carcinoma. — Varieties. — The  clinical  history  of  carcinoma  of  the 
mamma  varies  with  the  structure  of  the  tumor,  according  to  the  relative 
proportion  of  the  epithelial  cells  and  the  fibrous  tissue.  An  abundant 
growth  of  epithelial  cells  and  a  scanty  fibrous  stroma  indicate  an  actively 
malignant  course  for  the  disease.  Those  tumors  in  which  the  fibrous  tissue 
is  abundant  are  known  as  scirrhus.  We  may  distinguish  clinically  five 
types  of  carcinoma, — 1,  ordinary  carcinoma ;  2,  soft  carcinoma,  or  enceph- 
aloid ;  3,  scirrhus,  in  the  ordinary  form  of  which  there  is  considerable 
fibrous  tissue ;  4,  atrophic  scirrhus,  which  contains  very  few  epithelial  cells  ; 
5,  a  rare  form,  known  as  colloid  carcinoma.  The  colloid  form  can  be  dis- 
missed with  a  few  words,  as  it  is  very  rare  and  of  little  clinical  importance. 
The  tumors  are  very  slow  in  growth,  and  have  a  tendency  to  the  formation 
of  cysts  containing  a  colloid  material.  Clinically,  the  tumors  are  densely 
hard,  nodular,  do  not  ulcerate  very  rapidly,  and  the  skin  is  not  involved 
early.  The  nipple  is  retracted  and  the  glands  are  invaded,  but  the  course 
of  the  disease  is  a  slow  one,  the  patients  living  ten  years  or  more.  Cystic 
degeneration  of  ordinary  carcinoma  is  rare. 

Clinical  History. — Carcinoma  appears  most  commonly  about  the  cli- 
macteric, on  the  average  at  forty-eight  years  of  age,  rarely  before  thirty  or 
after  seventy  years,  and  apparently  without  reference  to  marriage,  child- 
birth, or  nursing.  In  a  small  percentage  of  cases  an  acute  mastitis  or  a  blow 
upon  the  breast  appears  to  be  the  direct  cause.  There  is  no  difference  between 
the  right  and  left  breasts  in  liability  to  the  disease.  The  tumors  grow  with 
considerable  rapidity  in  the  ordinary  cases,  on  the  average  reaching  the  size 
of  a  hen' s  egg  in  from  six  months  to  two  years.  They  are  situated  at  any 
part  of  the  gland,  but  are  most  frequently  found  in  the  upper  and  outer 
quadrants.  They  also  frequently  lie  directly  under  the  nipple,  occupying  the 
central  part  of  the  gland.     The  most  dangerous  situation  is  that  in  the  upper 


872 


CARCINOMA   OF  THE  BREAST. 


Fig 


inner  quadrant,  where  infection  of  the  lymphatics  within  the  chest  and  above 
the  clavicle  occurs  early.  In  rare  cases  the  entire  gland  is  attacked  at  once, 
lu  a  few  cases  the  second  breast  becomes  can- 
cerous, but  this  is  usually  an  independent 
tumor  and  not  a  metastasis  from  the  first. 
After  the  presence  of  the  tumor  has  been  no- 
ticed for  from  a  few  weeks  to  a  year  or  more, 
the  axillary  glands  can  be  felt  enlarged,  the 
average  time  being  about  fourteen  months,  and 
they  are  present  in  over  two-thirds  of  the  cases 
at  the  first  examination.  Instances  have  been 
noted,  however,  in  which  the  glands  appeared 
to  be  involved  from  the  very  first,  and  others 
in  which  they  were  free,  even  after  the  disease 
had  lasted  for  years.  We  have  removed  a  scir- 
rhus  carcinoma  from  an  aged  woman,  with  a 
history  of  six  or  seven  years'  duration,  in  which 
the  glands  showed  no  trace  of  involvement. 
(Fig.  737.)  In  the  later  stages  the  pressure 
of  the  glands  upon  the  axillary  vein  causes 
great  oedema  of  the  arm.  (Fig.  733.)  The  s^wi 
becomes  adherent  to  the  tumor  in  about  fifteen 
months  (Gross),  but  occasionally  a  few  weeks  after  the  tumor  appears.  This 
adhesion  of  the  skin  (Fig.  734)  is  caused  by  the  traction  of  the  new  growth 

Fig.  734. 


Oildema  of  arm  from  recurrent  cancer  of 
breast. 


Adhesion  of  sMn  over  malignant  tumor. 

on  the  fibrous  stroma  of  the  gland,  which  is  continuous  through  the  capsule 
with  the  subcutaneous  fibrous  tissue.  The  adherent  skin  is  often  peculiarly 
thickened,  the  mouths  of  the  sebaceous  ducts  being  more  evident  than  usual, 
having  the  appearance  of  the  skin  of  an  orange  or  of  pigskin  leather. 


CARCINOMA  OF  THE  BREAST. 


873 


Sometimes  deep  dimples  are  caused  by  the  retraction  of  the  stroma.  Ulcera- 
tion takes  place  in  about  eighteen  months,  although  it  may  be  absent  even 
in  tumors  which  have  existed  for  a  long  time  and  in  which  the  skin  is  evi- 
dently involved  in  the  process.  The  nipple  is  retracted  (Fig.  735)  in  the 
majority  of  cases,  this  change  being  evident  during  the  first  six  months. 
According  to  Gross,  retraction  is  found  in  fifty-two  per  cent.,  but  in  our 
experience  it  is  more  frequent.  A  discharge  from  the  nipple  is  sometimes 
seen,  being  usually  bloody  or  serous,  and  occasionally  milky. 

Pain  is  generally  absent  in  the  first  stages  of  the  disease,  and  this  fact 
cannot  be  too  much  insisted  upon,  for  it  is  a  common  error  to  suppose  that 
malignant  disease  is  invariably  painful.  The  pain,  as  a  rule,  is  slight  until 
the  tumor  has  attained  a  considerable  size  or  the  disease  has  progressed  into 
the  axilla,  where  it  may  press  upon  the  nerves,  and  cause  excruciating  pain. 
The  hreast  becomes  fixed  upon  the  i^ectoral  muscle  near  the  end  of  the 
second  year,  although  this  change  has  been  observed  even  in  the  first  three 
months.  To  test  fixation  the  arm  should  be  abducted  to  a  right  angle  and 
placed  in  extreme  outward  rotation  to  put  the  pectoral  muscle  on  the  stretch, 
and  the  breast  should  be  moved  back  and  forth  parallel  with  the  long  axis 
of  the  muscular  fibres.  Cachexia  follows  when  the  ulceration  has  been 
marked  and  some  septic  absorption  has  taken  place,  when  there  has  been 
much  loss  of  blood  or  great  pain,  or,  finally,  when  the  secondary  deposits 
in  important  organs  have  interfered  with  the  bodily  functions.  The  sec- 
ondarij  tumors  are  found  in  all  organs  of  the  body,  most  frecxuently  in  the 
lungs  and  the  liver,  more  rarely  in  the  bones  and 
the  brain.  It  should  be  noted  that  metastasis 
frequently  takes  place  before  the  lymph-nodes 
are  involved. 

The  ordinary  carcinoma  (Fig.  735),  as  a 
rule,  is  a  tumor  the  size  of  an  English  walnut, 
or  perhaps  as  large  as  a  hen's  egg  when  first  seen, 
densely  hard,  smooth  or  nodular  on  the  sm-face, 
generally  adherent  to  the  skin,  the  nipple  slightly 
retracted,  and  with  one  or  two  small  glands  to 
be  felt  in  the  axilla,  the  breast  being  movable 
upon  the.  pectoral  muscle.  In  some  cases  there 
will  be  early  ulceration  of  the  skin  even  in 
tumors  of  this  size,  and  in  others  the  tumor  will 
be  adherent  or  the  axillarj'  involvement  will  be 
far  in  advance  of  the  development  in  the  breast. 
In  the  soft  variety  of  carcinoma  (encephaloid) 
the  growth  is  more  rapid,  the  tumor  is  likely  to 
be  much  larger  when  first  noticed,  and  ulceration 
may  take  place  very  early.  In  cancerous  ulcer- 
ation the  skin  becomes  infiltrated  and  jjurple ;  it 
then  breaks  down  and  an  ulcer  is  formed  with  a 

red  or  yellow  sloughing  base  or  covered  with  ma.sses  of  malignant  tissue 
resembling  huge  dark-red  or  pale  granulations.  Even  in  this  stage  the 
breast  may  be  free  from  the  pectoral  muscle. 


Fig.  735. 


Carcinoma  of  breast,  with  retraction 
of  nipple. 


874 


CARCINOMA  OF  THE  BREAST. 


The  later  symptoms  in  these  two  varieties  consist  in  the  fixation  of  the 
breast  on  the  pectoral  miiscle,  the  involvement  of  the  glands  in  the  axilla, 

the  appearance  of  glands  in  the  neck, 
the  extension  of  the  ulceration,  anae- 
mia, exhaustion,  and  the  symptoms 
caused  by  secondary  growths.  Hem- 
orrhage from  the  ulcers  may  be  very 
free,  but  is  seldom  immediately  fatal 
unless  the  ulceration  has  penetrated 
some  of  the  large  axillary  vessels. 

In  scirrhus  the  tumor  is  rather 
small,  and  the  affected  breast  may 
aijpear  actually  smaller  than  its  fel- 
low. (Pig.  736.)  It  will  usually  in- 
volve most  of  the  breast  when  first  ob- 
served, although  it  may  exist  merely 
as  a  nodule  the  size  of  an  English 
walnut.  The  skin  is  very  adherent, 
and  if  the  breast  is  reduced  in  size 
the  skin  is  drawn  into  deep  folds  and 
wrinkled,  and  the  nipple  may  be  re- 
tracted out  of  sight.  The  glands  in  the  axilla  are  generally  involved  but 
slightly.     The  cut  surfaces  of  the  tumor  become  concave,  and  it  is  A^ery 

Fig.  737. 


Scirrhus  of  bre 


((  ase  of  Dr  ^^    It   Toiter.) 


Atrophic  scirrhus  of  breast  of  seven  years'  duration. 

crisp  on  section,  even  creaking  under  the  knife.     The  progress  of  scirrhus 
is  generally  marked  by  some  enlargement  of  the  tumor,  and  the  breast  may 


CARCINOMA  OF  THE   BREAST.  875 

be  twice  the  natural  size  unless  ulceration  takes  place.  The  breast  becomes 
adherent  to  the  pectoral  muscle  comparatively  early,  and  the  skin  is  likely 
to  show  patches  of  eiiithelial  growth. 

Atrophic  scirrhus  is  a  rare  form  of  the  disease,  in  which  the  breast 
shrinks  away,  no  tumor  being  formed.  The  skin  is  more  or  less  adherent, 
the  nipple  disappears,  the  entire  breast  is  flattened  and  shrunken.  (Fig.  737.) 
The  glands  are  involved  late,  although  occasionally  a  large  mass  of  glands 
will  be  found  with  a  very  atrophic  breast.  This  form  of  the  disease  is,  as  a 
rule,  very  insidious  in  its  development,  and  the  breast  has  almost  disappeared 
before  the  patient,  who  is  usually  advanced  in  age,  recognizes  that  there  is 
anything  wrong  with  it.  In  some  cases  ulceration  sets  in  comparatively 
early,  but  usually  the  same  slow  progress  characterizes  the  ulceration,  which 
spreads  very  little  into  the  surrounding  parts. 

Dissemination  in  the  skin  of  the  epithelial  growth  is  sometimes  seen 
accompanying  scirrhus,  or  even  ordinary  carcinoma,  but  it  is  most  com- 
monly observed  in  recurrent  tumors.  Hard  patches  appear  in  the  skin  in 
the  neighborhood  of  the  scar  of  the  previous  operation,  of  a  pink  or  dusky 
red,  often  with  dilated  capillaries  visible  to  the  naked  eye.  These  patches  are 
very  numerous  and  gradually  appear  at  distant  points,  spi'eading  from  the 
scar  as  a  centre.  Where  the  patches  are  thickest  they  run  together,  form- 
ing large,  flat  masses ;  but,  as  a  rule,  in  the  greater  i^art  of  their  extent 
they  remain  discrete.  The  disease  spreads  slowly  or  rapidly  over  the  side 
of  the  chest,  and  may  involve  one-half  of  the  thorax,  or  even  the  entire 
upper  half  of  the  body,  and  extend  well  down  upon  the  arms.  The  skin  in 
this  region  is  thickened  by  the  infiltration,  slightly  reddened,  breaking 
down  here  and  there  in  superficial  ulcerations.  This  variety  of  the  disease 
may  run  a  course  of  three  or  four  years.  The  pain  is  usually  slight,  but  an 
annoying  irritation  and  burning  is  occasionally  felt  in  the  nodules.  The 
discharge  from  the  ulcerated  surfaces  may  be  very  troublesome.  The  term 
cancer  €11  cuirasse  is  proj)erly  applied  to  a  wide  dissemination  of  cancer  in  the 
skin  of  the  chest  with  atrophic  contracting  changes. 

Diagnosis. — Carcinoma  of  the  breast  is  distinguished  from  benign 
tumors  by  its  rather  rapid  growth,  by  the  tendency  to  adhesion  of  the  skin, 
by  retraction  of  the  nipple,  bj^  the  fixation  of  the  gland  on  the  pectoral 
muscle,  and,  finally,  by  the  enlargement  of  the  lymijh-nodes  in  the  axilla. 
We  do  not  speak  of  the  later  symptoms,  such  as  ulceration,  for  to  be  of  any 
value  the  diagnosis  must  be  made  before  they  appear.  In  differentiating 
carcinoma  from  sarcoma  the  former  is  marked  by  the  more  advanced  age  of 
the  patient,  the  early  adhesion  of  the  skin,  the  involvement  of  the  lymph- 
nodes,  and  the  slower  growth  of  the  tumor. 

Prognosis. — Cancer  causes  death  unless  the  patient  dies  of  some  other 
disease  before  the  cancer  reaches  its  termination.  The  usual  duration  with- 
out operation  ajipears  to  be  nearly  two  years  and  a  half.  A  radical  oper- 
ation will  cure  from  twenty  to  thirty  per  cent.,  and  even  more  in  selected 
cases,  while  the  operation  generally  prolongs  life.  It  is  assumed  that  a 
patient  who  remains  well  for  three  years  after  operation  is  cured,  becaiise 
the  great  majority  of  recurrences  develop  before  that  time  expires.  Marked 
involvement  of  the  axillary  glands  of  the  skin  or  adhesion  of  the  breast  to 


876 


TREATMENT  OF  CARCINOMA  OF  THE  BREAST. 


tlie  pectoral  muscles  reduces  greatly  the  prospect  of  obtaining  a  cure.  The 
mortality  of  the  operation  should  not  be  over  two  or  three  per  cent.  Preg- 
nancy hastens  the  growth  and  dissemination  of  these  tumors,  but  the  claim 
that  unusual  youth  of  the  patient  has  a  similar  effect  is  not  proved. 

Treatment. — The  treatment  consists  in  complete  removal  of  the  dis- 
eased organ,  together  with  the  contents  of  the  axilla.  The  fascia  covering 
the  pectoral  muscle  must  also  be  removed,  because  it  has  been  shown  that 
the  lymphatics  of  the  breast  penetrate  the  capsule  and  ramify  in  the  loose 
connective  tissue  between  the  breast  and  the  fascia,  and  that  infection  of 
these  lymphatics  takes  place  very  early.     (Fig.  738.)     If  isolated  glands 

Fig.  738. 


Carcinoma  of  breast,  showing  mode  of  extension:  a,  a  lymph-nodK  iiifeclcd  at  its  lower  part;  b,  a 
lympliatic  channel  in  the  fat,  containing  cells  from  tlie  cancer ;  c,  fascia  over  the  pectoraiis  major  (the  cells 
infiltrate  it  but  do  not  involve  the  muscle  beneath) ;  d,  pectoraiis  major  ;  e,  vein  with  infected  wall ;  /,  the 
edge  of  the  carcinoma.    (F.  C.  Wood,  M.D.) 

are  removed  from  the  axilla,  the  lymx^hatic  vessels  which  connect  them  with 
the  breast  and  with  one  another  are  left  undisturbed  ;  therefore  the  entire 
mass  of  fat  and  cellular  tissue  from  the  edge  of  the  breast  up  to  the  apex  of 
the  axilla,  including  the  glands  and  their  vessels,  must  be  removed  in  one 
piece.  This  much  should  be  done  in  every  case  of  carcinoma  of  the  breast, 
no  matter  how  small  the  tumor  and  how  limited  the  infection  may  seem,  for 
it  is  known  that  glands  buried  in  the  axillary  fat  may  be  considerably 
enlarged  and  yet  may  escape  detection  through  the  skin.  It  is  also  known 
that  when  infection  takes  j)lace  the  size  of  the  glands  may  not  be  per- 
cei^tibly  increased  in  the  early  stages,  and  many  glands  which  appear  per- 
fectly normal  are  found  to  be  carcinomatous  at  the  centre. 

The  Typical  Operation. — Non-adherent  Tumors. — The  incision 
should  circumscribe  the  skin  over  the  tumor  and  the  nipple  and  areola.  It 
the  skin  is  adherent,  the  incision  should  pass  three  or  four  inches  away  from 
the  nearest  adherent  point ;  if  it  is  not  adherent,  it  will  be  sufficient  to 
sacrifice  that  part  of  the  skin  which  lies  directly  over  the  tumor.  The 
incision  should  always  lie  at  least  half  an  inch  away  from  the  areola,  so  that 


REMOVAL  OF  TUMORS  OF  THE   BREAST. 


877 


none  of  the  latter  is  left,  because  it  is  so  rich  in  lymphatic  vessels.  The 
amount  of  skin  to  be  removed  being  outlined,  it  will  usually  be  found  that 
an  elliptical  or  pear-shaped  incision  has  been  made,  and  it  should  then  be 
extended,  if  necessary,  in  au  oblique  line  towards  the  ensiform  cartilage  and 


/^ 


Incisions  for  removal  of  breast :  left  breast,  incision  of  text,  clotted  line  marks  addition  for 
extensive  disease ;  right  breast,  Halstead's  incision. 

upward  into  the  axilla  just  below  the  pectoral  fold.  (Pig.  739.)  The  skin  is 
to  be  dissected  up  on  each  side  of  the  part  to  be  removed,  keeping  clear  of 
the  surface  of  the  breast  until  the  flaps  have  been  raised  beyond  the  edge  of 


""^ 


._.  __  __  _y\"r^^^ 

Removal  of  breast :  the  gland  has  been  detached  with  the  fascia  of  the  pectoralis  major,  the  latter  retracted, 
and  the  fascia  of  the  pectoralis  minor  just  dissected  off  is  shown  in  the  grasp  of  the  forceps. 

the  gland  in  all  directions.  The  pectoral  fascia  is  then  divided  at  the  edge  of 
the  breast,  and  the  deep  fascia  towards  the  abdomen  is  divided  also.  The 
gland  and  the  tumor  are  to  be  turued  down  with  the  pectoral  fascia,  leaving 


878  REMOVAL  OF  TUMORS   OF  THE  BREAST. 

the  fibres  of  the  muscle  as  clean  as  in  an  anatomical  preparation.  The  fascia 
is  to  be  pared  off  the  posterior  surface  of  the  pectoral  muscle,  followed  in  to 
the  internal  margin  of  the  pectoralis  minor,  and  all  the  tissues  between  the 
two  muscles,  with  the  sheath  of  the  minor,  dissected  out.  (Fig.  740.)  The 
edge  of  the  pectoralis  minor  forms  a  guide  to  the  axillary  vessels,  and  the 
fascia  at  the  apex  of  the  axilla  is  to  be  cautiously  opened  by  being  picked 
up  with  forceps  and  snipjied  with  scissors.  As  soon  as  the  axillary  fat  is 
exposed  it  is  separated  cleanly  from  the  axillary  vessels,  and  stripped  down- 
ward from  the  apex  of  the  axilla  and  from  the  side  of  the  chest  to  the  edge 
of  the  latissimus  dorsi,  leaving  the  mass  of  fat  and  glands  in  connection  with 
the  breast  and  removing  the  whole  in  one  piece.     (Fig.  741. )     With  care  the 

Fig.  741. 


Kemoval  of  the  breast ;  the  dissection  of  the  axilla  lias  been  completed,  and  the  breast,  tumor,  and  glands 
are  ready  for  removal  in  one  mass. 

third  subscapular  nerve  can  be  preserved,  and  its  injury  should  be  avoided, 
because  it  supplies  the  latissimus  dorsi.  Some  surgeons  prefer  to  open  the 
axilla  first  and  remove  the  contents,  in  order  to  prevent  all  danger  of  infec- 
tion by  forcing  cancer-cells  into  the  vessels  by  the  handling  of  the  parts,  and 
then  excise  the  breast,  but  the  usual  practice  is  that  given  above,  and  it 
seems  easier  of  execution  and  sufficiently  safe. 

Adherent  Tumors. — For  larger  tumors  or  small  ones  which  have 
existed  for  three  months  or  more,  and  in  every  case  in  which  the  gland  has 
become  adherent  to  the  pectoral  muscle,  the  muscle  should  be  removed 
(Heidenhain).  In  such  cases,  when  the  skin-flaiis  are  made,  the  upper  and 
inner  flap  should  be  dissected  well  back  to  the  edge  of  the  insertion  of  the 
pectoralis  major.  The  space  under  this  muscle  being  opened,  the  finger 
rax)idly  separates  it  from  the  j)ectoralis  minor,  and  then  its  insertions  into 
the  ribs  towards  the  sternum  are  divided  with  the  scissors  and  all  but  the 
clavicular  part  of  the  muscle  drawn  outward,  together  with  the  breast  and 
the  tumor.  Before  dissecting  the  axilla  the  insertion  of  these  fibres  of  the 
pectoralis  major  into  the  humerus  is  to  be  exposed  and  divided.  When  the 
axilla  has  been  cleared,  in  such  cases  as  these,  the  dissectiou  should  be 
carried  under  the  pectoralis  minor,  and  the  triangle  of  Mohrenheim,  wliich 
lies  on  the  inner  side  of  the  pectoralis  minor,  between  it  and  the  clavicle, 
should  be  cleared  of  its  fat,  vessels,  and  lymx^hatics.     In  very  bad  cases  in 


PAGET'S  DISEASE.  879 

which  the  diseased  glands  can  be  felt  high  up  under  the  pectoralis  minoi', 
that  muscle  should  also  be  divided  transversely,  in  order  to  facilitate  the 
dissection  of  the  apex  of  the  axilla,  or  it  may  be  removed  (Meyer).  The 
divided  muscle  is  sutured  at  the  close  of  the  operation.  When  the  diseased 
parts  have  been  entirely  removed,  the  vessels  are  ligated  and  the  flaps 
turned  back  in  place,  and  the  wound  is  sutured.  If  much  skin  has  been 
removed,  additional  skin  may  be  obtained  by  dissecting  it  up  from  the  side 
of  the  chest  or  the  abdomen,  so  as  to  enable  the  flaps  to  slide  inward,  and 
this  may  be  assisted  by  proijerly  placed  radiating  incisions.  A  space  the 
size  of  the  hand  can  thus  be  covered.  If  a  raw  surface  remains,  it  can  be 
covered  with  Thiersch's  skin-grafts,  either  immediately  or  after  granulation 
has  begun.  In  the  majority  of  cases,  if  the  wound  is  sutured,  it  is  wise  to 
employ  drainage,  in  order  to  prevent  an  accumulation  of  blood.  The  dis- 
ability following  removal  of  the  muscle  is  remarkably  small  if  aseptic 
healing  is  obtained,  and  the  arm  is  almost  as  useful  as  before.  Halstead 
advocates  this  thorough  operation  in  every  case,  no  matter  how  limited. 
He  has  also  recently  urged  removal  of  the  supraclavicular  glands  as  a 
routine  practice  in  all  cases.  Few  surgeons  will  endorse  this  latter  method, 
for  if  the  disease  has  reached  the  cervical  glands,  the  mediastinal  glands 
must  also  be  involved  and  there  is  no  prospect  of  a  cure.  In  some  hopeless 
cases  temj)orary  arrest  and  even  disappearance  of  tumors  has  followed 
removal  of  the  ovaries,  but  the  fatal  i^rogress  has  only  been  delayed. 

Paget's  Disease. — A  peculiar  epitheliomatous  disease  of  the  nipple  is 
known  as  Paget's  disease.  It  begins  as  an  eczematous  condition  of  the 
nixjple,  involving  its  entire  surface  and  more  or  less  of  the  areola.  In  this 
stage  the  skin  seems  superficially  thickened,  but  is  still  soft,  and  there  is  no 
true  ulceration,  merely  a  rapid  desquamation  of  the  superficial  epithelium. 
Shallow  ulceration  occurs,  and  the  edges  of  the  ulcer  become  thickened. 
The  ulcer  may  be  limited  to  the  nipple,  and  the  latter  may  gradually  dis- 
appear, its  former  situation  being  marked  by  a  small  granulating  ulcer  level 
with  the  skin.  The  secretion  is  very  slight,  occasionally  bloody.  Probably 
from  an  early  period  some  thickening  of  the  breast-tissue  can  be  discovered 
underneath  the  nipple,  and  this  induration  gradually  spreads  throrrghout 
the  breast.  The  disease  is  very  slow  in  its  progress,  often  lasting  several 
years,  but  it  is  sure  to  terminate  in  true  carcinoma  of  the  breast.  The  early 
pathological  changes  are  those  of  chronic  inflammation  and  superficial  des- 
quamation of  the  epithelium  of  the  skin.  The  cornification  extends  more 
deeply  than  normal,  and  a  careful  search  will  show  some  places  in  which 
the  epithelial  cells  have  begun  to  penetrate  the  basement  membrane,  as  in 
true  epithelioma.  The  older  theory  as  to  Paget's  disease  assumed  that  it 
began  as  an  eczema,  becoming  malignant  from  long-continued  irritation ; 
modern  opinion  holds  that  the  disease  is  an  epithelioma  from  the  first, 
beginning  in  the  mouths  of  the  lacteal  ducts  (Thin).  It  should  be  noted 
that  an  ordinary  epithelioma  of  the  nipple  also  occurs  iu  rare  cases.  The 
diagnosis  of  Paget's  disease  from  simple  eczema  of  the  nipple  and  ulcera- 
tive processes  due  to  infection  can  generally  be  made  by  the  strict  limitation 
of  the  ulceration  to  the  nipple  and  by  the  obstinately  chronic  character  of 
the  disease.     The  prognosis  in  cases  left  without  treatment  is  hopeless. 


880  CYSTS   OF  THE   BREAST. 

WTiile  local  treatment  may  be  of  value  in  the  very  earliest  stages,  tlie 
only  rational  course  after  ulceration  has  begun  consists  in  the  typical 
removal  of  the  entire  breast. 

Cysts. — Cystic  degeneration  of  tumors  of  the  breast  is  quite  common, 
but  true  cysts  of  the  gland  form  only  two  per  cent,  of  its  tumors,  according 
to  Gross.  They  are  of  three  kinds, — epithelial,  lymphatic,  and  parasitic 
(hydatid).  The  epithelial  cysts  may  be  divided  into  the  so-called  involu- 
tion cysts  and  retention  cysts.  The  changes  in  the  breast  associated  with  its 
atrophy  after  lactation  or  in  old  age  produce  involution  cysts  similar  to 
such  cysts  in  other  glandular  organs.  In  these  cysts,  which  are  always  of 
small  size,  the  atroj)hying  tissue  retracts  and  draws  on  the  walls  of  the  acini, 
which  distend  under  the  traction,  and  at  the  same  time  it  obstructs  the  canals 
and  causes  dilatation.  These  cysts  usually  have  very  thin  walls,  contain  a 
thin  serous  fluid,  and  appear  as  tense  swellings  half  an  inch  or  so  in  diame- 
ter, which  are  easily  felt  when  directly  beneath  the  skin,  but  may  resemble 
solid  tumors  if  they  are  deep  in  the  breast.  Very  seldom  is  there  a  dis- 
charge from  the  nipple.  If  the  cysts  are  small,  multiple,  and  deeply  placed, 
the  breast  may  very  readily  be  suijposed  to  be  the  seat  of  cancer.  Simple 
evacuation  of  the  contents  of  the  single  cysts  by  a  hypodermic  syringe  con- 
firms the  diagnosis  and  frequently  effects  a  cure. 

Retention  Cysts. — -These  are  caused  by  obstruction  of  some  of  the  lacteal 
ducts  by  inflammatory  swelling,  by  a  cicatrix,  or  by  the  growth  of  a  tumor. 
In  these  cysts  the  cavity  is  made  uj)  of  one  or  more  acini,  and  may  include 
an  entire  lobe.  The  cavity  may  be  single  or  divided  into  several  chambers. 
The  contents  of  the  cyst  may  be  a  milky  fluid,  or  may  resemble  butter  or 
cheese,  galactocele  ;  or  it  may  be  serous  or  bloody  and  dark,  being  discolored 
by  hfemoglobin.  These  cysts  sometimes  attain  a  large  size,  especially  the 
galactoceles,  cysts  holding  several  ounces,  or  even  nine  pounds,  of  fluid, 
having  been  reported,  but  they  are  seldom  as  large  as  a  hen's  egg.  They  are 
seen  in  the  active  period  of  the  gland  in  middle  life,  and  frequently  follow 
pregnancy.  A  discharge  fi'om  the  nipi^le  is  found  in  about  one-fifth  of  the 
cases.  The  cysts  are  single  in  two-thirds  of  the  cases,  and  the  lacteal  cysts 
are  always  single,  according  to  Gross.     They  seldom  become  inflamed. 

Diagnosis. — The  diagnosis  of  retention  cysts  is  tolerably  easy  if  they  are 
fairly  large,  by  their  tension  or  fluctuation,  and  slow  development.  The 
skin  is  not  adherent  unless  they  become  inflamed,  and  the  nipple  is  not 
retracted,  although  it  may  be  pushed  aside  or  even  buried  between  the  pro- 
truding cysts.  The  galactoceles  are  generally  easily  recognized  by  their 
ra]3id  growth  during  lactation,  without  pain  and  without  great  tension. 

Lymphatic  Cysts. — These  develop  in  the  fibrous  stroma,  but  they  are 
rare.  They  have  occasionally  caused  the  removal  of  the  breast  under  the 
supposition  that  cancer  was  present.  They  occur  after  the  menopause,  as 
deep-seated,  single  or  multiple  cysts,  tense,  and  not  fluctuating.  They  are 
lined  with  endothelium,  and  their,  contents  are  said  not  to  contain  albumin. 

Mention  should  also  be  made  of  the  presence  of  hydatid  cysts  in  the 
breast,  although  these  are  rare,  particularly  in  America. 

Treatment. — The  treatment  of  cysts  is  evacuation  of  their  contents  by 
aspiration  or  incision,  and,  if  they  return,  the  injection  of  iodine  or  pure 


DISEASES   OF  THE  MALE  BREAST.  881 

carbolic  acid.  Galactoceles  may  require  extirpation,  because  they  are  lined 
with  an  active  secreting  epithelium,  and  they  should  be  removed  with  as 
little  damage  to  the  breast-tissue  as  i^ossible. 

Tumors  of  the  Mammary  Region.— Sebaceous  cysts  appear  in 
the  skin  over  the  breast,  and  particularly  iu  tlie  sebaceous  glands  of  the 
nipple.  Dermoid  cysts  are  rare.  Angioma  may  develop  on  the  skin  of 
the  breast,  and  occasionally  it  has  been  observed  iu  .the  nipple,  forming 
pendulous  tumors  requiring  removal.  Painless  fibroid  tumors  have  been 
observed  on  the  skin  of  the  breast,  and  these,  too,  should  be  removed. 
Epithelioma  of  the  skin  of  the  breast,  while  rare,  is  occasionally  met  with, 
and  runs  the  ordinary  course.  Lipoma  is  found  in  the  subcutaneous  fat 
over  the  breast,  and  sometimes  forms  large  tumors  behind  the  gland,  devel- 
oping between  it  and  the  pectoral  muscles.  The  latter  tumoi-s  are  often 
taken  for  an  abscess,  or  a  malignant  tumor  of  the  breast  itself  The  treat- 
ment of  all  these  tumors  is  removal.  Benign  tumors  situated  behind  the 
breast  can  be  removed  by  a  semicircular  incision  following  the  lower  border 
of  the  gland  and  lifting  the  latter  from  the  chest. 

DISEASES  OE  THE  MALE  BREAST. 

Although  an  atroijhied  organ  in  the  male,  the  mamma  is  liable  to  chronic 
mastitis,  and  carcinoma  is  found  quite  frequently, — about  one  case  to  one 
hundred  iu  the  female.     The  latter  runs  rather  a  slow  course,  but  is  apt  to 


Carcinoma  of  the  breast  in  tlie  male. 


be  discovered  too  late  to  allow  of  a  permanent  cure  by  oiJeration.  The 
ordinary  scirrhus  is  the  common  variety.  (Fig.  742.)  The  local  changes 
and  the  symptoms  of  these  conditions  are  similar  to  those  in  the  female. 


CHAPTER    XXXVI. 

rNJURIES  OF  THE   EYE  AND  ITS  APPENDAGES. 
By  Geobge  E.  de  Schweinitz,  M.D. 

Contusion  and  Concussion  of  the  Eyeball. — An  eyeball  injured 
by  a  blow  from  a  blunt  object — for  example,  a  fist,  a  billet  of  wood,  or  a 
cork — may  present  the  following  symptoms  :  discoloration  of  the  lid,  injec- 
tion of  the  bulbar  conjunctival  vessels,  and  hemorrhage  into  the  anterior 
chamber  (hypluemd).  Sometimes  the  cornea  assumes  a  greenish -brown  hue, 
owing  to  dissemination  of  hfematodin  in  its  layers  (blood-staining  of  the 
cornea).  Absorjption  of  the  hemorrhage  is  facilitated  by  instilling  a  drop 
of  atropine  and  covering  the  eye  with  a  light  pressure  bandage. 

In  addition  to,  or  in  place  of,  these  lesions,  there  may  be  dilatation  of  the 
pupil  (traumatic  mydriasis'),  accompanied  sometimes  by  rupture  of  the  sphinc- 
ter of  the  iris.     The  condition  is  not  altered  by  treatment. 

Under  other  circumvStances  the  force  of  the  blow  ruptures  the  ciliary 
attachment  of  the  iris,  causing  the  condition  known  as  irido-dialysis.  As 
long  as  any  signs  of  irritation  remain,  atropine  drops  (four  grains  to  the 
ounce)  should  be  instilled,  and  a  light  pressure  bandage  should  be  worn. 

Instead  of  rupture  of  the  ciliary  margin  of  the  iris  the  blow  may  be  fol- 
lowed by  displacement  of  this  membrane,  either  partial  or  complete  (trau- 
matic aniridia) . 

Finally,  contusion  of  the  eyeball  may  be  accompanied  by  rwpture  of  the 
cornea,  or  of  the  sclera.  Usually  the  rupture  includes  all  the  coats  of  the  eye, 
as  well  as  the  conjunctival  covering, — that  is  to  say,  the  wound  is  "com- 
pound;" but  the  conjunctiva  may  escape  laceration  and  cover  the  torn 
sclera  beneath  it. 

The  immediate  effect  of  rupture  of  the  eyeball  is  extensive  hemorrhage 
into  the  vitreous  and  the  anterior  chamber,  associated  with  prolapse  of  the 
vitreous  humor.  Sometimes  the  lens  escapes  entirely,  or  lies  beneath  the 
conjunctiva.  Marked  reduction  in  tension  will  lead  to  the  diagnosis  of  rup- 
ture of  the  eyeball,  even  when  the  conjunctiva  is  untoru  and  covers  the 
wound,  although  in  a  few  instances  there  is  a  similar  reduction  in  intra- 
ocular tension  merely  from  concussion  without  rupture. 

The  treatment  of  these  conditions  is  the  same  as  that  of  wounds  of  the 
eyeball,  and  will  he  considered  in  a  subsequent  section  (page  884). 

Traumatisms  of  the  Crystalline  Lens. — Injuries  of  the  eyeball, 
either  contusions  or  penetrating  wounds,  may  be  associated  with  two  impor- 
tant results,  so  far  as  the  crystalline  lens  is  concerned  : 

(1)  Dislocation  of  the  Crystalline  Lens. — Luxation  of  the  lens  may 

be  complete  or  incomplete.     If  it  is  partial,  the  margin  of  the  lens  may  be 

seen  with  the  ophthalmoscope  as  a  dark  line  ;  there  are  tremulousness  of  the 

iris  (irido-donesis),  from  weakening  or  rui^ture  of  the  suspensory  ligament, 

882 


TRAUMATIC  CATARACT.  883 

monocular  diplopia,  and  impaired  power  of  accommodation.  A  partially 
dislocated  lens  visually  remains  perfectly  clear,  and  vision  can  be  much 
improved  by  suitable  glasses,  operative  interference  being  required  only 
exceptionally. 

A  completely  dislocated  lens  may  be  lodged  in  the  vitreous,  or  in  the 
anterior  chamber,  or  may  pass  through  a  wound,  as  already  stated,  and  lie 
beneath  the  conjunctiva,  or  even  under  Tenon's  capsule. 

Treatment.— A  lens  dislocated  into  the  anterior  chamber  becomes 
opaque,  and  by  pressure  upon  the  iris  may  cause  inflammation,  and,  by 
occluding  the  angle  of  the  anterior  chamber,  secondary  glaucoma.  (Fig. 
743.)  It  should  be  removed  by  an  incision  through  the  corneoscleral 
margin,  made  with  a  narrow  cataract-knife,  large  enough  to  permit  the 
expulsion  of  the  lens. 

A  lens  lodged  beneath  the  conjunctiva  forms  a  rounded,  somewhat 
translucent  swelling,  the  overlying  conjunctiva  frequently  being  greenish 
or  brownish  in  color,  owing  to  staining  with  uveal  pigment.  The  lens 
may  be  exti'acted  through  a  small  incision  made  through  the  conjunctiva 
directly  over  it.     (Fig.   744.)     A  number  of  methods  have  been  devised 


Fig.  744. 


Dislocation  ol  lens  into  anterior  chamber. 
(De  Schweinitz.) 


Subconjunctival  dislocation  of  lens. 
(De  Schweinitz.) 


for  removing  a  lens  dislocated  into  the  vitreous  chamber.  According  to 
Knapj)  (and  this  method  the  author  has  followed),  the  best  plan  is  to  induce 
thorough  local  anaesthesia,  make  an  upper  corneal  section,  remove  the 
speculum,  and  expel  the  lens  by  methodically  pressing  on  the  lower  part 
of  the  sclera  directly  towards  the  centre  of  the  eyeball.  The  lens  will  pre- 
sent in  the  pupil,  and  may  be  removed  with  a  wire  spoon  in  its  unbroken 
capsule.  All  these  manipulations  require  great  dexterity,  and  are  liable  to 
be  followed  by  escape  of  vitreous. 

(2)  Traumatic  Cataract. — Traumatic  opacity  of  the  crystalline  lens 
occurs  either  from  direct  or  from  indirect  injury. 

In  the  first  instance  the  lens  and  its  capsule  are  injured,  the  aqueous 
humor  enters,  the  lenticular  substance  swells  and  becomes  oi^aque.  Absorp- 
tion may  gradually  occur,  or  the  swelling  of  the  lens  may  occasion  iritis, 
cyclitis,  or  secondary  glaucoma,  and  it  may  be  necessary  at  once  to  make 


884  ,  WOUNDS  OF  THE  EYEBALL. 

a  corneal  section  and  evacuate  the  swollen  lens  material.  This  is  performed 
as  follows  :  A  triangular  knife  or  keratome  is  inserted  one  millimetre  within 
the  margin  of  the  cornea  and  j)ushed  onward  until  a  wound  five  millimetres 
in  width  results,  the  point  of  the  keratome  having  been  made  to  pierce  the 
lens.  The  knife  is  now  slowly  withdrawn  and  presses  upon  the  posterior 
lip  of  the  wound.  This  causes  the  soft  lens  matter  to  extrude.  After  all  of 
it  is  evacuated  a  drop  of  atropine  solution  is  instilled  and  a  bandage  applied. 
If  there  is  no  call  for  immediate  operative  interference,  the  pupil  should  be 
dilated  with  atroi^iue  until  all  signs  of  irritation  have  passed  away,  and 
then  the  lens  may  either  be  absorbed  by  the  operation  of  discission, — i.e.,  by 
lacerating  the  lens  capsule  with  a  cataract  needle  and  allowing  the  aqueous 
access  to  the  lens  substance,- — or  it  may  be  removed  by  an  ordinary  cataract 
extraction. 

In  the  second  instance  the  blow  probably  causes  a  slight  rupture  of  the 
capsule,  and  the  cataract  is  known  as  a  concussion  cataract. 

Wounds  of  the  Eyeball.— Wounds  of  the  eyeball  may  be  divided 
into  those  which  are  superficial  and  non -penetrating,  and  those  which  are 
deep  and  penetrating. 

Wounds  of  the  conjunctiva  are  usually  lacerated,  and  generally  are 
situated  on  the  bulbar  exi^ansion  of  this  membrane. 

The  conjunctival  cul-de-sac  should  be  flushed  with  a  weak  antiseptic 
solution,  preferably  a  saturated  solution  of  boric  acid,  and  the  divided 
conjunctiva  united  with  a  few  points  of  fine  silk  suture,  which  may  be 
removed  on  the  third  day. 

Superficial  \vounds  of  the  cornea  usually  occur  in  the  form  of  an 
abrasion,  the  epithelium  having  been  scraped  away  by  the  impact  of  the 
wounding  substance,  for  example,  a  finger-nail,  an  iron  filing,  or  a  piece 
of  glass.  Although  the  lesion  is  insignificant,  it  gives  rise  to  sharp  pain, 
marked  photophobia,  and  copious  lachrymation. 

Abrasions  of  the  cornea  are  im]Dortant  because  they  are  frequently  the 
starting-points  of  serious  corneal  ulceration,  particularly  if  they  have 
occurred  in  an  eye  in  which  there  is  some  unhealthy  secretion  in  the  lachry- 
mal passages. 

Treatment. — This  consists  in  sterilization  of  the  conjunctival  cul-de-sac 
with  a  saturated  solution  of  boric  acid  or  a  solution  of  bichloride  of  mer- 
cury 1  to  10,000,  and  the  application  of  a  light  sterilized  pressure  bandage. 
If  there  is  much  ciliary  ii-ritation  there  is  no  objection  to  a  drop  of  atropine 
solution.  Usually  in  twenty-four  hours  the  abrasion  will  heal  and  the 
bandage  may  be  discontinued.  If  it  fails  to  heal  readily  it  should  be  touched 
with  a  probe  dipped  in  nitrate  of  silver  (two  per  cent.)  or  tincture  of  iodine. 
Powdered  iodoform  dusted  on  the  surface  is  valuable.  If  infection  should 
occur,  a  light  application  of  the  actual  cautery  may  be  required. 

Penetrating  wounds  of  the  eyeball  maybe  situated  in  any  portion- 
of  the  globe,  but  are  common  at  the  cor neo -scleral  junction,  or  between  the 
corneal  border  and  the  equator  of  the  eyeball.  A  penetrating  wound  of  the 
cornea  or  of  the  corneoscleral  junction  is  followed  by  evacuation  of  the 
aqueous  humor,  and  generally  by  entanglement  of  the  iris  in  the  corneal 
wound,  or  by  prolapse  and  staphylomatous  bulging. 


BURNS   OF  THE   CONJUNCTIVA.  885 

The  i^rolapsed  iris  may  be  seized,  drawn  forward,  and  abscised,  as  iu  the 
operation  of  iridectomy,  or  the  eye  may  be  treated  with  a  pressure  bandage 
to  prevent  staphyloma,  and  atropine  instilled  to  favor  reduction  of  the 
hernia  and  prevent  iritis.    In  the  majority  of  cases  the  first  plan  is  advisable. 

If  the  wounding  substance  penetrates  still  deeper,  it  may  lacerate  the 
iris,  the  capsule  of  the  lens,  or  the  lens  proj)er,  and  the  accident  is  then 
followed  by  the  symx^toms  already  detailed  under  traumatic  cataract.  If 
the  injury  is  not  so  severe  as  to  require  surgical  interference,  atropine 
should  be  instilled  to  alleviate  the  traumatic  iritis  which  will  follow,  and 
iced  compresses  should  be  applied  for  several  days. 

Wounds  passing  through  the  ciliary  body,  or  penetrating  the  sclera 
farther  on  towards  the  equator,  are  of  mirch  moi-e  serious  nature.  If  the 
lesion  has  been  an  extensive  one,  and  especially  if  infection  has  entered  and 
purulent  iritis  has  begun,  sight  being  lost,  the  eyeball  should  be  enucleated 
or  eviscei'ated,  to  avoid  the  danger  of  sympathetic  inflammation  of  the  oppo- 
site eye.  If  the  wound  is  not  too  extensive,  and  if  the  ciliary  body  is  not 
iuvolved  and  infection  has  not  begun,  au  attempt  should  be  made  to  save 
the  eye  by  suturing  the  wound.  First,  the  edges  of  the  wound  should  be 
carefully  cleansed  and  pencilled  with  a  solution  of  bichloride  of  mercury 
1  to  .5000  ;  then  the  overlying  conjunctiva  may  be  stitched  in  the  ordinary 
manner,  or  the  sutiues  may  pass  directly  through  the  sclera.  A  full  anti- 
septic dressing  may  be  applied,  or,  if  there  is  much  reaction,  iced  com- 
presses. These  directions  apply  only  when  the  surgeon  has  satisfied  himself 
that  there  is  no  foreign  body  retained  within  the  ej'e.  Under  the  latter 
circumstances  the  treatment  differs  according  to  the  directions  given  in  a 
subsequent  paragraph. 

Bvirns  and  Scalds  of  the  Conjunctiva  and  Cornea. — These  are 
commonly  inflicted  with  acids,  lime,  molten  metal,  flame,  hot  water,  or 
steam,  and  are  especially  serious  because  they  may  be  followed,  particularly 
when  lime  or  other  caustic  has  come  in  contact  with  the  conjunctiva,  by  the 
development  of  a  si/mblepharon.  After  a  superficial  burn  of  the  cornea  the 
whole  surface  epithelium  may  be  changed  into  a  white  scum.  The  destroyed 
tissue,  however,  is  speedily  replaced  by  a  new  layer  of  epithelium. 

All  foreign  substances  should  be  removed  immediately,  and  an  emollient, 
for  example,  castor  oil  or  liquid  vaselin  and  atropine  drops,  emploj'ed. 
Great  care  should  be  taken  to  prevent  adhesion  of  the  lids  to  the  eyeball. 
This  may  sometimes  be  accomplished  by  introducing  between  the  burned 
surfaces  a  small  sheet  of  gold-beater's  skin  or  by  breaking  up  granulations 
with  a  probe. 

Powder-burns  of  the  cornea  must  be  treated  on  the  principles  just 
described  after  the  particles  of  powder  have  been  removed  from  the  corneal 
tissue  with  a  spud  or  cataract-needle.  Dr.  Edward  Jackson  advises  that 
each  powder-grain  shall  be  touched  with  the  point  of  a  fine  electro-cautery 
needle. 

Foreign  Bodies  on  the  Cornea  and  Conjunctiva.— Foreign 
bodies  usually  consist  of  particles  of  sand,  splinters  of  iron,  bits  of  emery, 
or  cinders,  and  they  may  lodge  under  the  lid,  in  the  lower  cul-de-sae,  or 
become  embedded  in  the  substance  of  the  cornea.     Even  when  the  body  is 

57 


886  FOREIGN   BODIES  IN  THE  LENS. 

embedded  in  the  centre  of  the  cornea  the  source  of  irritation  is  commonly 
referred  to  the  under  surface  of  the  upper  lid. 

A  patient  complaining  of  a  foreign  body  in  the  eye  should  be  submitted 
to  the  following  inspection  :  first  the  lower  lid  should  be  drawn  downward 
and  the  exposed  conjunctival  folds  examined  with  oblique  illumination,  then 
the  surface  of  the  cornea  should  be  inspected  with  a  magnifying  glass,  and 
finally  the  iipper  lid  should  be  everted.  The  foreign  body  may  be  found  on 
the  surface  of  the  conjunctiva  thus  exposed,  but  sometimes  it  is  high  up 
in  the  retrotarsal  fold,  and  can  be  seen  only  by  making  the  patient  look 
strongly  downward  and  throwing  a  light  up  into  the  sulcus. 

Treatment. — To  remove  a  foreign  body  from  the  cornea,  after  the 
cornea  has  been  cocainized,  the  upper  and  lower  lids  are  held  apart  with  the 
thumb  and  forefinger  of  the  surgeon's  left  hand,  while  with  the  right  hand 
he  takes  a  flue  needle  or  spud  (Fig.  745)  and  lifts  the  body  from  its  position 

with  as  little  injury 
as  possible.  Instead 
of  using  a  spud,  if 
the  body  is  not  too 
deeply  embedded,  it 
may  be  removed  with 

Spud  for  removing  foreign  bodies.  ^^        applicator        On 

which  has  been 
twisted  a  wisp  of  cotton.  It  is  very  impoi-tant  to  sterilize  the  spud,  and  the 
conjunctival  cul-de-sac  should  be  thoroughly  flushed  with  boric  acid  solution 
after  the  removal  of  the  body. 

Foreign  bodies  in  the  anterior  chamber  may  fall  to  its  bottom,  or  may. 
become  entangled  in  the  meshes  of  the  iris.  If  there  is  no  available  wound 
of  entrance  through  which  the  foreign  body  has  passed,  the  anterior  chamber 
should  be  tapped  with  a  broad  needle,  and  through  the  wound  thus  made 
a  delicate  pair  of  forceps  should  be  passed  and  the  body  removed.  If  it 
is  deeply  entangled  in  the  meshes  of  the  iris,  the  j)ortion  of  this  membrane 
containing  the  foreign  body  should  be  withdrawn  and  abscised. 

Foreign  Bodies  in  the  Lens. — If  a  foreign  body  penetrates  still 
farther,  it  may  become  embedded  in  the  lens.  This  accident  is  usually 
followed  by  cataract,  either  complete  or  rarely  incomplete.  If  a  comjilete 
traumatic  cataract  forms,  an  attemjit  should  be  made  to  extract  the  lens 
with  the  foreign  body,  lest  the  particle  become  dislodged  and  pass  into  the 
deeper  structures  of  the  eye. 

Foreign  Bodies  within  the  Globe. — These  usually  consist  of  a  chip 
of  steel,  a  splinter  of  glass,  a  bullet,  or  a  piece  of  brass  flliug.  If  the  body, 
owing  to  opacities  of  the  media,  cannot  be  seen  with  the  ophthalmoscope, 
it  may  be  located  by  means  of  the  X-rays.  The  presence  of  metallic  foreign 
bodies  may  be  detected  with  the  sideroscope. 

Treatment. — If  the  surgeon  has  satisfied  himself  that  there  is  a  foreign 
body  within  the  globe,  an  attempt  may  be  made  to  extract  it  with  delicate, 
carefully  disinfected  forceps,  but  only  if  there  is  some  positive  indication  as 
to  the  direction  in  which  to  pass  the  forceps.  If  the  foreign  body  is  known 
to  be  of  iron  or  of  steel,  an  attempt  should  be  made  to  dislodge  it  with  the 


INJURIES  OF  THE  ORBIT.  887 

electro-magnet.  This  is  introduced  either  through  the  wound  of  entrance  or 
through  one  made  for  the  purpose,  in  the  position  indicated  by  the  X-ray 
examination.  The  giant  magnet  of  Haab  may  be  used  to  di-aw  the  body 
into  an  available  position  for  extraction.  If  the  surgeon  has  been  unsuc- 
cessful in  his  attempts  to  remove  the  foreign  body,  if  he  is  uncertain  that  he 
has  a  sterile  wound,  and  if  vision  is  much  depreciated  or  is  lost,  the  eye 
should  be  enucleated  or  eviscerated,  because  sympathetic  inflammation  is 
almost  sui-e  to  follow.  In  a  few  instances  foreign  bodies  have  been  tolerated 
in  the  background  of  the  eye  for  long  periods  of  time,  but,  as  Knapp  states, 
we  are  never  sure  that  they  may  not  be  the  origin  of  serious  mischief. 

Injuries  of  the  Eyelids. — Incised,  lacerated,  and  contused  wounds 
of  the  eyelids  do  not  differ  in  their  treatment  from  wounds  situated  in  any 
other  portion  of  the  body.  Wounds  inflicted  in  the  line  of  the  direction  of 
the  fibres  of  the  orbicularis  result  in  the  least  visible  scar,  owing  to  the 
absence  of  gaping.  There  is  no  difficulty  in  securing  accurate  approxima- 
tion of  the  wound,  preferably  with  fine  silk  sutures. 

Three  results  are  common  sequels  of  blows  on  the  eye, — namely,  wdema, . 
emphysema,  and  ecchymosis  of  the  lids. 

OEdema  requires  practically  no  treatment,  but,  if  desired,  an  evaporating 
lotion — for  example,  dilute  lead  water  and  laudanum — may  be  applied. 

Emphysema  may  follow  a  fracture  of  the  orbit,  which  permits  the  air  to 
escape  into  the  cellular  tissue  through  a  communication  with  the  ethmoidal 
or  the  frontal  sinus. 

Ecchymosis,  or  a  collection  of  blood  in  the  connective  tissue,  is  the 
"black  eye"  of  commoa  parlance.  It  is  also  seen  as  the  result  of  fi-acture 
of  the  base  of  the  skull,  and  is,  in  fact,  a  symptom  of  some  importance  in 
relation  to  head-injuries.  It  may  be  associated  with  emphysema  if  a  fracture 
has  involved  the  fi'outal  or  the  ethmoidal  cells.  Ecchymosis  should  be 
treated  with  applications  of  hamamelis  or  lead  water  and  laudanum,  but  not 
by  applying  leeches  to  the  swollen  lids. 

Burns  of  the  eyelids  should  be  managed  on  exactly  the  same  i^rinciples 
as  those  which  are  applicable  to  burns  situated  elsewhere  in  the  body.  They 
are  imj)ortant  chiefly  on  account  of  the  iisual  involvement  of  the  cornea  and 
conjunctiva. 

Injuries  of  the  Orbit. — These  include  fracture  of  its  bony  walls, 
penetrating  wounds,  the  lodgement  of  foreign  bodies,  and  contusions.  In- 
jury may  lead  to  phlegmonous  inflammation  (orbital  abscess),  hemorrhage, 
rupture  of  the  eyeball,  or  lesion  of  the  ojjtic  nerve. 

The  usual  symptoms  of  orbital  disease,  associated  with  accumulations  of 
pus,  blood,  or  exudate,  are  exophthalmos,  displacement  of  the  eyeball, 
diplopia,  and  disturbance  of  vision,  which  may  finally  be  completely  lost 
from  inflammation  or  atrophy  of  the  optic  nerve. 

After  a  penetrating  wound  of  the  orbital  tissues  careful  search  should  be 
made  for  the  j)resence  of  a  foreign  body.  If  there  has  been  much  hemor- 
rhage and  proptosis  from  effusion  into  Tenon's  capsule,  it  may  be  necessary 
to  make  incisions  to  evacuate  the  blood,  lest  the  pressure  upon  the  optic 
nerve  cause  blindness. 

Abscess  of  the  orbit  is  treated  on  the  general  principles  applicable 


888  TRAUMATIC  EXOPHTHALMOS. 

to  abscess  elsewhere.  It  is  desirable  that  evacuation  of  the  pus  shall  be 
obtained  at  the  earliest  possible  moment,  the  incisions  being  so  placed  as  to 
avoid  injuring  the  ocular  muscles  and  their  attachments. 

After  a  lacerated  wound  of  the  orbit,  the  surgeon  should  carefully 
examine  to  see  that  the  recti  muscles  have  not  been  torn.  If  they  are  lacer- 
ated or  detached,  an  endeavor  should  be  made  to  suture  the  divided  ends. 

Traumatic  Enophthalmos. — After  a  blow  upon  the  orbit  or  in  its 
immediate  neighborhood,  there  may  be  marked  sinking  of  the  eyeball  upon 
that  side,  giving  rise  to  an  appearance  which  causes  the  impression  that  the 
patient  is  wearing  a  badly  fitting  artificial  eye.  Cases  of  enophthalmos  are 
due  to  cicatricial  contraction  of  the  retrobulbar  connective  tissue  following 
periostitis  and  inflammation,  to  atrophy  of  the  orbital  cellular  tissue,  to 
paralysis  of  Miiller's  orbital  muscle  from  lesion  of  the  sympathetic,  or  to 
fracture  of  the  orbital  walls. 


CHAPTEE    XXXVII. 

INJURIES  AND  DISEASES  OF  THE  EAR. 
By  Henry  E.  Whakton,  M.D. 

Congenital  Defects  of  the  Ear. — These  may  involve  the  auricle, 
the  external  auditory  meatus,  the  middle  ear,  or  the  internal  ear. 

Congenital  Defects  of  the  Auricle. — These  may  be  unilateral  or 
bilateral,  and  result  from  imperfect  development  of  the  visceral  arches, 
consisting  in  suj)ernumerary  auricles  or  imi^erfect  development  of  the  auricle, 
and  may  be  associated  with  imperfect  development  of  the  auditory  meatus, 
the  bony  canal,  and  the  tympanic  ring.  These  defects  are  often  associated 
with  impaired  hearing.  The  auditory  canal  may  be  entirely  absent,  and  in 
such  cases  the  deformed  auricle  is  apt  to  be  very  movable,  and  is  not  situated 
in  its  normal  position,  being  nearer  the  cheek  or  the  neck. 

Congenital  Fistula. — This  deformity,  which  arises  from  arrested 
closure  of  the  first  visceral  cleft,  is  occasionally  seen.  It  consists  of  a  deep 
fossa  or  small  fistulous  opening,  which  may  be  symmetrical,  and  occupies  a 
position  in  fi-ont  of  the  tragus  or  the  helix,  or  in  the  concha ;  the  fistula  often 
extends  parallel  to  the  meatus,  but  leads  towards  the  pharynx,  and  occa- 
sionally discharges  a  watery  fluid  or  pus.  Treatment. — Supernumerary 
aui-icles  may  exist  without  marked  impairment  of  hearing,  and  the  removal 
of  these  appendages  may  be  undertaken  for  cosmetic  reasons.  Imperfect 
development  of  the  auricle,  if  not  accomx)auied  by  loss  of  hearing,  requires 
no  special  treatment,  but  if  associated  with  diminished  hearing  i^ower  and' 
partial  occlusion  of  the  meatus,  a  plastic  operation  to  enlarge  the  meatus 
and  expose  the  auditory  canal  may  be  undertaken,  with  occasional  good 
results.  In  cases  where  no  meatus  exists  and  the  malformed  auricle  is 
displaced,  the  auditory  canal  and  the  tympanic  cavity  are  in  all  probability 
absent,  and  no  operative  treatment  can  be  beneficial.  Congenital  fistula,  if 
not  accompanied  by  pain  and  purulent  discharge,  needs  no  treatment,  but 
if  the  opiiosite  conditions  are  i^reseut,  cauterization  or  antiseptic  injections 
may  be  employed,  but  often  the  lining  membrane  must  be  dissected  out  to 
obtain  a  permanent  closure  of  the  siniis. 

IJfJUEIES   AND   DISEASES   OF   THE   AUPaCLE. 

Wounds  of  the  Auricle. — Tliese  may  be  incised  or  lacerated,  or  may 
result  from  bites  of  animals ;  a  not  infrequent  injurj'  of  this  appendage 
occurs  from  an  ear-ring  being  forcibly  pulled  from  the  ear,  causing  a  cleft 
of  the  lobule.  Treatment. — In  wounds  of  the  auricle  the  separated  parts 
should  be  accurately  approximated  by  the  use  of  sutures,  care  being  talcen 
to  bring  together  inj  ured  portions  of  the  cartilage,  so  that  the  shape  of  the 

889 


890 


TUMORS  OF  THE   AURICLE. 


Fig.  746. 


ear  shall  be  preserved  as  far  as  possible.  An  antiseptic  dressing  is  applied, 
and,  on  account  of  the  great  vascularity  of  the  part,  prompt  healing  usually 
takes  place.  Clefts  of  the  lobule,  if  seen  early,  should  be  approximated 
with  sutures,  but  if  healing  has  occurred  before  the  case  comes  under  the 
care  of  the  surgeon,  leaving  a  fissure  in  the  lobule,  the  edges  of  the  cleft 
should  be  freshened  and  approximated  by  sutures.     ' 

Frost-Bite  of  the  Auricle.— Frost-bites  of  varying  degrees  of  severity 
are  common  accidents  in  cold  climates,  and  in  severe  cases,  if  sudden  reac- 
tion takes  place,  gangrene  of  the  auricle  is  apt  to  occur.  The  treatment  is 
similar  to  that  for  severe  frost-bites  in  other  parts  of  the  body.  The  greatest 
caution  should  be  observed  to  bring  about  reac- 
tion gradually.  After  reaction  in  these  cases 
and  in  the  case  of  superficial  frost-bites,  the  use 
of  an  ointment  of  ichthyol,  twenty-five  per  cent., 
and  petrolatum,  seventy-five  per  cent.,  is  fol- 
lowed by  the  best  results. 

Burns  and  scalds  of  the  auricle  are  also 
often  seeu,  and  their  treatment  is  similar  to  that 
employed  in  the  same  conditions  in  other  parts 
of  the  body. 

Tumors  of  the  Auricle,— The  auricle 
may  be  the  seat  of  various  tumors,  such  as 
cysts,   nsevus,    epithelioma,  fibroma,    sarcoma, 
and    lipoma.      Keloid   and   fibroma  following 
wounds  of  the  auricle  or  piercing  of  the  lobe 
for  the  apijlicatiou  of  ear-rings  are  not  uncom- 
mon, and  are  very  often  seen  in  negroes.     (Fig. 
746.)     The  treatment  of  tumors  of  the  auricle 
consists  in  excision  of  the  growth,  the  cartilage  being  preserved  as  far  as 
possible  if  it  is  not  diseased,  and,  if  a  large  gap  is  left,  skin-grafting  or  a 
plastic  operation  may  be  employed. 

Othaematoma,  or  Haematoma  of  the  Auricle.— This  consists  of 

a  cyst  containing  serum  or  blood,  which  results  from  injury  to  the  auricle 
(Fig.  747),  is  often  observed  in  boxers  or  foot-ball  players, 
and  is  also  common  in  insane  patients;  the  term  "asylum 
ear"  is  sometimes  applied  to  this  affection.  Its  presence  in 
the  insane  is  commonly  ascribed  to  minor  injuiies  to  the 
auricle,  which  in  their  depressed  vascular  condition  cause  the 
extravasation,  or  to  central  lesions,  the  restiform  bodies  being 
the  portion  of  the  brain  said  to  be  involved.  The  treatment 
of  htematoma  of  the  auricle  consists  in  the  use  of  pressiu-e 
and  massage,  or  of  mild  counterirritants,  and  asiDiration 
may  be  practised  with  good  results  in  some  cases.  It  is 
wiser  not  to  incise  the  swelling  unless  suj^puration  occurs,  in 
which  case  the  sac  shoiild  be  incised  and  irrigated  with  an 
antiseptic  solution,  and  gentle  pressure  made  by  an  anti- 
septic dressing.  Under  either  method  of  treatment  more  or  less  deformity 
is  apt  to  i-esult. 


Fibroma  of  the  auricle. 


Fig.  747 


Hsematoma  of  tlie 
auricle. 


PROMINENT  AURICLES. 


891 


Prominent  Auricles. — Undue  prominence  of  the  ears  constitutes  a 
marked  deformity.  The  condition  may  result  from  the  shape  of  the  carti- 
lages or  from  their  irregular  development.  In  addition  to  prominence  of 
the  ears  there  may  be  associated  a  dropping  forward  of  the  upi^er  portions, 
which  causes  the  ears  to  present  the  appearance  which  is  normal  in  the  ears 
of  fox-terriers.     (Fig.  748.)     The  latter  deformity  seems  to  be  due  to  irreg- 


Prominent  and  drooping  ears. 


Kesult  of  operation  for  prominent  ears. 


ular  development  of  the  cartilage,  which  is  abnormally  thick  at  some  parts 
and  very  thin  at  its  upper  part. 

Treatment. — Prominent  auricles  in  infants  can  often  be  corrected  by 
wearing  continuously  a  band  or  cap  holding  the  ears  against  the  head  ;  in 
children  or  adults  the  deformity  can  be  satisfactorily  corrected  by  a  plastic 
operation.  The  operation  consists  in  first  removing  an  elliptical  section  of 
skin  from  the  back  of  the  ear ;  when  the  cartilage  has  been  exposed,  an 
elliptical  section  of  the  cartilage,  about  one-quarter  of  the  size  of  the  section 
removed  from  the  skin,  is  excised,  care  being  taken  that  the  skin  upon  the 
anterior  surface  of  the  cartilage  is  not  perforated.  The  edges  of  the  wound 
in  the  cartilage  are  next  approximated  by  two  or  three  catgut  sutures,  and 
the  edges  of  the  skin  incision  are  also  brought  together  by  sutivres.  We 
usually  emijloy  a  suture  of  fine  chromicized  catgut.  After  the  sutures  have 
been  tied,  the  ear  is  brought  close  to  the  head,  and  an  antiseptic  dressing  is 
applied  and  held  in  place  by  a  bandage.  The  dressing  need  not  be  disturbed 
for  a  week  or  ten  days,  at  which  time  the  wound  is  generally  firmly  healed, 
and  if  silk  sutures  have  been  used  they  should  be  removed.  The  patient 
should,  however,  wear  at  night  a  cap  or  a  bandage  to  keep  the  ears  close  to 
the  head  and  prevent  stretching  of  the  scar  for  some  weeks.  The  residt  of 
an  operation  for  prominent  auricles  is  seen  in  Fig.  749. 

Acute  and  chronic  inflammation  of  the  auricles  may  arise  from  injuries,  or 
may  show  itself  in  the  form  of  erysipelas,  herj)es,  or  acute  or  chronic 
eczema.  The  treatment  of  these  conditions  is  similar  to  that  for  like  condi- 
tions in  other  parts  of  the  body,  and  need  not  be  detailed  here. 


892  TUMOES   OF  THE  AUDITORY  MEATUS. 

INJUEIES  AND   DISEASES   OE   THE   EXTERNAL   AUDITOEY   MEATUS. 

Wounds  of  the  Meatus. — These  may  result  from  foreign  bodies 
forced  into  the  ear,  or  from  blows  or  falls  rupturing  the  skin  lining  the 
canal.  Free  hemorrhage  iisually  results  from  such  wounds.  The  meatus 
should  be  carefully  irrigated  with  a  warm  antiseptic  solution  or  with  steril- 
ized water  to  remove  the  blood,  the  surface  of  the  wound  covered  with 
powdered  boric  acid  or  iodoform,  and  a  plug  of  antiseptic  cotton  worn  in 
the  external  meatus  for  a  few  days. 

Follicular  Abscess,  or  Furuncle  of  the  Meatus. — This  is  a 
very  common  and  painful  alfection,  which  results  from  the  infection  of  the 
hair-follicles  by  septic  matter,  usually  introduced  in  cleaning  the  ear  with  a 
stick  or  a  pencil.  When  infection  occurs,  itching  is  first  noticed,  soon  fol- 
lowed by  severe  pain  and  marked  swelling  of  the  soft  parts  in  the  auditory 
canal.  If  the  furuncle  is  situated  deeply  in  the  canal,  it  may  be  difficult  to 
expose  it  to  view  even  by  the  use  of  a  speculum.  Treatment. — This  con- 
sists in  syringing  the  canal  with  hot  water  or  mopping  it  with  peroxide  of 
hydrogen,  and  the  use  of  a  cotton  tampon  saturated  with  a  ten  per  cent, 
solution  of  ichthyol ;  as  soon  as  pointing  has  occurred  the  furuncle  should 
be  incised,  antiseptic  irrigation  employed,  and  ichthyol  subsequently  apiDlied, 
pressure  being  made  with  a  cotton  tampon. 

Cellulitis  of  the  External  Meatus.— This  is  a  not  uncommon  affec- 
tion, which  results  from  infection  and  causes  marked  swelling  of  the  soft  parts 
of  the  meatus,  and  may  be  accompanied  by  a  purulent  discharge ;  if  the 
discharge  contains  mucus  as  well  as  pus,  it  is  an  evidence  that  the  tympanic 
and  accessory  cavities  are  also  inflamed.  The  symptoms  of  diffused  inflam- 
mation of  the  external  auditory  meatus  are  rapid  swelling  of  the  soft  parts, 
narrowing  of  the  canal,  and  intense  pain.  Treatment. — This  consists  in 
the  use  of  injections  of  warm  antiseptic  solutions ;  if  the  pain  is  not  soon 
relieved  a  few  deep  incisions  should  be  made  through  the  swollen  tissues, 
and  warm  antiseptic  irrigation  subsequently  employed. 

Tumors  of  the  Auditory  Meatus.— Sebaceous  Cysts. — These 
are  occasionally  seen  occui^ying  the  outer  portion  of  the  canal,  and  are 
similar  to  those  observed  upon  the  scalp  and  other  parts  of  the  body.  As 
they  increase  in  size  they  close  the  canal  and  jjroduce  tinnitus  and  deafness, 
and,  if  not  removed  by  operation  or  spontaneous  rupture,  may  result  in 
necrosis  or  caries  of  the  sm-rouuding  bone  from  the  pressure  which  they 
cause.  Treatment. — This  consists  in  incising  the  wall  of  the  tumor  and 
turning  out  its  contents,  and,  if  possible,  dissecting  out  the  sac ;  if  this  is 
not  practicable,  the  inner  surface  of  the  sac  should  be  cauterized  or  curetted 
and  loosely  packed  with  gauze. 

Epitheliojna  of  the  External  Auditory  Meatus. — This  growth  may 
develop  in  the  auditoi-y  canal,  or  the  canal  may  be  involved  by  extension 
of  a  growth  from  without.  When  the  growth  originates  in  the  canal,  pain 
is  a  very  prominent  symptom.  After  exposing  the  canal  with  a  speculum 
the;  growth  can  be  seen  ;  a  portion  may  be  removed  by  forceps  or  a  curette 
and  examined  microscopically  to  confirm  the  diagnosis.  The  treatment  con- 
sists in  removing  the  growth  as  far  as  possible  by  the  use  of  a  curette. 


POLYPI   OF  THE   AUDITORY   CANAL.  893 

Exostoses  of  the  Auditory  Canal. — Bony  growths  of  the  auditory 
canal  occasionally  occur,  and  are  said  to  be  most  common  in  swimmers, 
whose  ears  are  frequently  exposed  to  cold  water.  The  growths  increase 
slowly  in  size,  but  may  attain  such  dimensions  that  they  obstiuct  the  canal 
and  produce  deafness.  The  treatment  consists  in  incising  the  skin  over  the 
tumor  and  dissecting  it  free  from  the  growth ;  this  may  then  be  removed 
by  dividing  its  base  with  a  fine  chisel,  or  it  may  be  cut  away  by  a  burr  or 
trepbine  attached  to  a  dental  engine. 

Polypi  of  the  Auditory  Canal.— These  tumors  may  be  composed  of 
granulation-tissue,  or  may  be  of  the  fibro-cellular  variety,  and  usually  grow 
from  the  mucous  membrane  of  the  tympanum,  but  may  also  arise  from  the 
deeper  portions  of  the  ai;ditorjr  canal,  springing  from  the  inflamed  and 
macerated  cutis  in  connection  with  cases  of  chronic  otorrhoea,  or  from 
granulations  about  the  opening  of  a  furuncle  the  healing  of  which  has  been 
delayed.  Their  presence  is  accompanied  by  muco-purulent  discharge  and 
blood  ;  pain  may  or  may  not  be  a  prominent  symptom.  Treatment. — The 
seat  of  the  polypi  being  exposed  bj'  a  sijeculum,  the  growths  may  be  removed 
by  a  snare,  or  twisted  oS  by  fine  angular  aural  polyj)us  forceps,  and  after 
they  bave  been  removed  their  bases  may  be  touched  with  chromic  acid, 
great  care  being  taken  to  use  only  enough  acid  to  cover  the  base  of  the  tumor. 
The  subsequent  treatment  consists  in  keeping  the  canal  clean  by  the  use  of 
irrigation  with  antisei^tic  solutions,  or  by  cleansing  it  with  cotton  applied 
by  an  applicator,  and  the  insufflation  of  a  powder  of  boiic  acid  and  aristol 
or  of  iodoform. 

Impacted  Cerumen. — This  usually  results  from  injudicioas  attempts  to 
remove  the  cerumen  by  a  swab,  by  which  means  the  wax  is  pushed  inward 
and  forms  a  considerable  mass,  whicii  gradually  increases  in  size  until  the 
auditory  canal  is  filled  with  the  secretion.  The  symptoms  of  impacted 
cerumen  are  singing  or  buzzing  in  the  ear  and  more  or  less  impairment  of 
hearing,  coming  on  suddenly.  These  symptoms  should  lead  to  an  examina- 
tion of  the  ear  with  a  speculum,  when  a  brown  mass  can  be  seen  filling  the 
auditory  canal.  Treatment. — Impacted  cerumen  is  best  removed  by 
syringing  with  warm  water,  105°  to  110°  F.  ;  this  will  usually  be  followed 
by  the  escape  of  the  mass  of  wax  in  fragments,  unless  the  mass  is  very  dry, 
in  which  case  it  may  be  softened  by  introducing  into  the  ear  a  solution  of 
bicarbonate  of  sodium,  gr.  xx ;  glycerin,  fgi,  water,  fsi ;  a  few  drops  of 
this  solution  should  be  dropped  into  the  ear  at  intervals  of  an  hour  or  so 
before  the  syringe  is  used,  and  after  this  treatment  the  mass  can  usually  be 
promptly  removed  by  syringing  with  warm  water. 

Foreign  Bodies  in  the  Auditory  Canal. — These  may  consist  of 
animate  or  inanimate  objects.  The  animate  objects  which  find  their  way 
into  the  canal  are  flies,  ants,  bugs,  or  moths,  or  the  larvae  of  flies  may  be 
deposited  here,  giving  rise  to  maggots.  The  movements  of  these  objects 
where  they  gain  access  to  the  ear  often  cause  severe  pain ;  they  can  be 
quickly  killed  by  dropping  a  little  sweet  oil  into  the  ear,  or  by  allowing 
the  fumes  of  chloroform  or  ether  to  enter  the  auditory  canal,  and  their 
subsequent  removal  may  be  accomplished  by  syringing  the  ear  with  warm 
water,  or  by  using  a  speculum  and  forceps. 


894  MYEIXGITIS. 

A  great  variety  of  inanimate  objects  are  found  in  the  auditory  canal, 
such  as  pebbles,  beans,  peas,  small  buttons,  and  grains  of  wheat  or  corn. 
These  objects  are  generally  introduced  into  their  own  ears  by  children  in 
play.  They  usually  iDroduce  little  discomfort  at  first,  and  it  is  only  after 
they  have  been  in  the  canal  for  some  time  and  set  up  inflammation  that 
their  presence  is  recognized.  Dry  objects,  such  as  peas,  beans,  or  grains 
of  corn,  which  absorb  moisture  and  increase  in  size,  may  produce  pain  by 
pressure,  and  such  objects  are  often  quite  diificult  to  remove. 

Treatment. — The  safest  method  of  removing  foreign  bodies  from  the 
ear  is  by  syringing  the  canal  with  warm  water,  which  usually  will  be  fol- 
lowed by  the  removal  of  the  body.  In  cases,  however,  in  which  the  body 
has  become  swollen  and  impacted,  it  may  be  necessary  to  use  a  wire  loop, 
forceps,  or  a  scoop  to  dislodge  and  remove  it.  Great  damage  has  often  been 
done  to  the  ear  by  unskilful  attemj)ts  to  remove  a  foreign  body  by  forceps 
or  a  scoop,  so  that  syringing  should  always  first  be  employed,  and  these 
instruments  should  be  used  only  under  general  anaesthesia  where  syringing 
has  been  unsuccessful. 

IN.JUEIES   AND   DISEASES   OF   THE   MEMBEANA   TTMPANI. 

Injuries  of  the  Membrana  Tympani. — Eupture  of  this  membrane 
may  result  from  blows  upon  the  ear,  or  from  the  explosion  of  powder  or 
gases,  or  the  membrane  may  be  perforated  by  sharp  objects  introduced  into 
the  auditory  canal,  such  as  nails,  pins,  pencils,  or  sticks.  When  rupture  of 
the  membrane  occurs,  there  are  experienced  a  ringing  sound  and  pain,  and 
often  nausea  and  dizziness,  with  more  or  less  impairment  of  hearing. 

Treatment. — In  traumatic  rupture  or  perforation  of  the  tympanic  mem- 
brane no  attempt  should  be  made  to  inject  fluids  into  the  ear  to  cleanse 
the  wound,  as  they  are  apt  to  set  ujj  inflammation  of  the  middle  ear ;  but 
the  auditory  canal  should  be  closed  with  a  plug  of  antiseptic  cotton,  and 
this  should  be  allowed  to  remain  in  place  for  a  few  days.  These  wounds 
usually  heal  promptly,  satisfactory  repair  often  occurring  in  one  or  two  days. 

Myringitis. — Inflammation  of  the  membrana  tympani  may  exist  as  an 
acute  or  a  chronic  affection.  Acute  myringitis  may  be  excited  by  the 
entrance  of  irritants  into  the  ear,  by  cold  air  or  cold  water,  or  by  the  growth 
of  aspergillus  upon  the  membrana  tympani.  The  membrane  becomes  red- 
dened and  swollen,  and  sharp  pain  may  be  experienced.  When  the  myrin- 
gitis is  due  to  the  presence  of  aspergillus  the  membrane  is  covered  with  a 
grayish  layer  of  tissue,  which  may  extend  to  the  walls  of  the  auditory  canal, 
and  resembles  in  appearance  wet  paper ;  there  are  also  itching  and  pain  and 
a  scanty  watery  discharge.  The  diagnosis  of  aspergillus  can  be  confirmed 
onlj'  by  microscopic  examination  of  the  false  membrane. 

Treatment. — In  cases  of  myringitis  due  to  cold  water  or  cold  air,  dry 
heat  should  be  applied  to  the  ear,  and  its  use  is  often  followed  by  relief  of 
the  pain ;  if  not  relieved  by  this  treatment,  scarification  of  the  membrane 
should  be  practised.  If  there  is  discharge  from  the  ear,  the  auditory  canal 
should  be  sj'riuged  with  a  1  to  60  carbolic  solution,  and  powdered  boric  acid 
insufflated.  In  case  of  myringitis  due  to  aspergillus  the  cavity  should  be 
illuminated  by  a  head-mirror,  and  the  membrane  carefully  detached  by  the 


INFLAMMATION   OF  THE   MIDDLE   EAR.  895 

use  of  delicate  forceps,  or  by  syriuging  the  ear  with  a  solution  of  peroxide 
of  hydrogen  or  alcohol  1  part,  warm  water  3  parts,  the  surface  then  being 
dusted  with  a  powder  composed  of  salicylic  acid  1  part,  boric  acid  16  parts. 

DISEASES   OF   THE    MIDDLE    EAR. 

Inflammation  of  the  Middle  Ear. — This  is  one  of  the  most  common 
aural  diseases,  and  maj-  exist  as  a  catarrhal  or  as  a  purulent  affection. 

Otitis  Media  Catarrhalis. — This  consists  in  a  catarrhal  inflammation 
of  the  mucous  membrane  of  the  middle  ear,  and  usually  results  from  cold  iu 
the  head.  It  is  very  common  iu  children,  but  is  also  seen  in  adults,  and  is 
characterized  by  intense  jjain  or  earache.  From  infection  this  variety  of 
inflammation  of  the  middle  ear  may  pass  into  the  purulent  form  consti- 
tuting the  aifection  known  as  otitis  media  purulenta.  This  latter  afl'ection  is 
often  observed  as  a  sequel  of  the  exanthemata  in  children.  Treatment. — 
This  consists  iu  the  application  of  dry  heat  to  the  ear,  which  is  accomplished 
by  the  use  of  a  hot- water  bag  or  bottle  or  a  Japanese  hand- warmer,  or  by  the 
injection  of  water  into  the  auditory  canal  as  hot  as  the  patient  can  bear.  If 
this  does  not  relieve  the  pain,  an  anodyne  may  be  required.  If  the  pain  is 
not  relieved  by  this  treatment,  it  is  probable  that  the  catarrhal  otitis  will 
soon  pass  into  the  purulent  form,  and  to  avoid  suppuration  leeches  should 
be  applied,  two  Swedish  leeches  being  placed  iu  front  of  the  tragus  and  one 
beneath  the  lobule  of  the  ear.  If  in  spite  of  these  measures  the  pain  con- 
tinues, the  patient  should  be  etherized  and  the  tympanum  perforated  with  a 
paracentesis  knife  or  needle,  the  point  of  the  j)erforation  being  indicated  by 
the  bulging  of  the  membrane.  The  after-treatment  consists  iu  the  use  of  hot 
douches,  if  antiseptic  gauze  tampons  do  not  suffice  to  remove  the  secretion 
as  fast  as  it  is  formed. 

Chronic  Catarrh  of  the  Middle  Ear.— This  affection  results  fi-om 
repeated  attacks  of  acute  catarrh  of  the  nasopharynx  or  middle  ear,  and  is 
accompanied  by  a  chronic  hypertrophic  condition  of  the  mucous  membrane 
of  the  tympanic  cavity  and  its  contents,  with  retraction  of  the  menibrana 
tympani  and  partial  ankylosis  of  the  ossicles.  The  symptoms  of  chronic 
catarrh  of  the  middle  ear  are  tinnitus  and  more  or  less  impairment  of  hear- 
ing ;  pain  is  usually  slight.  Treatment. — As  this  affection  depends  largely 
upon  disease  of  the  nasopharyngeal  membrane,  the  treatment  of  that  con- 
dition is  a  prime  factor  in  the  cure  of  the  disease,  and  consists  in  the  use  of 
medicated  sprays  and  local  applications,  as  well  as  the  removal  of  the  hyper- 
trophied  tissues,  where  accessible,  by  the  use  of  the  galvauo-cautery.  The 
catarrhal  swelling  of  the  mucous  membrane  prevents  the  entrance  of  air 
into  the  tympanic  cavity,  and  the  inflation  of  the  Eustachian  tube  and  the 
cavity  of  the  tymj)auum  should  be  accomplished  by  the  use  of  Politzer's 
method  or  the  Eustachian  catheter.  The  method  of  inflation  known  as 
Politzer's  is  that  most  easily  practised,  and  consists  in  throwing  air  into 
both  tympanic  cavities  at  the  moment  of  swallowing  by  a  rubber  bag,  the 
nozzle  of  which  is  i^laced  in  one  nostril  while  the  other  uostril  is  closed. 
The  patient  takes  a  mouthful  of  water  and  at  a  word  from  the  surgeon 
swallows  it,  when  the  latter  compresses  the  gum  bag,  forcing  the  air  into  the 
Eustachian  tubes.     This  inflation  should  be  repeated  two  or  three  times  a 


896  MASTOID  DISEASE. 

week.  Various  methods  of  autoinflation,  sucli  as  blowing  with  the  mouth 
and  nose  closed,  are  also  practised,  but  are  not,  as  a  rale,  to  be  recom- 
mended unless  done  under  the  direction  of  the  surgeon.  Pneumatic  mas- 
sage with  the  Siegle  speculum  or  with  the  finger-tip  is  often  very  useful 
in  improving  hearing  and  lessening  tinnitus. 

Chronic  Otorrhoea,  or  Otitis  Media  Piirulenta  Chronica. — This  is 
a  very  common  and  dangerous  affection,  in  which  a  muco-purulent  discharge 
escapes  from  the  ear  or  ears  through  a  perforation  in  the  membrana  tympani ; 
the  ossicles,  the  bony  walls  of  the  tymjianic  cavity,  and  the  mastoid  cells 
may  become  necrosed,  and  polypi  are  generally  present,  growing  from  the 
walls  of  the  tympanic  cavity  or  the  membrana  tym^Dani.  The  affection  often 
occurs  in  children  as  a  secxuel  of  scarlet  fever  or  measles.  A  patient  suffer- 
ing from  chronic  purulent  otitis  may  develop  cerebral  abscess,  phlebitis, 
thrombosis  of  the  lateral  or  petrosal  sinuses,  or  general  pyaemia.  So  fully 
is  the  danger  of  this  condition  recognized  that  no  life  insurance  company 
will  accept  as  a  risk  a  person  who  ijresents  a  running  ear. 

Symptoms. — The  most  marked  symptoms  of  chronic  purulent  otitis  are 
a  chronic  muco-purulent  and  often  an  offensive  discharge,  and  pain  at  times 
if  the  discharge  is  retained,  with  more  or  less  impairment  of  hearing. 

Treatment. — The  treatment  of  this  affection  consists,  first,  in  keeping 
the  cavity  of  the  ear  clean  by  the  daily  use  of  injections  of  warm  water 
or  warm  boric  solution,  or  by  carefully  cleansing  the  ear  with  absorbent 
cotton  on  an  applicator,  and  the  subsequent  injection  of  a  solution  of  car- 
bolic acid  1  to  40,  or  bichloride  of  mercury  1  to  2000.  The  ear  after  being 
carefully  dried  should  be  treated  by  insufflations  of  boric  acid  finely 
powdered,  or  of  a  powder  of  aristol  and  boric  acid.  This  is  especially 
useful  if  the  perforation  in  the  tympanic  membrane  is  a  large  one.  The 
occasional  application  of  a  ten-  to  thirty-grain  solution  of  nitrate  of  silver 
by  means  of  a  cotton  applicator  is  also  of  advantage.  If  granulations  or 
poypi  are  xsresent,  these  should  be  diminished  under  the  above  treatment, 
but  if  they  are  not  they  should  be  removed  by  a  snare,  or  may  be  destroyed 
by  the  careful  application  of  a  little  chromic  acid  applied  by  means  of  a 
probe.  If  it  is  found  that  the  ossicles  or  the  bony  walls  of  the  tympanic 
cavity  are  necrosed,  excision  of  the  ossicles  is  demanded,  as  well  as  the 
removal  of  the  surrounding  necrosed  bone.  These  operations  are  extremely 
delicate,  and  for  their  description  the  reader  is  referred  to  special  works 
upon  Aural  Surgery.  The  sequelte  of  chronic  x^uruleut  otitis  media,  such 
as  thrombosis  of  the  petrosal  or  lateral  sinuses,  and  cerebral  or  cerebellar 
abscess,  are  considered  under  Diseases  of  the  Head,  pages  728  and  729. 

Mastoid  Disease. — Periostitis  of  the  external  surface  of  the  mastoid 
may  result  from  acute  or  chronic  inflammation  of  the  external  auditory 
canal  or  middle  ear,  especially  deep  furuncles,  but  inflammation  of  the 
mastoid  cells,  resulting  in  necrosis  of  the  bone,  usually  follows  chronic  or 
acute  purulent  inflammation  of  the  middle  ear,  and  may  occur  at  any  age. 
The  involvement  of  the  mastoid  usually  develops  suddenly  after  exposure 
to  cold  or  the  introduction  of  cold  water  into  the  ear.  The  development  of 
inflammation  of  the  mastoid  is  evidenced  by  the  occurrence  of  throbbing 
and  boring  j)ain,  and  of  tenderness  upon  deep  pressure  over  the  mastoid 


TREATMENT  OF  MASTOID   DISEASE. 


process.  At  the  same  time  the  discharge  from  the  ear  diminishes  or  ceases, 
and  more  or  less  marked  febrile  symptoms  develop.  Facial  paralysis  caused 
by  the  pressure  of  the  s^vollen  mucous  membrane  or  of  pus  upon  the  facial 
nerve  is  not  an  uncommon  symptom.  The  purulent  collection  resulting 
from  inflammation  of  the  mastoid  cells  may  be  confined  for  a  time  in  these 
cells,  but  soon  perforates  the  bony  walls,  and  may  enter  the  cranial  cavity, 
giving  rise  to  meningitis  or  a  cerebral  abscess,  or  there  may  develop  sinus- 
thrombosis,  or  the  collection  may  escape  by  perforating  the  external  surface 
of  the  mastoid,  or  may  find  its  exit  by  the  digastric  fossa,  causing  a  swell- 
ing behind  the  ear  or  beneath  the  origin  of  the  sterno-cleido-mastoid,  limit- 
ing the  movements  of  the  lower  jaw.  If  not  relieved  by  rupture  externally, 
the  condition  is  a  most  serious  and  fatal  one  unless  free  drainage  is  effected 
by  surgical  aid.  The  swelling  of  the  mastoid  tissue,  with  an  abscess  under 
the  periosteum,  forces  the  auricle  outward  and  forward,  causing  the  appear- 
ance well  shown  in  Fig.  7.50.  Chronic  inflammation  of  the  mastoid  may 
result  in  a  sclerosis  or  thickening  of 
the  bone,  with  disappearance  of  the 
cells,  a  condition  sometimes  accom- 
panied with  much  neuralgic  pain, 
which  can  be  relieved  by  chiselling  an 
opening  into  the  thickened  bone. 

Treatment. — As  soon  as  it  is  evi- 
dent that  inflammation  of  the  mastoid 
is  present,  a  free  incision  should  be 
made  through  the  skin  and  perios- 
teum, a  quarter  of  an  inch  behind  the 
auricle,  extending  the  whole  length  of 
the  mastoid  process,  and  the  auricle 
and  skin  should  be  drawn  forward. 
If  a  sinus  in  the  bone  is  exposed,  this 
should  be  enlarged  by  cutting  away 
its  walls  freely  with  a  gouge,  so  as  to 
expose  the  mastoid  cells,  or  if  discol- 
oration indicates  the  location  of  the 

underlying  disease  an  opening  should  be  made  into  the  cells  through  the  dis- 
colored area.  If  no  sinus  or  discoloration  exists,  the  bone  should  be  perfo- 
rated with  a  small  trephine  or  gouge  at  a  point  one-eighth  of  an  inch  below 
the  superior  border  of  the  meatus  and  three-sixteenths  of  an  inch  behind 
the  meatus  ;  the  wound  should  be  carefully  enlarged,  keeping  the  opening 
in  the  bone  always  parallel  with  the  meatus  until  the  mastoid  cells  have 
been  freely  opened,  care  being  taken  to  avoid  injury  of  the  lateral  sinus, 
which  is  in  close  relation  to  the  mastoid  antrum  at  this  point.  In  long  and 
narrow  skulls  the  sinus  is  not  likely  to  be  encountered  (Korner),  but  in  short, 
broad  skulls  and  in  childi-en  it  lies  more  superficially.  When  the  cells  have 
been  freely  exposed,  pus  and  necrosed  tissue  should  be  carefully  removed 
with  a  curette.  If  the  lateral  sinus  is  injured,  free  venous  bleeding  occurs, 
which  may  be  controlled  by  packing  the  wound  with  iodoform  gauze.  The 
cavity  should  next  be  freely  irrigated  with  an  antiseptic  solution,  or  dry 


Deformity  from  mastoid  abscess. 


898  TREATMENT  OF  :MAST0ID  DISEASE. 

mopping  may  be  employed,  and,  finally,  loosely  packed  with  gauze.  If  no 
internal  perforation  has  occurred,  the  symptoms  of  mastoid  disease  rapidly 
disappear  after  this  operation,  and  the  wound  gradually  heals  by  granula- 
tion, leaving  a  depressed  scar.  In  a  considerable  group  of  cases  there  is 
extension  to  the  inner  surface  of  the  bone,  with  pus-collection  external  to 
the  diira,  which  is  generally  thickened  and  granular.  Involvement  of  the 
adjacent  cerebrum  or  cerebellum  is  apt  to  follow,  going  on  to  abscess- 
formation.  (For  the  treatment  of  cerebral  abscess  following  mastoid  disease, 
see  page  731.) 


CHAPTEE  XXXVIII. 

surgery  of  the  abdomen. 
By  B.  Fabquhar  Curtis,  M.D. 

ixjupjes  of  the  abdomen. 

Pathology. — Contusions  of  the  abdomen  are  often  the  result  of  so- 
called  "bumper  accidents,"  the  body  being  caught  between  two  cars  in 
motion,  or  between  the  tail  of  a  cart  and  a  wall,  and  they  are  also  very  fre- 
quently produced  by  kicks  from  horses.  The  great  danger  in  these  injuries 
is  the  liability  of  serious  damage  to  the  abdominal  viscera  or  the  great 
vessels,  and  it  is  possible  for  rupture  or  laceration  of  these  organs  to  be 
produced  without  ecchymosis  or  other  trace  of  injury  on  the  skin.  Lacera- 
tion of  the  stomach  and  intestines  is  exceedingly  dangerous,  on  account 
of  the  large  number  of  bacteria  in  their  contents  and  the  certainty  of  peri- 
tonitis. The  solid  organs,  such  as  the  liver,  kidney,  and  spleen,  are  lacer- 
ated by  the  pressure  of  the  blow.  The  bladder  is  ruptured  by  the  force  of 
the  blow  when  distended,  because  its  contents  cannot  escaije.  but  laceration 
of  the  stomach  and  intestine  is  probably  j)roduced  by  the  crushing  of  the 
organs  against  the  vertebral  column.  The  walls  of  the  stomach  and  bowel 
may  be  contused  and  slough  later,  and  in  this  case  perforative  peritonitis 
will  not  develop  for  some  hours  after  the  injury. 

Wounds  of  the  abdominal  wall,  whether  gunshot  or  incised,  if  they 
involve  only  the  skin  and  muscle,  are  not  of  great  importance,  except  that 
a  hernia  is  likely  to  form  in  the  scar  if  the  muscles  be  widely  divided  unless 
they  are  properly  united.  Subcutaneous  laceration  of  the  abdominal  muscles 
has  been  known  to  occiu'  from  muscular  effort  or  severe  blows. 

Penetrating  wounds  of  the  abdomen  are  very  serious,  even  if  small. 
They  may  simply  open  the  peritoneal  cavity,  rendering  it  liable  to  infection, 
or  they  may  divide  the  abdominal  walls  so  freely  that  some  of  the  contained 
organs  prolapse  in  whole  or  in  part,  and  in  almost  every  case  a  fragment 
of  the  omentum  protrudes.  The  penetrating  object  may  enter  the  abdomen 
through  the  back,  the  diaphragm,  or  the  pelvis.  An  indi\ddual  may  fall  upon 
a  stake  which  may  pierce  the  perineum  or  enter  the  anus  or  vagina  and  sub- 
sequently penetrate  into  the  peritoneal  cavity.  The  chief  danger  in  these 
wounds  is  the  development  of  peritonitis.  The  viscera  may  be  injured  by 
the  penetrating  object.  In  gunshot  injuries  the  ball  may  pass  through  both 
walls  of  the  abdomen,  perforating  any  of  the  viscera  or  the  vessels  in  its 
course.  The  canal  through  the  solid  viscera  will  be  straight,  but  the  pas- 
sage of  the  missile  through  the  intestine  and  stomach  may  produce  many 
openings,  because  those  organs  may  be  folded  upon  themselves,  and  as  many 
as  twenty  or  thirty  perforations  of  the  intestine  have  been  caused  by  a  single 
bullet.  The  bullet  may  be  arrested  in  any  part  of  its  course,  and  it  has  often 
been  found  inside  of  one  of  the  hollow  organs.    It  has  been  vomited  with  the 

899 


900  PEXETRATIXG   WOUNDS  OF  THE  ABDOMEN. 

contents  of  the  stomach,  having  penetrated  only  one  wall  of  that  organ  ;  it 
has  been  passed  with  the  fseces,  proving  that  it  entered  the  bowel ;  and  it 
has  been  found  enclosed  in  the  gall-bladder  at  autopsy  years  afterwards, 
the  jiatieut  having  made  a  complete  recovery.  Fragments  of  clothing  and 
other  foreign  bodies  may  be  carried  into  the  wound.  Bullets  may  pass 
entirely  through  the  abdomen  without  wounding  any  of  the  viscera,  but 
such  cases  are  very  great  rarities,  and  it  is  safe  to  assume  that  when  a  ball 
has  passed  through  the  abdomen  some  of  the  organs  have  been  injured. 

Incised  or  stab  wounds  of  the  abdomen  may  or  may  not  injure  the  con- 
tained viscera.  The  liability  to  visceral  injurj-  by  cutting  weapons  is  less 
than  that  by  bullets,  the  velocity  being  less  and  the  organs  having  time  to 
retreat  before  the  weapon.  The  liver,  kidney,  and  bladder  may  be  reached 
by  cutting  weapons  without  involving  the  peritoneal  cavity  and  without 
danger  of  subsequent  peritonitis. 

Symptoms  and  Diagnosis.— The  first  effect  of  the  abdominal  injury 
is  shown  in  the  shock.  The  shock  of  stab  wounds  is  greater  than  that  of 
gunshot  wounds,  while  that  of  severe  contusions  of  the  abdomen  with  injury 
to  the  viscera  is  still  more  violent.  A  blow  upon  the  abdomen  may  cause 
death  from  the  shock  to  the  visceral  nerves  without  producing  any  visible 
lesion.  The  shock  manifests  itself  by  failure  of  the  pulse,  superficial  respi- 
ration, cold  sweating,  and  occasionally  by  vomiting.  The  pain  produced  by 
these  injuries  is  very  variable,  and  depends  largely  upon  the  amount  of 
extravasation  of  the  contents  of  the  injured  organ.  The  signs  of  hemor- 
rhage often  form  an  essential  part  of  the  primary  symptoms,  and  the  loss  of 
blood  may  result  fatally  in  a  few  minutes  if  the  liver  or  spleen  is  ruptured 
or  if  one  of  the  large  vessels  has  been  severed.  In  the  milder  cases  the  dis- 
tinction between  shock  and  hemorrhage  is  not  easy,  but  simple  shock  is 
transitory  in  its  effects,  and  hemorrhage  usually  causes  shooting  pains  run- 
ning down  the  limbs,  restlessness,  and  rapid  respiration,  consciousness 
remaining  unimpaired.  When  the  hemorrhage  is  very  copious  the  effused 
blood  may  cause  dulness  on  percussion  in  the  dependent  parts  of  the  abdo- 
men. The  abdominal  wall  is  held  against  the  liver  by  the  atmospheric 
pressure,  and  if  gas  from  the  intestine  enters  the  peritoneal  cavity  it  causes 
a  separation  to  take  place  between  the  two,  and  a  tympanitic  note  from  the 
layer  of  gas  takes  the  place  of  the  usual  dulness  on  percussion  due  to  the 
liver.  This  disappearance  of  the  liver  dulness  is  considered  a  pathogno- 
monic sign  of  ijerforation  of  the  stomach  or  intestine,  but  it  is  not  absolutely 
reliable  unless  there  is  evidence  that  the  liver  dulness  existed  just  before 
the  accident.  A  fold  of  the  colon  may  lie  between  the  liver  and  the  abdom- 
inal wall,  and  thus  simulate  the  falling  away  of  the  liver  caused  bj'  free  gas. 
On  the  other  hand,  adhesions  may  hold  the  liver  against  the  abdominal  wall 
even  when  gas  is  present,  or  the  gas  may  be  confined  by  adhesions  around 
the  organ  from  which  it  escapes,  so  that  it  cannot  reach  the  hepatic  region. 
Gas  also  forms  in  the  peritoneal  cavity  in  some  rare  cases  of  infection  with- 
out perforation.  The  escape  of  gas,  however,  through  an  external  wound 
in  cases  of  recent  injury  may  be  relied  upon  as  evidence  of  perforation  of 
the  stomach  or  the  bowel.  According  to  Hartmann  rigidity  of  the  abdom- 
inal muscles  is  a  reliable  sign  that  grave  internal  injury  exists.     Rupture 


PENETRATING   WOUNDS   OF  THE  ABDOMEN.  901 

of  the  spleen  may  occasion  severe  and  even  fatal  hemorrhage  without  other 
symptoms,  or  there  may  be  vomiting  and  pain  in  the  left  shonldei'.  Lacer- 
ation of  the  great  vessels  also  presents  only  the  symptoms  of  internal  hem- 
orrhage, but  paralytic  intestinal  obstruction  and  distention  of  the  injured 
loop  may  develop  later  if  part  of  the  intestine  has  had  its  blood  supply  cut 
off.  Laceration  of  the  liver  may  be  recognized  by  the  signs  of  severe  hem- 
orrhage in  the  first  stage,  followed  by  tenderness  over  the  organ  and  pain  in 
the  right  shoulder,  and  occasionally  by  a  low  grade  of  peritonitis,  caused  by 
the  escape  of  bile  into  the  peritoneal  cavity.  The  peritonitis  after  this  acci- 
dent is  occasionally  acute,  and,  on  the  other  hand,  the  peritoneal  cavity  has 
been  found  to  contain  large  quantities  of  bile  escaping  from  a  laceration  of 
the  gall-bladder  or  ducts,  with  scarcely  any  sign  of  inflammation.  EuiJture 
of  the  kidney  will  be  recognized  by  the  signs  of  internal  hemorrhage,  the 
appearance  of  blood  in  the  iirine,  and  the  formation  of  a  retroperitoneal 
tumor  of  considerable  size  about  the  kidney,  caused  by  the  extravasated 
blood.  Eupture  of  the  bladder  will  be  recognized  by  inability  to  pass  the 
urine,  and  the  retention  may  be  accompanied  by  tenesmus.  If  cystitis  be 
present,  a  verj^  acute  peritonitis  may  follow  the  accident,  but  the  perito- 
neum reacts  slowly  to  healthjr  urine,  and  in  some  cases  the  symptoms  of 
inflammation  have  been  obscure  for  three  or  four  days  after  the  accident. 
Eupture  of  the  bladder  may  also  take  place  in  that  i^art  of  the  organ  which 
is  not  covered  with  peritoneum,  in  which  case  urine  is  extravasated  in  the 
cellular  tissue,  and  results  in  the  formation  of  abscesses  in  the  pelvis  and- 
lower  part  of  the  abdomen.  An  injury  of  the  stomach,  if  slight,  may  be 
accompanied  by  vomiting,  and  bright  blood  may  be  thrown  up,  but  when 
the  wound  is  extensive  vomiting  is  imj^ossible.  Peritonitis  sets  in  quite 
promptly,  and  food  may  find  its  way  through  the  wound  into  the  peritoneal 
cavity,  and  produce  intense  pain,  as  in  perforation  of  the  stomach  by  an 
ulcer.  The  wound  of  the  stomach  may  be  situated  on  the  posterior  wall, 
and  a  subphrenic  abscess  will  then  result  instead  of  a  general  peritonitis. 
In  very  small  punctured  wounds  of  the  stomach  and  intestine  the  mucous 
membrane  generally  becomes  everted,  blocking  the  opening  and  preventing 
escape  of  the  contents.  Meanwhile,  adhesions  may  form,  and  an  abscess  or 
spontaneous  closure  and  recovery  may  result,  but  this  fortunate  conclusion 
is  very  rare.  If  the  stomach  or  intestine  is  empty  at  the  time  of  the  acci- 
dent there  may  be  no  sign  of  injury  until  extravasation  takes  place  some 
houi'S  later,  when  pain  and  shock  may  apj)ear  suddenly.  Laceration  of  the 
intestine  is  followed  by  the  i^roduction  of  a  localized  or  general  peritonitis, 
according  to  the  size  of  the  wound  and  the  amount  of  fecal  extravasation. 
In  none  of  these  latter  accidents  is  hemorrhage  an  important  factor  unless 
there  has  been  some  injui-y  of  the  mesentery  as  well.  Injury  of  the  large 
intestine  is  less  dangerous  than  that  of  the  small,  as  the  contents  are  likely 
to  be  more  solid  and  the  fecal  extravasation  is  less  extensive.  The  introduc- 
tion of  hydrogen  gas  into  the  bowel  to  determine  if  a  xjerforatiou  is  present 
is  dangerous,  as  it  increases  the  existing  tympanites  and  may  cause  addi- 
tional fecal  extravasation. 

Treatment. — The  treatment  of  these  injuries  depends  upon  the  partic- 
ular organ  involved,  and  in  the  first  place  one  should  determine,  if  possible, 

5S 


902       TREATMENT  OF  PENETRATING  AVOUNDS  OF  THE  ABDOMEN. 

whether  any  of  the  Aascera  have  been  injured.  The  diagnosis  must  be  made 
before  peritonitis  develops,  for  if  interference  is  delayed  until  symptoms  of 
peritonitis  ■  appear  it  will  be  too  late  usually  to  save  the  patient.  Wounds 
of  the  abdominal  wall  without  injury  to  the  viscera  are  to  be  closed  by 
sutures  after  careful  sterilization.  In  every  case  the  wound  should  be 
explored  and  enlarged  if  necessary  to  ascertain  if  it  has  penetrated  the 
abdomen  and  injured  any  internal  organ.  The  wound  should  be  wiped  out 
thoroughljr  and  carefully  packed  with  gauze,  then  the  stin  is  to  be  cleansed 
and  sterilized,  and,  finally,  the  wound  itself  washed  with  the  sterilizing 
solutions,  with  due  care  that  none  enters  the  peritoneal  cavity.  If  the 
omentum  prolaj)ses,  the  protruding  part  should  be  ligated,  cut  away,  and 
the  stumj)  replaced.  The  prolapsed  viscera  should  be  cleansed  and  returned, 
the  wound  being  enlarged,  if  necessary.  The  prolapsed  si^leen  has  fre- 
quently been  ligated  and  removed  with  a  successful  result.  The  results  of 
the  earliest  laparotomies  for  visceral  injuries  are  not  good,  the  mortality 
being  from  fifty  to  seventy-five  per  cent.  It  is  estimated  that  contusion  of 
the  abdomen  with  rupture  of  the  liver  or  spleen  results  in  death  in  about 
five-sixths  of  the  cases.  Injuries  of  the  stomach  and  intestine,  if  left 
untreated,  have  a  mortality  even  higher  than  this,  although  instances  of 
spontaneous  recovery  are  not  unknown  when  the  perforation  was  small.  It 
may  be  considered  settled  that  if  a  patient  has  suffered  from  an  injury 
severe  enough  to  make  it  probable  that  one  of  the  abdominal  organs  has 
been  injured  and  that  there  is  danger  of  peritonitis,  laparotomy  should  be 
performed,  provided  that  it  can  be  done  within  from  twelve  to  twenty-four 
hours  after  the  accident  by  a  surgeon  of  experience  and  with  all  the  facili- 
ties of  a  modern  hospital.  A  delay  of  a  few  hours  is  likely  to  be  fatal. 
But  if  hospital  advantages  are  not  at  hand,  it  will  be  wiser  to  trust  to 
nature.  Laparotomy  for  gunshot  wounds  will  probably  never  be  a  suc- 
cessful feature  of  military  surgery,  because  it  is  impossible  on  the  field  to 
secure  the  facilities  for  performing  this  heroic  operation,  and  it  is  too  late 
to  attempt  it  by  the  time  the  wounded  man  reaches  the  main  hospitals. 

Operations  of  this  kind,  whether  in  cases  of  contusion  or  of  gunshot 
wound,  are  performed  like  any  ordinary  laparotomy,  except  that  great 
rapidity  of  execution  is  necessary  in  order  to  lessen  the  shock.  If  the 
patient  is  already  in  severe  shock  from  the  injury,  the  operation  should  be 
deferred  until  reaction  has  been  obtained.  During  the  operation  the  abdo- 
men and  all  exposed  viscera  must  be  kept  carefully  covered  with  hot  damp 
cloths.  The  incision  should  be  sufficientlj'  large  to  permit  rapid  exami- 
nation of  the  abdomen.  The  situation  of  the  contusion  or  wound  is  the 
guide  to  the  organ  injured,  and  this  region  should  first  be  examined  and 
any  woimds  treated  as  necessary.  But  the  surgeon  should  not  be  content 
with  this,  and  every  part  of  the  abdomen  should  be  carefully  explored,  for 
it  has  frequently  occurred  that  one  wound  of  the  intestine  has  been  found 
and  treated,  while  other  injuries  have  been  overlooked.  Single  wounds  of 
the  gut  or  stomach  are  closed  by  Lembert  sutures,  or,  if  the  bowel  has  been 
entirely  divided,  its  ends  should  be  united  by  a  Murphy  button  or  a  lateral 
anastomosis  made.  If  there  are  several  wounds  close  together,  the  entire 
loop  of  bowel  should  be  resected.     Wounds  of  the  bowel  can  sometimes  be 


TECHNIQUE  OF  ABDOMINAL  OPEBATIONS. 


903 


closed  most  rapidly  by  stitchiug  the  serous  surface  of  a  neighboring  hjop  of 
intestine  against  the  open  wound  without  uniting  the  edges  of  the  latter. 
It  may  be  necessary  to  secure  the  open  ends  of  the  bowel  in  the  abdominal 
wound  without  attempting  to  suture  them,  if  the  patient  is  in  collapse.  If 
a  large  quantity  of  blood  is  found  on  opening  the  abdomen,  the  operator  or 
his  first  assistant  should  immediately  comxiress  the  aorta  at  the  root  of  the 
mesentery  with  one  hand  while  the  wounded  part  is  being  sought  for.  The 
lacerated  spleen  should  be  removed  after  ligatuie  of  the  pedicle.  Wounds 
of  the  liver  may  be  brought  together  and  all  hemorrhage  controlled  by  a 
few  deep  sutures,  or  they  may  be  packed  with  gauze.  Injury  to  the  mesen- 
teric vessels  requires  resection  of  as  much  of  the  bowel  as  has  its  circulation 
impaired.  The  injurj-  to  the  viscera  having  been  dealt  with,  the  wound  is 
to  be  rapidly  closed.  If  fecal  extravasation  has  occurred,  the  peritoneal 
cavity  should  be  washed  out  and  drainage-tubes  inserted.  (For  the  treat- 
ment of  injuries  of  the  kidney  and  bladder,  see  those  chaj)ters.) 

THE  GENERAL  TECHNIQUE  OF  ABDOMINAL  SURGERY. 

The  opening  of  the  peritoneal  cavity  has  usually  been  called  laparotomy, 
but  some  prefer  the  term  coeliotomy  for  such  operations,  whether  the  cavity 
is  opened  through  the  abdominal  wall  or  through  the  vagina. 

Fig.  751. 


Abdominal  incisions :  a  and  B,  median  ;  c,  ileo-ciecal ;  d,  left  inguinal  colostomy ;  E,  nephrectomy  : 
F,  gall-bladder ;  g,  gastrostomy ;  A,  iliac  artery ;  K,  through  rectus  muscle. 

The  Incision. — Nearly   all   operations    upon    the    abdominal    organs 
require  the  opening  of  the  peritoneal  cavity,  and  the  incision  usually  chosen 


904 


TECHNIQUE  OF  ABDOMINAL  OPERATIONS. 


is  in  the  median  line,  although  it  is  not  absolutely  necessary  to  confine  it  to 
the  liuea  alba.  (Fig.  751.)  The  hemorrhage  is  least  and  the  adjustment  of 
the  edges  easiest  at  this  point.  Some  surgeons  claim  that  a  broader  surface 
is  obtained  for  apposition  and  the  risk  of  hernia  is  lessened  by  incising 
through  the  rectus.  Other  incisions,  vertical,  oblique,  or  transverse,  may 
also  be  made  through  the  abdominal  muscles,  but  the  different  layers  of 
muscle  are  difficult  to  approximate,  and  a  hernia  or  weakness  of  the  abdom- 
inal wall  is  more  to  be  feared.  This  defect  is  less  important  in  the  upper 
part  of  the  abdomen,  because  the  intra-abdominal  pressure  is  not  so  great  as 
below  the  navel,  and  hernia  is  less  likely  to  develop.  For  operating  on  the 
appendix,  McBurney  has  suggested  that  after  the  skin  has  been  incised  the 
fibres  of  the  abdominal  muscles  should  be  separated  in  the  direction  of  their 
length,  the  oi^ening  in  the  external  oblique  being  nearly  at  right  angles  to 
that  in  the  internal  oblique.     (Fig.  752.)     The  opening  thus  obtained  is 

Fig.  752. 


McBurney's  incision.    Skin  and  external  oblique  divided,  internal 
oblique  showing. 


about  two  inches  in  diameter  (Fig.  753),  and  after  the  operation,  when  the 
muscular  fibres  are  brought  together,  the  lines  of  incision  in  the  two  muscles 
cross  each  other,  and  firm  support  is  given  to  the  abdominal  contents.  This 
method  of  making  the  incision  is  very  useful  for  many  other  operations, 
such  as  resection  of  the  bowel  and  exploration  of  the  kidney.  When  more 
room  is  needed  the  sheath  of  the  rectus  can  be  split  transverselj'  in  line  with 
the  splitting  of  the  internal  oblique  and  the  muscular  fibres  retracted 
inward. 

The  size  of  the  incision  must  be  proportionate  to  the  work  to  be  done. 
Solid  tumors  require  larger  incisions  than  cystic,  because  the  size  of  the 
latter  may  be  reduced  by  aspirating  their  contents.     Any  dissection  or  the 


TECHNIQUE  OF  ABDOMINAL  OPERATIONS. 


905 


introductiou  of  sutures  deep  iu  the  abdomen  also  requires  large  incisions, 
and  while  the  expert  may  venture  to  separate  adhesions  by  touch  only,  and 
to  work  through  a  small  opening,  the  majority  of  surgeons  should  see  clearly 
what  they  do.  In  making  an  abdominal  incision  the  skin  and  muscles  or 
aponeuroses  are  divided  down  to  the  peritoneum,  and  all  bleeding  vessels 
secured  before  opening  that  membrane.  The  peritoneum  is  then  picked  up 
between  two  forceps  and  lifted  free  from  the  underlying  omentum  or  bowel. 
A  small  opening  having  been  made  in  it,  the  air  enters  and  the  omentum  or 
bowel  falls  away,  so  that  the  incision  can  be  readily  enlarged  by  the  scissors. 

Fig.  753. 


McBurney's  incision.    External  oblique  retracted  laterally  ;  internal  oblique 
up  and  down  ;  peritoneum  bulging  into  wound. 

If  the  parietal  peritoneum  is  adherent  to  the  viscera,  great  care  is  necessary 
to  avoid  injury  to  the  latter,  and  the  adhesions  should  be  separated  as  the 
incision  is  enlarged.  Flat  sponges  or  flat  pads  of  gauze  are  then  intro- 
duced, so  as  to  hold  back  the  intestines  from  the  field  of  operation,  and  if 
it  is  exi^ected  that  pus  or  fecal  matter  will  enter  the  field,  the  gauze  must  be 
very  carefully  placed  between  the  edges  of  the  wound  and  the  organ  to 
be  attacked.  This  having  been  done,  tumors  may  be  removed,  abscesses 
evacuated,  or  the  stomach  or  intestine  opened  freely  without  the  danger  of 
exciting  peritonitis.  After  the  intra-abdominal  work  is  completed  the  field 
of  operation  must  be  thoroughly  wiped  dry,  and  then  the  layei-s  of  gauze 
or  sponges  are  removed. 

Trendelenburg's  Position. — When  the  patient  is  placed  on  an  inclined 
plane,  head  downward,  with  the  knees  flexed,  the  weight  of  the  body  being 
held  by  the  bent  legs  and  the  shoulders  being  much  lower  than  the  hips,  the 


906 


TREATMENT  OF  PEDICLES. 


abdominal  contents  all  tend  to  settle  to  the  upper  part  of  the  abdomen,  and 
the  pelvic  region  is  emptied  of  everything  except  the  organs  fixed  in  it. 
This  position  is  known  as  Trendelenburg's,  and  it  overcomes  the  difficulty 
of  preventing  loops  of  intestine  from  slipj)ing  into  the  field  of  operation. 
Before  the  abdominal  wound  is  closed  the  patient  should  be  lowered,  or 
intestinal  obstruction  maj^  result  from  the  displaced  intestine.  It  is  necessary 
also  to  detect  any  bleeding  which  may  result  from  the  change  of  position. 
The  table  should  be  well  padded  to  avoid  paralysis  of  the  popliteal  nerves. 
Peritoneal  Adhesions. — Adhesions  are  separated  with  the  fingers,  and 
experience  is  necessary  to  determine  the  amount  of  force  which  it  is  safe  to 
employ.  If  the  adhesions  are  verj^  dense,  they  may  be  dissected  off  with 
the  scissors  or  the  knife,  under  control  of  the  eye ;  or,  if  they  are  band-like, 
they  may  be  divided  between  two  clamps  or  two  ligatures. 


Cleveland's  ligature- passer. 


Treatment  of  Pedicles. — The  pedicles  of  tumors  are  tied  off  by  pass- 
ing double  ligatures  through  them  with  an  aneurism-needle  or  ligature- 
passer  (Pig.  754),  dividing  the  loop,  making  the  two  strands  cross,  and  then 
tying  each  pair  of  ends  upon  opposite  sides  of  the  pedi- 
cle. Instead  of  crossing  the  ends,  after  cutting  the  loop 
a  knot  may  be  tied  in  the  two  strands  near  the  middle 
and  the  knot  then  drawn  into  the  centre  of  the  pedicle. 


Staffordshire  knot  for  pedicle  ;  ss,  section  of  pedicle  ;  a,  loop  of  silk  passed  through  pedicle  ;  b  and  c, 
ends  of  the  ligature  to  be  tied.  Fig.  1. — First  step, — ligature  passed  through  the  pedicle.  Fig.  2. — Loop  of 
ligature,  a,  thrown  over  the  tumor  so  as  to  surround  pedicle  and  lie  upon  the  ends  b  and  c.  Fig.  3.— The 
end  c  drawn  through  the  loop  so  as  to  lie  over  it,  b  remainii:ig  under  it.  Fig.  4. — Loop  drawn  tightly  around 
pedicle  and  the  knot  in  the  ligature  begun.     (Byford.) 

when  any  two  ends  from  opposite  sides  may  be  tied  without  delay.     For 
small  tumors  Tait's  Staffordshire  knot  is  convenient ;  it  is  made  by  leaving 


SUTURE   OF  STOMACH  AND   INTESTINE. 


907 


the  loop  of  the  ligature  uncut,  slipj)iug  it  over  the  tumor  and  over  one  of 
the  free  ends  of  the  thread,  drawing  both  ends  of  the  thread  until  the  loop 
is  pulled  tight  around  the  pedicle,  and  then  tying  the  ends  across  the 
thread  of  the  loop  as  it  lies  between  them.  (Fig.  755.)  In  a  broad,  flat 
pedicle  the  knot  should  be  tied  upon  the  edge  of  the  pedicle.  The  tumor 
can  then  be  cut  away,  leaving  sufficient  tissue  beyond  the  ligature  to  pre- 
vent the  thread  from  slipping  off.  In  some  cases,  as  in  the  broad  ligament, 
the  j)edicle  may  be  too  broad  and  flat  to  allow  of  a  single  ligature,  and  a 
number  of  ligatures  may  then  be  passed,  the  adjacent  loops  interlocking ; 
or  a  cobbler's  stitch  may  be  made  with  a  thread  having  a  round-pointed 
needle  on  each  end,  which  is  run  back  and  forth  through  the  ligament  and 
the  ends  tied.  In  operations  upon  very  vascular  organs,  such  as  the  uterus 
and  spleen,  a  temporary  ligature,  iisually  of  rubber  cord,  may  be  applied 
around  the  pedicle  and  a  bloodless  field  of  operation  thus  obtained.  Care 
must  be  taken  in  passing  the  ligatures  that  the  ureters  and  other  organs  are 
not  constricted  by  them. 

Count  of  Instruments,  etc. — The  number  of  instruments  and  of  pads 
or  sponges  in  use  during  a  laparotomy  should  be  noted  before  the  operation, 
and  they  should  be  counted  afterwards,  in  order  to  make  sure  that  none  are 
left  in  the  abdominal  cavity,  an  accident  which  is  very  likely  to  occur.  It 
is  an  excellent  plan  to  have  a  long  tape  fastened  to  each  pad  or  sponge,  the 
tape  being  left  hanging  out  of  the  wound  when  the  pad  is  placed  in  the 
abdomen,  as  it  is  then  less  likely  to  be  overlooked.  If  the  tapes  of  six  pads 
are  tied  together,  every  one  being  cut  free  when  needed,  the  number  of  cut 
ends  left  in  the  knot  will  indicate  the  number  of  j)ads  to  be  accounted  for 
after  the  operation. 

Suture  of  Stomach  and  Intestine. — As  it  has  been  shown  that  the 
peritoneal  sui-faces  iinite  very  rapidly,  the  best  suture  for  uniting  wounds 
involving  this  membrane  is  the  Lembert  su- 
ture (Figs.  756  and  757),  which  includes  only  Fif'-  ''57- 
the  serous  membrane  and  a  little  of  the  sub- 
jacent tissues  without  penetrating  the  cavity  of 
any  hollow  organ,  and  thus  brings  serous  sur- 
faces in  apposition.     These  sutures  may  be 


Lembert  sutures  in  circular  suture  of  the  intestine. 
(Asjuew.) 


Section  ot  the  intustiiic  thiougli  a 
longitudinal  wound  united  by  two  tiers 
of  Lembert  sutures,    (.\gnew.) 


interrupted  or  continuous,  and  passed  in  the  ordinary  manner  or  like  a 
quilted  suture.  (Fig.  758.)  In  closing  wounds  of  hollow  organs  a  suture 
should  first  be  made  passing  entirely  through  the  thickness  of  their  walls  in 


908  DRAINAGE  IN  ABDOMINAL  OPERATIONS. 

order  to  hold  the  parts  firmly  together,  and  then  the  Lembert  suture  is 
applied  outside,  inverting  the  first  tier  and  covering  it  over  completely.  A 
circular  suture  of  the  intestine  should  always  begin  at  the  mesenteric  bor- 
der, and  a  portion  of  the  mesentery  may  be 
resected  in  order  to  make  nice  apposition,  but 
this  is  seldom  necessary.  The  mesentery  must 
be  left  attached  to  the  bowel  right  up  to  the 
edge  of  the  wound,  or  necrosis  will  result. 
^^-^      ^-^     *""— ^^       When  the  stomach  is  to  be  opened  during  a 

Continuous  quilted    Lembert   suture.     ,  ,  .,  j_iiiii  ,     -, 

(Agnew.)  laparotomy  its  contents  should  be  prevented 

from  escaping  by  compression  by  the  assist- 
ant's fingers.  The  intestine  can  be  isolated  in  the  same  way,  or  by  a  strip 
of  gauze  passed  through  the  mesentery  and  tied  around  it,  or  by  a  special 
clamp.  After  squeezing  the  intestinal  contents  away  from  the  seat  of  the 
wound  the  tapes  or  clamps  can  be  applied  at  some  distance  above  and 
below,  so  as  not  to  interfere  with  the  operation.  The  intestine  or  stomach 
should,  if  possible,  be  drawn  out  of  the  abdominal  wound,  which  is  filled 
with  gauze  pads  or  sponges,  and  then  the  organs  can  be  incised  without 
danger  of  infecting  the  peritoneum. 

Drainage. — Much  judgment  is  required  to  decide  whether  to  drain  after 
a  laparotomy.  .  The  wound  may  be  closed  without  drainage  if  there  is  no 
danger  of  hemorrhage,  and  if  no  infectious  material  has  reached  the  perito- 
neal cavity.  When  there  is  a  possibility  of  hemorrhage  after  the  operation, 
it  is  wise  to  insert  a  drain,  to  give  prompt  warning  when  the  bleeding  begins. 
If  pus  or  fecal  material  has  escaped  into  the  abdomen,  even  when  it  has 
been  thoroughly  washed  out,  it  is  best  to  drain.  If  no  inflammation  follows, 
the  drain  may  be  removed  in  twenty-four  hours,  and  the  opening  for  it  can 
be  closed  by  a  suture,  which  may  be  introduced  at  the  time  of  operation,  but 
left  untied.  Drainage  may  be  made  by  rubber  or  glass  tubes,  the  latter 
being  more  easily  rendered  aseptic,  but  liable  to  cause  damage  by  pressure 
on  the  bowel.  Very  excellent  capillary  drainage  is  made  by  rubber  tissue 
loosely  rolled  into  a  spiral,  or  around  some  iodoform  gauze,  and  flaccid  tubes 
of  thin  rubber  can  be  obtained  into  which  the  gauze  wick  can  be  drawn. 
The  rubber  covering  the  gauze  prevents  adhesions  and  facilitates  removal, 
while  the  advantage  of  capillary  drainage  is  obtained.  When  gauze  pack- 
ing is  left  in  the  abdomen  the  wound  must  be  left  oj)en  for  its  removal,  and 
drainage-tubes  may  not  be  necessary. 

Closing  the  Abdominal  Wound. — The  wound  may  be  closed  by 
sutures  of  heavy  silk  or  silkworm-gut  inserted  through  the  entire  thickness 
of  the  abdominal  wall,  about  four  or  five  sutures  to  the  inch,  care  being 
taken  that  the  edges  of  the  peritoneal  surfaces  and  muscular  layers  are  in 
proper  apposition.  A  better  method  is  to  make  a  separate  suture  of  the 
peritoneiim,  and  then  pass  hea\^  sutures  throvigh  the  rest  of  the  abdominal 
wall  without  penetrating  that  membrane,  thus  shutting  off  the  peritoneal 
cavity  from  the  possibility  of  infection  by  pus  collecting  along  the  outer 
sutures.  Another  method  is  to  suture  each  layer  of  the  abdominal  wall,  the 
peritoneum,  the  muscular  and  tendinous  structures,  and  the  skin,  separately. 
Catgut  may  be  used   for  all  these  sutures,  and  the  sutures  may  be  made 


EXTRAPERITONEAL  OPERATIONS.  909 

continuous.  Some  surgeons  pi-efer  a  more  durable  material  ibr  the  muscular 
and  tendinous  layers,  and  employ  buried  sutures  of  silk,  silkworm-gut, 
chromicized  catgut,  or  kangaroo  tendon.  We  employ  chromicized  catgut, 
because  buried  sutures  of  silk  and  silkworm-gut  are  of  no  advantage,  for 
they  loosen  in  a  few  hours,  and  they  are  a  source  of  danger,  being  liable  to 
cause  abscesses  from  latent  spores  contained  in  them. 

After-Treatment. — The  after-treatment  of  ordinary  laparotomy  cases 
consists  in  rest  in  bed,  low  diet,  and  attention  to  the  bowels.  The  practice 
of  surgeons  differs  as  to  the  administration  of  purgatives,  some  preferring 
to  give  them  at  ouce  on  the  least  sign  of  disturbance,  and  others  delaying. 
Under  ordinary  circumstances  the  bowels  should  be  moved  by  an  enema  on 
the  second  or  third  day,  and  sulphate  of  magnesium  may  be  given  if  neces- 
sary, iiarticularly  if  there  is  a  rise  of  temperature,  pain,  or  tympanites.  In 
cases  of  suture  of  the  stomach  and  intestine,  however,  or  of  ligation  of  the 
stump  of  the  apisendix,  nothing  should  be  given  to  excite  peristalsis  for 
three  or  four  days,  as  otherwise  the  visceral  wound  may  open.  Some  sur- 
geons allow  patients  to  get  up  on  the  tenth  or  fourteenth  day  if  primary 
union  of  the  abdominal  wall  has  taken  place.  Experiments  show,  however, 
that  it  requires  at  lesist  three  weeks  for  the  new  connective  tissue  to  become 
firm,  and  if  any  tension  is  put  on  the  abdominal  walls  before  that  time  there 
is  great  danger  that  the  new  cicatricial  tissue  will  stretch,  and  a  hernia  will 
be  i^roduced.  When  suj)puration  has  taken  place  in  the  wound  this  period 
should  be  lengthened,  because  there  is  then  more  cicatricial  tissue  and  more 
danger  of  a  hernia.  For  similar  reasons  the  patient  should  wear  an  abdomi- 
nal belt  as  a  suj^port  for  at  least  a  year  after  the  operation,  and  the  scar  should 
always  be  watched,  so  that  on  the  least  apiiearance  of  hernia  a  belt  or  truss 
may  be  applied  at  ouce.     Hernia  usually  develops,  if  at  all,  in  the  first  year. 

Extraperitoneal  Operations. — Many  of  the  organs  in  the  abdomen,  and 
many  inflammatory  foci  as  well,  may  be  reached  without  opening  the  perito- 
neal cavity.  The  pelvic  cavity  can  be  made  accessible  by  incisions  parallel 
to  Poupart's  ligament,  the  parietal  peritoneum  being  stripped  up  as  in  the 
old  ojjeration  for  ligature  of  the  iliac  artery,  and  the  uterus,  bladder,  ureter, 
or  other  organs  reached,  or  deep  collections  of  pus  evacuated,  even  if  they 
are  intraperitoneal,  by  dividing  the  peritoneum  where  they  are  adherent  to 
it.  The  kidneys  can  be  removed  through  incisions  in  front,  somewhat 
external  to  the  rectus  muscles,  the  peritoneum  being  stripped  up  and  carry- 
ing the  large  intestine  with  it  until  the  surface  of  the  kidney  comes  into 
view.  Extraperitoneal  operations  are  also  possible  in  operating  for  appen- 
dicular abscesses,  but  are  now  seldom  used.  Care  is  necessary  in  handling 
the  delicate  peritoneum,  but  rents  in  it  may  be  easily  closed  by  suture  and 
the  operation  proceeded  with.  If  pus  is  to  be  discharged,  the  wound  should 
be  protected  with  gauze,  as  described  for  intraperitoneal  operations,  and 
the  question  of  drainage  should  be  treated  on  the  same  principles.  The 
abdominal  incision  is  closed  in  the  usual  manner. 

DISExVSES   OF   THE    ABDOMINAL   WALL   AND   NAVEL. 

Inflaramation, — Ordinary  cellulitis  of  the  abdominal  wall  is  not  very 
common,  and  the  surgeon  should  make  certain  that  it  does  not  arise  from 


910  INJURIES   OF  THE  PERITONEUM. 

some  interual  lesion.  The  abdominal  wall  may  be  the  seat  of  abscesses  as 
the  result  of  infection,  and  subcutaneous  or  muscular  gummata  are  not 
infrequent  in  this  region,  being  often  mistaken  for  some  form  of  neoplasm. 
Inflammation  of  the  navel  from  lack  of  cleanliness  is  very  common,  but  any 
deep  abscess  or  sinus  of  this  part  should  awaken  suspicion  of  congenital 
deformity.  Actinomycosis  may  also  attack  the  abdominal  wall,  originating 
from  the  intestine.  Abscesses  frequently  form  between  the  bladder  and  the 
pubes  (space  of  Eetzius),  making  a  tumor  resembling  the  distended  bladder. 
They  are  caused  by  infection  from  the  genito-urinary  or  intestinal  tracts, 
from  the  pelvic  bones,  or  from  lymphatic  glands.  The  early  symptoms  may 
resemble  those  of  pelvic  peritonitis,  as  there  are  fever,  jpain,  flexion  of  the 
hips  and  trunk,  tension  of  the  recti,  and  urinary  symptoms  such  as  tenesmus, 
frequent  micturition,  or  retention.  These  abscesses  should  be  drained  early 
by  a  median  suprapubic  incision.  A  search  should  be  made  for  the  cause 
of  the  inflammation,  in  order  to  apply  treatment  to  that  condition  also. 
Tumors  of  the  abdominal  wall  arising  from  the  skin  are  similar  to  those 
in  other  parts.  Subcutaneous  lipomata  and  sebaceous  cysts  are  fi'equent. 
The  navel  is  especially  apt  to  be  the  seat  of  tumors.  Dermoids  and  primary 
epithelioma  are  found  here  and  seldom  elsewhere.  Sarcoma  occurs  at  the 
navel  and  in  the  muscles  and  fascia.  The  latter  are  especially  liable  to  a 
peculiar  form  of  fibrous  tumor  called  a  desmoid,  which  resembles  sarcoma, 
but  is  less  malignant.  Desmoid  tumors  form  flat  masses,  arising  from  the 
tendons  and  fascia,  varying  in  size  from  small  nodules  to  the  size  of  the 
hand  and  sometimes  three  or  four  inches  in  thickness.  It  is  difficult  to 
distinguish  them  from  sarcoma-  and  from  chronic  inflammatory  conditions, 
such  as  gumma.  The  treatment  should  be  thorough  extirpation,  as  other- 
wise they  are  liable  to  return.  Extensive  sacrifice  of  muscles  and  peritoneum 
may  be  necessary.    The  defect  in  the  latter  can  be  covered  with  omentum. 

THE  PERITONEUM. 

The  peritoneum  is  a  closed  serous  sac  covering  the  viscera  and  enabling 
them  to  move  easily  upon  each  other.  This  sac  has  free  communication 
with  the  lymphatic  system.  Wounds  or  ulcers  which  perforate  the  hollow 
organs  where  they  are  covered  with  x^eritoneum  result  in  peritonitis,  but,  as 
the  peritoneum  does  not  entirely  surround  all  the  abdominal  organs,  per- 
forations of  the  extraperitoneal  ijortions  of  the  latter  may  occur  without 
peritonitis,  the  cavity  of  the  peritoneum  not  being  invaded.  Cellulitis 
follows  the  extraperitoneal  perforations.  The  surface  of  the  peritoneum  is 
nearly  as  great  as  that  of  the  external  surface  of  the  body,  and  its  absorbing- 
powers  are  very  acti'\'e,  therefore  general  septic  poisoning  is  easily  produced 
when  its  cavity  contains  infectious  fluid.  The  peristaltic  movements  tend 
to  diffuse  infectious  materials  in  the  cavity,  and  also  hasten  their  absorption. 
The  peritoneum  reacts  to  irritation  by  forming  an  abundant  exudate,  the 
fibrinous  portion  of  which  quickly  shuts  off  the  irritated  part  from  the 
general  cavity  by  adhesions. 

Injuries. — The  most  important  consideration  in  injuries  of  the  perito- 
neum is  the  possibility  of  septic  infection,  which  may  take  place  from  with- 
out or  from  injury  of  any  of  the  contained  organs.     The  infection  may  be 


INFLAMMATION   OF  THE  PERITONEUM.  911 

direct,  through  a  penetrating  wound,  or  as  a  result  of  sloughing  after  a 
severe  contusion.  In  the  repair  of  wounds  of  the  peritoneum  union  takes 
place  most  rapidly  when  the  serous  surfaces  are  brought  in  apposition. 
Lymph  is  thrown  out  between  the  serous  surfaces,  the  cells  proliferate 
and  emigrate  into  the  lymph,  and  finally  the  lymph  is  formed  into  new 
connective  tissue,  the  endothelial  cells  becoming  fixed  cells.  These  changes 
take  place  very  rapidly,  and  within  twenty-four  hours  the  edges  are  firmly 
adherent.  When  a  penetrating  wound  reaches  one  of  the  hollow  organs  or 
an  ulcer  threatens  to  i^erforate  its  walls  and  there  is  danger  of  infection  of 
the  peritoneal  cavity,  the  irritation  of  the  beginning  infection  caiises  the 
throwing  out  of  lymph  and  the  formation  of  adhesions  which  surround  the 
infected  area,  and  may  succeed  in  limiting  the  infection  to  that  portion  of 
the  cavity  already  invaded.  If  serious  infection  takes  place  in  a  fresh 
wound,  however,  union  of  the  serous  surfaces  is  impeded,  and  may  be 
entirely  prevented,  showing  that  a  slight  infection  causes  the  formation  of 
adhesions,  whereas  a  virulent  one  prevents  it.  Foreign  bodies  may  enter 
the  peritoneal  cavity  by  accident,  and  ligatures  are  placed  there  during 
surgical  operations,  while  sponges  and  instruments  have  sometimes  been 
overlooked  after  operations  and  left  in  the  cavity.  If  these  bodies  are  sterile 
they  become  encapsulated  in  the  peritoneum  by  the  adhesions  which  form 
around  them,  aud  large  bodies,  such  as  sponges  and  pads  of  gauze,  have 
been  known  to  remain  in  the  abdomen  for  years  without  symptoms.  If  they 
are  not  aseptic,  however,  peritonitis  may  be  set  up,  or  an  abscess  surrounded 
by  adhesions  may  form.  In  several  instances  the  forgotten  instruments  or 
sfionges  have  penetrated  the  intestinal  wall  and  have  caused  intestinal 
obstruction,  or  have  even  entered  the  lumen  of  the  bowel  and  been  dis- 
charged by  the  anus  with  no  symptoms  of  peritonitis. 

Inflammation. — Etiology. — Chemical  substances  may  excite  inflam- 
mation of  the  peritoneum,  and  sterile  foreign  bodies,  such  as  have  been 
mentioned,  may  give  rise  to  a  low  grade  of  irritation,  which  is  little  more 
than  takes  place  in  repair.  Even  the  intestinal  contents,  if  thoroughly 
sterilized,  fail  to  set  \ip  inflammation  when  placed  in  the  peritoneal  cavity, 
showing  that  the  bacteria  in  the  faeces  must  be  the  cause  of  the  peritonitis 
which  invariably  follows  fecal  extravasation.  The  bacteria  may  enter  the 
peritoneal  cavity  through  external  wounds,  the  open  Fallopian  tube,  or  per- 
forating lesions  of  any  of  the  hollow  abdominal  organs.  Infection  may  also 
take  place  through  the  lymphatics  of  the  diaphragm  (empyema)  or  by 
bacteria  in  the  circulating  blood.  The  walls  of.  healthy  organs,  such  as 
intestine,  resist  the  passage  of  the  bacteria  which  they  contain,  but  the  latter 
can  pass  through  if  the  tissues  have  been  injured  by  contusion  or  inflam- 
mation. The  normal  peritoneum  is  also  able  to  resist  bacteria  in  pure  cul- 
ture even  in  considerable  quantity.  This  resistance  is  easily  overcome  if 
in  addition  to  the  bacteria,  serum,  blood,  or  a  small  quantity  of  sloughing 
material  in  which  the  germs  can  grow,  are  present.  The  presence  of  foreign 
bodies  also,  even  if  they  are  in  themselves  harmless,  introduced  at  the  same 
time  as  the  bacteria,  enables  the  latter  to  set  up  peritonitis.  The  power  of 
the  bacteria  to  excite  inflammation  appears  to  reside  only  in  their  chemical 
products  or  toxines,  and  it  is  necessary  for  the  germs  to  have  a  growing 


912  INFLAMMATION   OF  THE   PERITONEUM. 

place  where  they  can  produce  these  toxiues  before  they  can  excite  inflam- 
mation. When  i^eritonitis  is  not  set  np,  the  noxious  materials  are  absorbed 
or  encapsulated.  If  the  circulation  of  the  peritoneum  is  imj)aired,  either 
in  a  limited  portion  by  a  contusion,  or  in  its  entire  extent  by  heart  disease 
or  nephritis,  for  example,  the  growth  of  bacteria  and  consequent  peritonitis 
are  favored.  The  practical  conclnsions  from  these  facts  are  important  and 
obvious.  Not  only  must  the  surgeon's  hands,  insti'uments,  etc. ,  be  steril- 
ized, if  he  is  to  operate  within  the  peritoneal  cavity  without  exciting 
inflammation,  but  he  must  be  careful  to  leave  no  foreign  bodies  or  sloughing 
tissue  in  the  cavity,  and  to  remove  from  it  all  blood  and  serum,  or  to  pro- 
vide drainage  for  the  latter.  The  peritoneum  must  be  protected  from 
strong  chemicals  and  from  drying  by  exposure  to  the  air,  for  these  lower  its 
vitality  and  impair  its  resistance  to  the  bacteria. 

Pathology. — The  first  sign  of  inflammation  of  the  peritoneum  is  con- 
gestion, then  lymph  is  thrown  out,  the  endothelial  cells  are  detached,  and 
the  membrane  loses  its  lustre.  The  endothelia  multiply,  the  fixed  cells  in 
the  connective-tissue  layers  also  increase,  and  both  assist  in  providing  the 
wandering  cells  which  penetrate  the  layers  of  lymph  and  form  pus  when 
the  inflammation  is  acute.  In  cases  of  severe  infection  serum  is  thrown 
out,  becoming  cloudy  as  the  pus-cells  appear.  The  exudate  has  a  fecal 
odor  if  there  is  a  perforation  of  the  bowel,  and  occasionally  even  when  no 
perforation  exists.  If  the  process  does  not  go  so  far  as  to  produce  pus,  the 
lymph  thrown  out  glues  together  the  serous  surfaces  which  are  in  contact, 
forming  adhesions  {adhesive  peritonitis).  The  adhesions  disappear  when  the 
inflammation  ends  in  resolution,  or  they  become  organized  into  strong  con- 
nective-tissue layers  and  bands.  If  pus  is  produced  (suppurative  peritonitis'), 
the  adhesions  formed  at  the  edges  of  the  inflammatory  area  may  completely 
shut  it  in  and  produce  local  peritonitis  or  abscess.  Or  the  adhesions  may 
gradually  give  way  as  the  inflammation  intensifies  behind  them,  and  a 
progressive  suppurative  peritonitis  results.  In  other  cases  the  infection  practi- 
cally begins  simultaneously  in  all  parts  of  the  cavity  and  a  general  suppura- 
tive peritonitis  follows,  but  even  then  many  adhesions  are  present  which 
divide  the  cavity  into  numerous  spaces,  which  are  not,  however,  completely 
shut  off  from  each  other.  Intraperitoneal  abscesses  may  form  anywhere  in 
the  abdomen  as  the  result  of  local  suiJiourative  peritonitis.  The  abscesses 
may  evacuate  themselves  by  penetrating  the  abdominal  wall  or  any  of  the 
hollow  organs,  by  perforating  the  diaphragm  and  flooding  the  pleura,  or 
even  by  discharging  through  the  bronchi.  When  there  is  free  pus  in  the 
general  cavity  it  collects  in  Douglas's  cul-de-sac,  where  it  can  be  felt  by 
rectal  or  vaginal  examination. 

In  addition  to  these  forms  of  inflammation,  a  septiccemia  of  peritoneal 
origin  may  be  caused  by  absorption  of  the  septic  products  formed  in  the 
infected  peritoneum.  The  latter  may  not  react  to  the  infection  with  the 
changes  and  symptoms  of  inflammation,  and  the  clinical  picture  is  merely 
that  of  a  profound  septicsemia,  while  the  autopsy  reveals  only  slight  inflam- 
mation and  but  little  exudate  in  the  peritoneal  cavity.  A  toxcemia,  is  also 
caused  by  absorption  of  the  intestinal  contents  when  they  are  stagnant  by 
reason  of  intestinal  paralysis. 


TEAr:\IATIC  PERITONITIS.  913 

Symptoms. — Traumatic  Peritonitis. — Au  external  wound  of  the 
peritoneum  may  be  infected  at  once,  or  an  originally  clean  wound  maj' 
become  infected,  but  in  either  case  a  strictly  localized  peritonitis  or  a  local 
abscess  is  apt  to  be  the  result.  The  symptoms  are  a  little  tenderness  in  the 
neighborhood  of  the  wound  and  some  pain,  which  increase  until  the  abscess 
bursts  through  the  wound  or  is  discharged  by  incision.  Whenever  there  is 
an  intraperitoneal  abscess,  however,  there  is  always  danger  of  subsequent 
general  peritonitis  from  that  source.  Traumatic  peritonitis  may  also  be 
caused  by  wounds  of  the  viscera,  and  its  intensity  will  depend  upon  the 
-\ascera  involved,  the  most  virulent  forms  following  injury  to  the  stomach 
and  intestine,  on  account  of  the  bacteria  in  their  contents.  When  the  first 
symptoms  of  such  an  injury  have  passed  off  and  the  patient  has  recovered 
from  the  shock,  if  any  infectious  material  has  escaped  into  the  i^eritoneal 
cavity  from  the  wounded  organ,  symptoms  of  inflammation  set  in,  with 
abdominal  pain,  which  may  be  so  severe  that  it  cannot  be  relieved  even  by 
large  doses  of  morphine.  There  is  vomiting,  the  abdomen  is  rigid,  and  dis- 
tention and  tympanites  follow.  Both  pul«e  and  temperature  are  uncertain 
symptoms,  but  the  typical  cases  show  a  temperature  of  101°  to  105°  F., 
usually  without  a  chill,  and  a  hard  wiry  pulse  of  100  to  130.  Leucocytosis 
is  generally  present,  but  may  be  absent,  especially  in  the  severely  septic 
cases.  The  respiration  becomes  thoracic,  suj)erlicial  and  rapid,  because  of 
the  pain  caused  by  movements  of  the  belly,  or  the  mechanical  interference 
of  the  tympanites.  The  latter  is  due  to  distention  of  the  stomach  or  intes- 
tine, but  gas  sometimes  exists  in  the  peritoneal  cavity.  The  patient  looks 
anxious,  the  features  drawn,  the  coloring  yellow.  Consciousness  is  undis- 
turbed until  the  later  stages,  when  a  typhoid  delirium  is  common.  Peri- 
staltic movements  cease  and  absolute  constipation  is  the  riile,  although 
diarrhoea  is  in  rare  cases  i^resent.  The  patient  becomes  cyanotic,  the 
extremities  cold  in  spite  of  the  high  fever,  and  death  ensues  from  exhaustion. 
But  the  symjitoms  which  begin  so  violently  may  diminish  if  the  infection 
becomes  localized,  the  tympanites  growing  less,  the  vomiting  ceasing,  and 
the  pain  and  tenderness  becoming  limited  to  one  point  where  the  abscess  is 
forming.  The  presence  of  an  abscess  is  shown  by  a  palpable  mass  or  local- 
ized sense  of  resistance.  The  mass  is  formed  by  the  fluid  and  solid  exudate 
and  by  the  adherent  organs.  There  may  be  dulness  on  jjercussion  over  the 
abscess,  but  sometimes  there  is  gas  in  its  cavity  and  there  will  be  no  dulness. 
In  other  cases  the  patient  may  die  within  twenty-four  hours  of  the  acute 
septic  jjoisoning  from  absorption  of  the  infectious  matter,  no  active  inflam- 
mation of  the  peritoneum  having  had  time  to  develop.  In  such  a  case  the 
l^atient  may  present  few  symj)toms,  vomiting,  pain,  tympanites,  and  even 
abdominal  rigidity  being  absent ;  but  he  rapidly  sinks  into  a  typhoid  condi- 
tion, with  a  low  grade  of  fever.  In  still  other  cases  the  inflammation  runs 
a  chronic  course,  being  partially  localized,  but  spreading  first  in  one  direc- 
tion and  then  in  another,  several  abscesses  forming  in  succession,  the 
so-called  progressive  peritonitis.  This  form  of  the  disease  may  last  for  many 
weeks,  terminating  in  death  or  in  recovery.  The  2}'ognosis  of  traumatic 
peritonitis  is  very  bad,  almost  the  only  chance  of  recovery  being  in  the 
immediate  jjcrformance  of  laparotomy. 


914  TREATMENT  OF  PERITONITIS. 

A  traumatic  peritonitis  following  lajjarotomy  shows  itself  in  very  acute 
cases  by  an  immediate  rise  of  temperature  and  the  development  of  tym- 
panites, with  vomiting  and  constipation,  and  its  course  is  usually  rapidly 
fatal.  Septic  poisoning  without  inflammation  also  occurs  after  laparotomy, 
and  in  some  cases  the  condition  of  intestino-peritoneal  se]5tic£emia  is  set  up, 
in  which  the  patients  appear  to  be  poisoned  by  the  decomposing  contents  of 
the  paralyzed  bowel  even  more  than  by  the  exudate  in  the  peritoneum.  The 
autopsy  in  these  cases  shows  little  or  no  fluid  in  the  peritoneal  cavity,  but 
the  membrane  is  reddened  and  slight  adhesions  exist,  with  a  little  mucoid 
fluid  in  the  pelvis,  the  coils  of  bowel  being  immensely  distended  and  filled 
with  foul  gas  and  fecal  material. 

Perforative  Peritonitis. — The  symptoms  of  perforative  peritonitis  vary 
with  the  organ  from  which  it  originates,  and  may  be  preceded  by  symptoms 
of  disease  of  that  organ.  The  peritonitis  develops  rapidly  or  slowly,  and 
the  course  and  symptoms  are  like  those  of  traumatic  peritonitis.  It  may  be 
general  or  localized.  The  special  varieties  will  be  considered  in  connection 
with  the  various  organs. 

Treatment  of  Peritonitis.— During  the  early  stages,  before  pus  has 
formed,  the  patient  should  be  kept  recumbent  and  perfectly  quiet,  the  use 
of  the  bed-pan  being  insisted  upon  lest  adhesions  be  ruptured  and  the 
infection  spread.  An  ice-bag  or  cold  coil  should  be  applied  to  the  abdomen 
and  enough  codeine  given  to  control  vomiting  and  modify  pain,  but  not 
enough  to  mask  the  symptoms  and  confuse  the  diagnosis.  Peptonized  milk 
alone  should  be  given  for  food,  and  the  rectum  may  be  washed  out  with  a 
small  injection  of  water,  but  no  laxatives  should  be  given.  Ochsner  recom- 
mends rectal  alimentation,  giving  nothing  whatever  by  mouth,  and  we  have 
found  this  an  excellent  method.  Suppurative  peritonitis  can  be  treated 
with  success  only  by  sm-gical  measures,  for  the  instances  of  recovery  by 
spontaneous  discharge  of  the  pus  are  too  rare  to  admit  of  temporizing 
methods.  Whatever  the  origin  of  the  peritonitis,  the  operative  treatment 
must  depend  upon  the  local  or  general  character  of  the  inflammation. 

Localized  Peritonitis. — When  localized  peritonitis  results  in  abscess, 
the  pus  should  be  discharged,  if  possible,  without  exposing  any  of  the  unin- 
fected peritoneal  surfaces.  This  can  easily  be  done  when  adhesions  exist 
between  the  abscess- cavity  and  the  abdominal  wall,  as  is  often  the  case  in 
abscesses  from  appendicitis,  by  making  the  incision  at  that  point.  Pelvic 
abscesses  can  be  discharged  through  incisions  in  the  vagina.  The  older 
method  of  evacuating  them  through  the  rectum  is  now  seldom  used,  because 
of  the  danger  of  fecal  infection  of  the  abscess-cavity,  but  would  be  permis- 
sible when  the  patient's  condition  forbade  other  incisions.  The  incision 
should  be  large  enough  to  allow  thorough  exploration  of  the  cavity  with  the 
finger  or  the  eye.  When  the  abscess  has  been  opened,  the  pus  should  be 
carefully  sponged  out  and  the  cavity  irrigated  with  sterilized  water.  After 
the  cavity  has  been  thoroughly  cleansed,  a  search  for  the  original  cause  of 
the  inflammation  should  be  made,  a  gangrenous  ai^ftendix  or  a  suppui-ating 
Fallopian  tube  being  removed,  or  a  perforating  ulcer  of  the  stomach  or 
intestine  closed  by  sutures,  unless  the  patient's  condition  is  so  bad  that  these 
procedures  will  endanger  his  life.     A  large  drainage-tube  should  be  inserted 


TREATMENT  OF  PERITONITIS.  915 

at  the  most  dependent  part  of  the  cavity  and  the  latter  lightly  packed  with 
gauze,  the  external  wound  being  packed  also  or  pai'tly  closed  with  sutures 
in  case  it  is  very  large.  When  it  is  necessary  to  invade  the  uuinflamed  part 
of  the  peritoneum  in  order  to  reach  the  encapsulated  pus,  the  surgeon  should 
pack  gauze  under  the  edges  of  the  abdominal  incision,  so  as  to  shut  off  the 
general  cavity,  and  the  abscess  may  then  be  opened  and  the  pus  discharged 
at  once.  If  it  is  possible  to  thoroughly  cleanse  the  cavity  of  the  abscess, 
this  gauze  is  replaced  by  a  fresh  joacking,  but  otherwise  it  must  be  left  in 
place  for  two  or  three  days  after  the  operation.  While  there  is  some  danger 
of  causing  a  general  peritonitis  by  this  procedure,  it  is  not  very  great,  and 
it  is  not  necessary  to  delay  opening  the  pus-cavity  for  twenty-four  hours  to 
allow  additional  adhesions  to  form  between  the  abscess  and  the  abdominal 
wall.  If  the  pus  bursts  through  the  adhesions  as  soon  as  the  peritoneal 
cavity  is  opened,  before  this  protective  packing  can  be  arranged,  the  surgeon 
should  keep  the  abdominal  wound  wide  open  and  have  the  patient  imme- 
diately placed  in  such  a  jjosition  that  the  wound  will  be  at  the  most  depend- 
ent part  of  the  cavity,  so  as  to  favor  free  escape  of  the  pus. 

General  Peritonitis. — When  general  peritonitis  exists,  a  median  inci- 
sion sufficient  to  permit  introduction  of  the  hand  should  be  made  low  down, 
the  pus  discharged,  and  the  cavity  dried  out  with  sponges  or  sterilized  gauze 
pads  as  completely  as  possible.  The  original  cause  of  the  distiu'bance  should 
be  removed  if  possible,  other  incisions  being  made  for  this  purpose  if  it  can- 
not be  readily  reached  from  the  median  one,  as  will  frequently  be  the  case 
in  general  peritonitis  arising  from  appendicitis.  All  adhesions  must  be 
broken  down,  in  order  to  discharge  the  pus  collected  between  the  various 
loops  of  bowel  and  omentum.  Particular  attention  must  be  iiaid  to  the  pelvis 
and  to  the  depressions  which  exist  on  each  side  of  the  vertebral  column  in  the 
lumbar  region.  A  long  dressing-forceps  is  introduced  through  the  median 
wound  and  passed  into  the  lumbar  region  on  each  side,  so  as  to  make  promi- 
nent the  abdominal  wall  just  in  front  of  the  attachment  of  the  mesocolon,  and 
counter-openings  are  made  by  cutting  on  this  from  without.  Large  drain- 
age-tubes are  inserted  in  all  the  incisions,  and  the  entire  cavity  flushed  with 
hot  sterilized  water,  the  hand  being  passed  back  and  forth  to  disseminate 
the  fluid  thoroughly  and  bring  out  all  the  pus.  The  patient  should  be 
rolled  first  on  one  side  and  then  on  the  other,  in  order  to  discharge  as  much 
of  the  fluid  as  possible.  When  there  is  doubt  whether  the  entire  peritoneal 
cavity  is  infected,  the  first  incision  should  be  made  in  the  part  where  it  is 
evident  that  inflammation  exists,  and  after  treatment  of  this  region  as  if  for 
a  localized  abscess,  small  exploratory  incisions  should  be  made  in  the  median 
line  or  lumbar  region,  the  hands  and  instruments  being  sterilized  again,  so 
that  in  case  no  peritonitis  is  found  there  will  be  no  danger  of  spreading  the 
infection.  The  operation  must  be  as  rapid  as  possible,  for  the  shock  is  gen- 
erally very  severe,  and  vigorous  stimulation  will  be  necessary  afterwards, 
with  elevation  of  the  foot  of  the  bed  and  hot  bottles  placed  about  the  body. 
As  soon  as  reaction  sets  in  the  patient  should  be  placed  in  such  a  position 
that  the  drainage-tubes  shall  be  at  the  most  dependent  point,  raising  the 
head  and  shoulders  to  make  the  fluid  drain  into  the  pelvis,  or  turning  the 
Ijatient  on  the  side  if  there  is  a  lateral  incision  as  in  appendicitis. 


916  TUBERCULAR   PERITONITIS. 

If  the  patient's  temperature  is  already  high  at  the  time  of  operation,  a 
fall  may  be  expected  within  a  few  hours.  If,  on  the  other  hand,  the  tem- 
perature is  low  from  toxic  poisoning,  as  is  seen  in  some  cases  of  general 
peritonitis,  the  operation  will  be  followed  by  an  immediate  great  elevation 
of  temperature,  and  this  is  likely  to  terminate  in  death  if  it  continues  long. 
As  soon  as  the  shock  has  been  overcome,  the  heavy  dressing  should  be 
removed  and  replaced  by  a  few  layers  of  gauze  laid  upon  the  abdomen, 
and  over  this  the  ice-coil  should  be  applied.  Enough  morphine  is  to  be 
given  hypodermically  to  relieve  the  pain,  and  no  attempt  should  be  made 
to  move  the  bowels  for  several  days.  This  is  the  method  with  which  we 
have  had  the  best  success ;  but  some  surgeons  prefer  to  begin  at  once  with 
large  doses  of  suli^hate  of  magnesium  in  order  to  obtain  free  movements 
of  the  bowels.  It  has  been  our  experience,  however,  that  this  method 
of  treatment  increases  the  vomiting,  and  that  it  is  usually  imj)ossible  to 
get  the  bowels  to  move  under  these  circumstances.  McCosh  has  reported 
a  series  of  successful  cases  treated  by  the  injection  of  one  drachm  of  a  satu- 
rated solution  of  magnesium  sulphate  into  a  high  loop  of  the  small  intestine 
with  a  hypodermic  syringe  during  the  operation,  the  puncture  being  closed 
by  a  Lembert  suture.  There  is  no  objection  to  attempts  at  moving  the 
bowels  by  enemata,  but  these  are  rarely  successful.  Stimulants  are  generally 
necessary  in  large  doses  to  combat  the  septic  poisoning,  and  the  inhalation 
of  oxygen  assists  this  object.  The  feeding  must  be  carried  out  with  small 
doses  of  milk  at  short  intervals,  varied  by  beef  extracts  and  assisted  by 
rectal  feeding.  Washing  out  the  stomach  by  the  stomach-tube  will  some- 
times arrest  the  vomiting. 

Gonorrhoeal  Peritonitis.— Peritonitis  from  gonorrhoeal  infection  begins 
in  the  pelvis,  and  is  almost  always  a  mixed  infection.  The  infectious  mate- 
rial finds  access  to  the  peritoneum  by  the  Fallopian  tubes,  through  the  wall 
of  the  bladder,  or  through  the  lymphatic  vessels  of  the  spermatic  cord.  The 
lesions  are  usually  limited  to  the  pelvis,  and  the  disease  has  a  subacute 
course  like  pelvic  peritonitis,  ending  in  resolution  or  abscess.  It  is  seldom 
possible  to  make  the  diagnosis  before  operation.  The  treatment  is  the  same 
as  described  above. 

Tubercular  Peritonitis. — Tubercular  peritonitis  or  tuberculosis  of  the 
peritoneum  appears  in  two  forms.  In  the  dry  variety  a  fibrous  exudate  is 
produced.  In  the  ascitic  form  large  quantities  of  serum  are  thrown  out,  the 
peritoneum  at  the  same  time  being  thickened.  The  serous  membrane  of  the 
parietes  and  of  the  various  organs  is  found  studded  with  tubei'cles,  and  large 
tuberculous  masses  form  in  the  thick  fibrinous  exudate.  These  may  break 
down  and  form  abscesses,  which  may  make  their  way  externally  or  pene- 
trate any  of  the  hollow  organs.  The  disease  is  secondary  to  a  lesion  in  some 
of  the  abdominal  organs,  and  most  frequently  in  the  intestine,  from  two- 
thirds  to  three-quarters  of  the  cases  having  this  origin,  while  about  one- 
quarter  of  them  arise  from  the  female  genitals.  Peritoneal  tuberculosis 
is  most  frequent  in  childhood  and  early  adult  life,  but  occurs  at  all  ages. 
It  is  far  more  common  in  women  than  in  men,  but  apparently  the  majority 
of  the  former  recover  from  the  disease,  as  it  is  more  frequently  found  in 
men  at  post-mortem  examinations.     Tlie  symptoms  of  tuberculosis  of  the 


SUBPHRENIC  ABSCESS.  917 

peritoneum  are  clistention  of  the  abdomen,  emaciation,  fever,  ascites,  and 
the  formation  of  masses  of  exudate  in  the  abdomen.  The  fever  is  of  the 
hectic  type,  and  a  subnormal  temperature  may  last  for  days  at  a  time  in 
some  cases.  Palpation  reveals  great  thickening  and  hardening  of  the  ab- 
dominal wall,  even  when  there  is  great  distention.  The  peritoneal  exudate 
may  be  so  limited  as  to  form  solid  or  cystic  tirmors,  and  the  omentum  is 
rolled  up  so  as  to  make  a  band  which  can  be  felt  stretching  across  the  abdo- 
men at  the  navel.  Tumors  may  also  be  formed  by  the  enlarged  glands 
behind  the  peritoneum.  The  disease  progresses  slowly,  as  a  rule,  and  about 
one-quarter  of  the  well-marked  cases  end  iu  spontaneous  recovery,  especially 
in  children. 

Treatment. — Medical  treatment  is  of  little  avail,  while  surgical  methods 
have  succeeded  iu  curing  nearly  three-quarters  of  the  cases  operated  upon. 
SimjDle  tapping  in  the  ascitic  form  has  occasionally  resulted  in  a  cure. 
Aspiration  followed  by  the  injection  of  sterilized  air  has  been  successful  in 
a  few  cases,  and  injections  of  iodoform-glycerin  or  iodoform-oil  (ten  per 
cent. )  have  also  been  tried  with  benefit.  There  can  be  no  question  as  to  the 
power  which  a  sim^jle  exploratory  lai^arotomy  ijossesses  of  curing  extensive 
tuberculous  peritonitis  Avith  universal  adhesions,  innumerable  tubercles,  and 
large  masses  of  exudate,  althongh  the  manner  in  which  it  acts  is  incompre- 
hensible. If  any  operation  is  done,  the  original  source  of  the  disease  is  to 
be  sought  for  and  removed,  if  possible,  the  diseased  portion  of  the  intestines 
being  resected  or  the  Fallopian  tubes  removed.  Some  surgeons  di'ain  if 
there  is  much  fluid,  but  the  writer's  experience  with  seven  successful  cases 
favors  laparotomy  followed  by  the  injection  of  two  to  four  ounces  of  ten  per 
cent,  iodoform-glycerin  into  the  cavities  and  suturing  the  wound  without 
drainage. 

Subphrenic  Abscess. — Subphrenic  abscesses  are  intraiseritoneal  in 
such  a  large  number  of  cases  that  they  are  best  considered  together  with 
peritonitis.  The  abscesses  are  usually  very  large,  and  displace  the  liver  on 
the  right  side  and  the  stomach  and  spleen  on  the  left,  forcing  the  diaphragm 
upward  into  the  chest  to  the  level  of  the  fourth  or  third  rib.  They  may 
cause  a  secondary  empyema,  either  by  directly  perforating  the  diaphragm 
or,  more  commonly,  by  infecting  the  pleura  through  the  lymphatics.  If  an 
empyema  forms  it  may  discharge  into  the  bronchi,  or  if  the  lungs  be  adher- 
ent to  the  diaphragm  the  subphrenic  abscess  may  perforate  directly  into  the 
bronchi.  The  organs  of  the  chest  are  thus  involved  secondarily  in  nearly 
one-half  of  the  cases.  Almost  one-half  of  these  abscesses  contain  gas  in 
considerable  amount,  on  account  of  their  frequent  communication  with  gas- 
containing  organs.  The  most  common  cause  of  subphrenic  abscesses  is 
perforating  ulcer  of  the  stomach,  but  they  may  arise  from  suppurative 
processes  in  almost  any  of  the  abdominal  organs,  and  many  of  them  are 
secondary  to  appendicitis  or  suppuration  of  the  pleura.  Their  limitation  to 
the  upper  part  of  the  abdomen  is  due  to  the  partial  transverse  division  of 
that  cavity  by  the  mesocolon  and  omentum.  The  gall-bladder  and  vermi- 
form appendix  generally  cause  abscesses  on  the  right  of  the  coronary  liga- 
ment of  the  liver,  while  those  on  the  left  usually  originate  from  the  stomach, 
duodenum,  or  spleen.     The  symptoms  of  these  abscesses  consist  in  hectic 

59 


918  TUMORS   OF  THE  PERITONEUM. 

fever  and  the  evidences  of  a  large  tumor  succeeding  the  symptoms  of  the 
disease  from  which  they  originate.  They  may  begin  acutely  like  any  local- 
ized peritonitis,  or  with  very  vague  symptoms  of  general  sej)ticfemia,  the 
abdomen  remaining  soft,  not  distended,  and  not  tender  to  pressure. 

Diagnosis. — It  is  important  to  distinguish  between  subphrenic  abscesses 
and  empj'ema  or  abscess  of  the  liver,  for  both  may  cause  distention  and 
dulness  on  percussion  of  the  lower  thorax.  In  empyema  the  upi^er  surface 
of  the  fluid  will  describe  a  curved  line  on  the  side  of  the  chest,  concave 
upward.  In  subphrenic  abscess  the  upper  limit  of  the  fluid  will  be  convex, 
the  pus  being  contained  beneath  the  diaphragm.  If  an  aspirating  needle  is 
inserted,  the  flow  of  the  fluid  from  an  empyema  will  be  sti'ongest  during 
expiration,  and  that  from  a  subphrenic  abscess  strongest  during  inspiration, 
the  fluid  from  the  latter  being  pressed  out  by  the  descent  of  the  diaphi-agm. 
A  similar  phenomenon  will  be  observed  if  gag  be  contained  in  the  pleural 
or  abscess  cavity  which  the  needle  enters,  as  can  be  demonstrated  by  placing 
the  end  of  the  needle  under  water,  or  holding  a  lighted  match  near  it.  In 
some  cases  of  subphrenic  abscess  the  aspirating  needle  has  an  oscillating 
movement,  owing  to  the  movement  of  the  diajDhragm,  which  it  has  trans- 
fixed, whei'eas  in  empyema  the  needle  is  always  stationary.  Abscess  of  the 
liver  does  not  contain  gas,  its  pus  is  usually  sterile,  and  it  generally  alters 
the  shape  of  the  liver.  The  presence  of  gas  in  the  cavity  of  these  abscesses 
is  demonstrated  by  the  tympanitic  percussion-note  and  by  the  change  in  the 
level  of  the  fluid  x^roduced  by  changing  the  position  of  the  patient,  as  in 
ascites.  The  j^rognosis  without  oj)eration  is  very  bad.  About  one-half  of 
the  cases  may  be  cured  by  early  operation,  but  usually  sei)tic  poisoning  is 
already  present  when  the  surgeon  is  consulted. 

Treatment. — The  abscess  should  be  opened  by  an  incision  through  the 
abdominal  parietes,  and  if  necessary  one  of  the  ribs  may  be  resected,  as  in 
the  operation  for  opening  an  abscess  of  the  liver.  Abundant  drainage  must 
be  provided,  and  when  the  circumstances  of  the  case  and  the  condition  of 
the  patient  permit  it,  a  search  should  be  made  for  the  cause,  such  as  perfora- 
tion of  the  stomach  or  duodenum.  The  primary  lesion  should  be  treated 
by  suture  or  otherwise. 

Tumors  of  the  Peritoneum. — Tumors  may  develop  in  the  perito- 
neal membrane,  but  usually  they  are  secondary  to  disease  elsewhere,  either 
carcinoma  or  sarcoma.  The  primary  tumors  form  small  nodular  masses, 
scattered  over  the  surface,  and  cause  a  hemorrhagic  serous  effusion.  They 
are  incurable,  and  are  of  consequence  surgically  only  because  they  may  be 
confounded  with  other  conditions.  From  tuberculosis  they  are  distinguished 
by  their  occurrence  at  a  later  period  in  life,  by  the  greater  cachexia,  and  by 
the  blood  in  the  ascitic  fluid.  Hydatid  cysts  are  also  found  in  the  peritoneal 
cavity,  but  clinically  they  are  best  studied  with  hydatids  of  the  liver,  to 
which  they  are  usually  secondary. 


Wounds  of  the  liver  have  been  considered  with  the  injuries  of  the 
abdomen.  The  liver  is  occasionally  displaced,  its  ligaments  being  relaxed 
so  that  it  may  descend  even  into  the  lower  x^art  of  the  abdomen,  and  attempts 


ABSCESS   OF  THE  LIVER.  919 

to  secure  it  in  its  proper  jjositiou  by  suturing  it  to  the  abdominal  wall  have 
been  made  with  fair  success. 

Abscess. — Abscesses  of  the  liver  may  be  single  or  multiple.  They 
may  be  due  to  the  suppuration  of  a  htematoma  produced  by  an  injury,  or  of 
a  hydatid  cyst ;  and  they  are  also  caused  by  gall-stones.  Most  frecxuent, 
however,  are  the  pyajmic  and  the  tropical  abscesses.  Pyremic  abscesses  and 
those  caused  by  gall-stones  are  generally  multiple.  Tropical  abscess  is 
usually  single  and  of  large  size,  and  is  situated  in  the  right  lobe  in  three- 
quarters  of  the  cases.  These  abscesses  may  also  occur  in  cool  countries, 
although  not  so  frequently  as  in  hot,  and  they  are  generally  secondary  to 
dysentery.     They  are  supj)osed  to  be  due  to  infection  by  the  amoeba  coli. 

The  pus  of  liver  abscesses  is  frequently  sterile  and  does  not  contain  bac- 
teria, biit  this  apparently  sterile  pus  when  injected  exjierimentally  into  the 
rectum  of  cats  has  caused  proctitis  and  secondary  abscesses  of  the  liver. 
The  single  large  abscesses  most  frequently  demand  surgical  attention.  They 
increase  very  slowly,  with  vague  symptoms,  until  they  attain  a  considerable 
size,  when  septictemia  generally  develops,  and  the  diagnosis  is  rendered 
possible  by  the  enlargement  of  the  liver  and  the  pain  due  to  distention. 
Leucocytosis  is  not  always  marked  and  may  be  absent  in  amoebic  abscess. 

Treatment. — Single  abscesses  can  be  treated  successfully  by  operation, 
but  the  multiple  abscesses  are  incurable.  The  abscess  may  be  drained  by  a 
large  trocar  puncture  or  by  free  incision.  The  situation  of  the  pus  in  the 
liver  is  determined  by  capillary  puncture  with  a  fine  needle,  and  when  the 
pus  has  been  found  the  needle  should  be  left  in  xjlace  and  cut  down  upon  at 
once,  in  order  to  avoid  the  leakage  of  pus  into  the  peritoneal  or  the  pleural 
cavity.  It  may  be  necessary  to  pass  through  the  pleural  cavity  as  well  as 
the  peritoneum  to  reach  some  of  these  abscesses.  "When  the  i^eritoneal 
cavity  only  is  to  be  opened,  the  incision  is  made  through  the  abdominal 
wall,  the  peritoneum  is  stitched  to  the  sirrface  of  the  liver  by  a  complete 
circle  of  sutui-es,  and  the  liver  is  incised  in  the  centre  of  this  ring.  The 
pus  may  lie  at  a  depth  of  two  or  three  inches,  and  it  is  best  to  use  the 
thermo-cautery  in  making  this  incision,  in  order  to  lessen  the  hemorrhage. 
Incisions  above  the  line  of  the  diaphragm  may  invade  the  pleura.  In  this 
case  a  portion  of  one  or  two  ribs  is  resected,  the  visceral  pleura  is  stitched 
down  to  the  diaphragm  by  a  circle  of  sutures,  and  the  diaphragm  is  then 
incised.  If  the  peritoneal  cavity  is  free  between  the  diaphragm  and  the 
liver,  this  is  also  protected  by  a  circle  of  sutures  before  the  liver  is  incised. 
If  haste  is  not  necessary,  the  liver  may  be  exposed  in  the  wound  and  the 
latter  packed  with  gauze  for  twenty-four  hours  in  order  to  allow  adhesions 
to  form.  The  after-treatment  cousists  in  irrigation  of  the  cavity,  and  the  use 
of  tonics  and  stimulants.     The  abscess- cavities  are  very  slow  in  contracting. 

Tumors  of  the  Liver. — It  is  seldom  that  tumors  of  the  liver  are 
primary  or  are  recognized  early  enough  to  allow  of  surgical  treatment. 
Keen  has  collected  twenty  cases  of  partial  resection  of  the  liver  for  tumors, 
however,  with  a  mortality  of  only  ten  per  cent.  ;  biit  the  majority  of  the 
growths  were  pedunculated  or  occupied  small  pedunculated  lobes. 

Hydatid  Cyst  of  the  Liver. — Hydatids  are  not  infrequent,  although 
rare  in  America.    They  originate  by  the  implantation  of  a  parasite,  which 


920  HYDATID   CYST   OF  THE  LITER. 

grows  into  a  cyst  and  forms  secondary  daughter-cysts.  Symptoms  are  gen- 
erally absent  until  the  cyst  has  attained  considerable  size  on  account  of  its 
slow  growth.  It  is  said,  however,  that  bile-pigment  is  found  very  early  and 
constantly  in  the  urine  in  these  cases,  even  when  the  cyst  is  pedunculated. 
Attacks  of  urticaria  are  also  seen.  Suppuration  of  the  hydatid  causes  inflam- 
matory symptoms  like  those  of  abscess.  Late  in  the  disease  hemorrhages 
take  place  from  the  mucous  membranes  of  various  organs,  and  intermittent 
albuminm-ia  is  found.  The  main  symptom,  however,  is  the  distention  of  the 
liver  by  the  cyst,  the  organ  reaching  the  navel  or  the  pelvis  and  forming  one 
or  more  smooth  rounded  tumors.  Vomiting  and  cough  are  frequently  caused 
by  the  pressure  on  the  vagus,  and  a  caput  Medusce  or  cii'cle  of  distended 
veins  forms  about  the  umbilicus.  Jaundice  is  a  rare  symptom.  The  tumor 
may  rupture  in  various  directions.  If  it  bursts  into  the  pleura  it  causes 
pain  in  the  side  and  asphyxia,  empyema  develops,  and  the  pus  may  per- 
forate the  lung  ultimately.  The  lung  may  be  involved  directly  when  it 
is  adherent  to  the  diaphragm  before  perforation  occurs,  pneumonia  devel- 
oping and  the  contents  of  the  cyst  being  coughed  up  when  rupture  takes 
place.  Eupture  into  the  pericardium  is  followed  by  instant  death.  Rupture 
into  the  peritoneum  causes  sharp  pain,  followed  by  peritonitis.  In  some 
cases  the  cyst  ruptures  into  the  gall-ducts,  producing  an  attack  of  pain  like 
gaU-stone  colic,  followed  by  jaundice  and  sometimes  by  inflammation  of  the 
ducts.  The  cyst  may  also  perforate  the  stomach,  intestines,  or  urinary 
organs,  when  its  contents  will  escape  by  the  natural  passages. 

Diagnosis. — The  cyst  is  smooth  and  globular,  fluctuating,  as  a  rule, 
and  sometimes  giving  a  peculiar  thrill.  This  thrill  is  felt  by  percussing  the 
tumor  in  the  ordinary  way,  while  an  assistant  makes  the  sac  tense  by  the 
pressui-e  of  his  hand  on  its  surface  near  by.  The  sensation  resembles  that 
produced  by  drawing  a  wet  finger  over  a  thin  distended  india-rubber  bladder. 
It  is  rarely  simulated  by  certain  abdominal  cysts,  and  we  have  observed  a 
similar  thrill  in  a  case  of  hydronephrosis.  Hydatids  also  develop  between 
the  liver  and  the  diaphragm,  and  then  the  diagnosis  from  pleurisy  is  not 
easy.  In  pleurisy,  however,  there  is  an  acute  onset  of  pain,  with  fever  and 
dyspncEa,  which  are  apt  to  grow  less  as  the  fluid  exudation  develops,  unless 
the  latter  is  very  abundant.  In  echinococcus  the  onset  is  gradual,  and  the 
pain  and  dyspnoea  continue  to  increase  as  the  enlargement  progresses.  In 
pleurisy  there  is  uniform  enlargement  of  the  chest  with  bulging  of  the  inter- 
costal spaces,  but  in  subphrenic  hydatid  the  lower  part  of  the  chest  is  more 
enlarged  and  the  intercostal  spaces  do  not  change.  Depression  of  the  dia- 
phragm by  pleuritic  effusion  simply  pushes  the  liver  downward,  but  the 
growth  of  a  hydatid  may  change  the  shape  of  the  liver.  In  j)leui'isy  the 
line  of  dulness  on  percussion  on  the  side  of  the  chest  is  concave  above,  but 
as  the  hydatid  is  below  the  diai^hragm  the  arched  outline  of  the  latter  is 
preserved,  and  the  dulness  makes  a  line  convex  above.  Echinococcus  may 
also  develop  in  the  plem-al  cavity,  and  is  to  be  distinguished  from  pleui'isy 
by  the  convex  line  of  dulness  and  by  the  fact  that  the  line  is  unaltered  by 
changes  in  position.  The  lung-sounds  also  are  ijerfeetlj-  healthy  up  to  the 
sharp  limit  of  this  line.  The  shape  of  the  chest  in  these  cases  is  that  of  a 
keg  or  a  barrel,  while  in  subphrenic  hydatids  it  is  that  of  a  bell.     The  liver 


DISEASES  OF  THE   GALL-BLADDEK   A^-D   BILIARY   DL'CTS.  921 

is  more  depressed  by  a  pleural  hydatid  than  by  one  below  the  diaphragm, 
because  the  latter  forces  the  diaphragm  upward  and  paralyzes  it  so  that  the 
resi)iratory  movement  of  the  liver  is  lost. 

Treatment. — The  treatment  of  hydatid  cysts  depends  upon  the  vitality 
of  the  parasite.  The  entrance  of  the  hydatid  poison  into  the  veins  may 
cause  instant  death,  and  the  entrance  of  the  living  parasite  may  result  in 
secondary  growths  elsewhere.  If  the  parasite  should  be  alive  when  the  case 
comes  under  treatment,  therefore,  it  must  fii-st  be  killed  by  aspirating  the 
contents  of  the  cyst  and  injecting  a  1  to  1000  bichloride  solution,  not  over 
one  hundred  grammes  being  injected,  and  the  injection  being  made  very 
slowly.  The  best  method  of  operation  is  one  similar  to  that  described  for 
abscesses,  securing  the  liver  to  the  chest  wall  or  to  the  abdominal  wall  by 
sutures,  then  opening  the  sac,  evacuating  it,  and  draining  it.  In  some  cases 
a  living  hydatid  may  be  extirpated  without  previous  injection,  but  this  is 
dangerous  on  account  of  the  liability  to  absori^tion  of  the  fluid.  The  wall 
of  the  sac  should  be  removed  if  it  can  be  easily  detached. 

Diseases  of  the  Gall-Bladder  and  Biliary  Ducts.— Cholecys- 
titis and  Cholangitis. — Intlammation  of  the  gall-bladder  and  of  the  ducts 
may  be  catarrhal  or  suppurative.  The  catarrhal  form  is  not  apt  to  require 
immediate  surgical  treatment :  but  its  results,  such  as  the  production  of  gall- 
stones, may  demand  operation.  Inflammation  of  the  hepatic  ducts  is  of  little 
interest  to  the  surgeon,  for  mild  cases  are  not  recognized,  and  if  suj)puration 
follows,  multiple  abscesses  of  the  liver  are  produced,  which  are  not  amenable 
to  treatment.  Inflammation  of  the  common  duct  is  generally  accompanied 
by  cholecystitis.  The  gall-bladder  may  be  infected  by  bacteria  ascending 
the  ducts  from  the  intestine,  or  reaching  its  walls  from  neighboring  organs, 
or  from  the  circulating  blood.  The  presence  of  gall-stones  is  a  predisposing 
cause.  Very  virulent  infection  may  result  in  gangrenous  inflammation  and 
immediately  fatal  septicemia.  "WTien  suppuration  occurs,  the  inflammation 
may  be  limited  to  the  mucous  membrane,  its  products  being  discharged  bj' 
the  ducts,  and  recovery  taking  place  with  a  shrunken  thickened  bladder. 
Ulceration  may  lead  to  perforation  and  a  local  or  general  peritonitis.  The 
perforation  may  form  a  permanent  flstula  with  some  adherent  organ,  or  an 
abscess  may  break  externally.  In  some  cases  septicaemia  with  pysemic 
abscesses  develops  from  a  limited  ulceration  of  the  gall-bladder,  which  has 
given  no  local  symptoms.  When  the  ducts  are  obstructed  perforation  of 
the  infected  bladder  may  occur,  or  the  bladder  may  resist  the  infection  and 
the  latter  may  die  out,  leaving  the  bladder  very  much  distended  and  filled 
with  a  mucous  or  serous  sterile  fluid  (Jiydrojjs).  In  some  cases  the  bladder 
is  distended  with  pus  {empyema).  Chronic  inflammation  of  the  gall- 
bladder causes  thickening  of  the  walls,  shrinking  of  the  cavity,  and  the 
formation  of  adhesions,  which  may  make  it  impossible  to  find  any  remains 
of  the  organ.  It  also  tends  to  the  production  of  gall-stones.  The  analogj" 
between  cholecystitis  and  appendicitis  is  very  close. 

Symptoms. — Acute  attacks  begin  suddenly  with  violent  pain,  vomiting, 
chills,  high  temperature,  and  local  tenderness  and  rigidity  of  the  right  rectus 
muscle.  In  the  majority  of  ctises  the  symptoms  develop  more  gradually. 
Jaundice  may  be  caused  by  the  pressure  of  the  distended  gall-bladder  upon 


922  CHOLELITHIASIS. 

the  common  duct,  or  from  a  coincident  inflammation  of  the  duct.  The  pain 
radiates  to  the  right  shoulder  and  may  be  paroxysmal,  like  that  of  biliary 
colic.  The  gall-bladder  generally  presents  a  palpable  tender  tumor  at  the 
border  of  the  liver,  internal  to  the  mamillary  line,  but  it  may  be  displaced 
in  any  direction,  and  sometimes  cannot  be  felt  because  it  lies  so  deeply  under 
the  liver.  A  tongue  of  liver  tissue  may  be  drawn  down  with  it  as  it  elongates. 
The  right  rectus  muscle  is  rigidly  contracted  and  palliation  may  be  impos- 
sible. The  point  of  greatest  tenderness  is  over  the  gall-bladder.  There  may 
be  symptoms  of  general  peritoneal  infection,  and  fatal  peritonitis  is  not  very 
infi'equent.  Sepsis  may  develop  early.  Leucocytosis  is  as  unreliable  here 
as  in  appendicitis,  but  a  very  high  count  indicates  suppuration  or  gangrene. 
Some  cases  have  repeated  attacks  of  great  or  slight  severity,  a  chronic 
inflammation  existing  in  the  interval.  Chronic  cholecystitis  may  run  a 
course  absolutely  without  symptoms,  but  usually  there  are  slight  attacks  of 
pain  and  vomiting,  or,  at  least,  of  gastric  dyspepsia. 

Diagnosis. — The  situation  of  the  greatest  tenderness  and  the  tumor 
indicate  the  gall-bladder  as  the  cause  of  the  symj)toms.  In  certain  cases 
there  is  great  difficulty  in  distinguishing  between  cholecystitis,  appendicitis, 
and  pyelitis.  The  most  reliable  symptoms  as  to  the  severity  of  the  lesion 
are  the  temperature,  pulse,  and  vomiting,  but  some  very  serious  cases  have 
mild  symptoms,  and  exploratory  incision  should  be  resorted  to  in  any 
doubtful  case. 

Treatment. — In  mild  cases,  local  application  of  cold,  codeine  in  small 
doses  (so  as  not  to  mask  the  symptoms),  abstinence  fi'om  food  by  mouth,  and 
rectal  feeding  will  generally  cause  the  symptoms  to  subside.  If  the  tem- 
perature is  high,  the  pulse  rapid  and  wiry,  the  face  anxious,  with  tender- 
ness and  rigidity  of  the  entire  abdomen,  peritonitis  is  threatening,  if  not 
already  present,  and  immediate  operation  is  necessary.  If  in  a  patient  with 
these  symptoms,  but  in  very  feeble  condition,  a  distended  gall-bladder  can 
be  felt,  an  exploratory  incision  should  be  made  with  local  anaesthesia,  and 
if  there  is  no  peritonitis  the  gall-bladder  can  be  sutured  to  the  parietal  peri- 
toneum and  drained.  But  if  the  patient's  condition  permits,  general 
anaesthesia  is  preferable,  and  the  gall-bladder  should  be  removed  to  secure  a 
prompt  recovery  and  safety  from  future  attacks.  In  recurrent  cases  the 
gall-bladder  should  be  removed  in  the  quiet  period  after  an  attack.  (See 
Cholecystectomy,  page  925).  General  peritonitis  requires  the  treatment 
outlined  on  page  915. 

Cholelithiasis. — Gall-stones  almost  invariably  form  in  the  gall-bladder, 
but  in  rare  cases  they  may  form  in  the  ducts  or  in  the  biliary  passages  of 
the  liver.  Their  production  is  the  result  of  bacterial  infection  and  of 
obstruction  of  the  biliary  passages,  cholesterin  and  bile-pigment  being 
deposited  from  the  stagnant  bile.  They  vary  in  size  from  minute  gravel  to 
stones  two  or  three  inches  in  diameter.  The  common  bile-duct  will  allow 
the  ]3assage  of  a  stone  the  size  of  a  hazel-nut,  and  if  larger  stones  than  these 
are  passed  in  the  stools  they  indicate  that  an  unnatural  communication  has 
formed  between  the  intestine  and  the  gall-bladder.  In  the  majority  of  cases 
the  calculus  drops  back  into  the  bladder  or  duct  at  the  termination  of  biliary 
colic,  and  therefore  no  stones  are  found  in  the  stools.     The  calculi  may  be 


TUMORS   OF  THE  GALL-BLADDER.  923 

discharged  externally,  having  perforated  the  gall-bladder  and  abdominal 
wall  by  suppuration,  or  may  enter  any  of  the  neighboring  organs.  Gall- 
stones are  usually  multiple  and  faceted  on  the  sides  where  they  are  pressed 
together.  They  often  cause  inflammation  of  the  gall-bladder  and  ducts, 
and  sometimes  iilcers,  which  may  ijerforate  and  result  in  intraperitoneal 
abscesses  or  abscesses  of  the  liver. 

Symptoms. — Gall-stones  may  exist  without  symptoms,  for  they  are 
found  in  from  three  to  ten  per  cent,  of  all  cadavers  at  autopsy,  in  the  great 
majority  of  cases  having  given  no  symptoms.  When  they  become  imj)acted 
in  the  gall-ducts,  however,  they  cause  sharp  colicky  pain  in  the  right  side, 
shooting  backward  under  the  scapula,  lasting  from  a  few  minutes  to  several 
hours  or  days,  and  sometimes  followed  by  jaundice  or  by  signs  of  peritoneal 
inflammation  in  the  neighborhood  of  the  gall-bladder.  These  symptoms  are 
probably  due  to  the  accomiianjdng  cholecystitis  and  are  inflammatory,  not 
merely  the  result  of  mechanical  obstruction.  Leucocytosis  may  be  present. 
Jaundice  occurs  only  when  impaction  takes  place  in  the  common  duct,  and, 
as  the  cystic  duct  is  smaller  than  the  common,  any  stone  which  can  pass 
the  cystic  duct  should  not  cause  jaundice  ;  but  stones  sometimes  lie  in  the 
common  duct  and  increase  in  size  until  they  are  too  large  to  pass  into  the 
intestine,  when  they  may  cause  typical  biliary  colic  and  jaundice.  The  gall- 
bladder is  shrunken  and  buried  in  adhesions  from  previous  inflammation, 
very  seldom  being  distended.  The  attack  of  colic  may  terminate  within  a 
few  hours,  but  there  is  a  liability  to  a  repetition  at  irregular  intervals,  and 
the  attacks  may  be  so  frequent  that  the  patient  is  worn  out  with  pain.  The 
stone  usually  slips  back  into  the  bladder  from  the  cystic  duct,  but  it  may 
make  its  way  into  the  bowel  and  be  found  in  the  stool.  If  the  gall-stone 
remains  impacted  in  the  common  duct,  a  deep  jaundice  is  produced,  the 
stools  are  clay-colored  and  digestion  is  impaired.  The  pains  die  out,  recur- 
ring at  intervals,  fever  is  often  present,  and  septicemia  may  develop  from 
the  inflammation  accompanjing  the  stone.  Death  may  result  from  sepsis 
and  exhaustion,  or  the  calculus  may  perforate  the  duct  and  cause  an  abscess, 
or  if  adhesions  have  formed  with  the  intestine  the  stone  may  perforate 
directly  into  the  bowel,  and  if  the  stone  is  very  large  it  may  then  give  rise 
to  intestinal  obstruction.  The  signs  of  perforation  of  the  bladder  and  ducts 
are  those  of  localized  peritonitis, — j)ain,  tenderness,  fever,  and  the  forma- 
tion of  a  tumor  by  adhesions  and  pus. 

Tumors. — Tumors  of  the  gall-bladder  and  ducts  are  probably  not  so 
rare  as  has  been  supposed,  and  a  number  of  cases  of  small  tumors  causing 
obstruction  of  the  duct  are  on  record.  They  may  be  recognized  by  the  fact 
that  the  gall-bladder  is  invariably  distended,  while  in  gall-stone  disease  the 
gall-bladder  is  usually  small.  Icterus  is  a  more  common  symptom  than  in 
cases  of  gall-stones,  and  there  may  be  no  biliary  colic. 

Treatment. — The  majority  of  the  cases  of  gall-stone  disease  and  biliary 
obstruction  can  be  treated  by  medical  measures,  but  operation  is  indicated 
when  the  attacks  of  colic  are  very  frequent  and  severe,  when  the  jaundice 
is  very  marked,  and  when  there  are  signs  of  suppurative  inflammation  in 
the  gall-bladder  or  its  neighborhood.  Severe  cholsemia  is  apt  to  weaken  the 
heart  and  predispose  to  hemorrhage,  but  jaundiced  patients,  as  a  rule,  bear 


924  OPERATIONS  UPON  THE  GALL-BLADDER. 

operations  well.  The  gall-bladder  may  be  exposed  by  an  incision  at  the 
right  border  of  the  right  rectus  muscle  or  by  a  median  incision  (Fig.  751 B), 
but  some  prefer  an  oblique  incision  ijarallel  to  the  ribs  (Fig.  751  F),  or  a 
Yertical  incision  with  a  transverse  branch  on  either  side  in  the  shape  of  a 
|—  or  an  L-  The  subsequent  steps  will  depend  upon  the  condition  found. 
If  a  calculus  is  impacted  in  the  cystic  duct,  the  bladder  is  to  be  opened  and 
the  stone  removed.  If  this  is  impossible  the  calculus  may  be  crushed  by 
forceps  in  the  duct,  or  may  be  broken  by  padded  forceps  outside  of  the  duct, 
or  by  a  needle  inserted  through  the  wall,  and  the  fragments  abstracted.  An 
enlarged  lymphatic  gland  near  the  duct  may  be  mistaken  for  a  calculus. 
When  the  obstruction  has  been  removed,  the  bladder  may  be  sutured  by 
Lembert  sutures  if  it  is  healthy  and  if  no  obstruction  exists  iu  the  common 
duct,  but  these  favorable  conditions  are  rare.  If  the  bladder  is  diseased,  it 
may  be  drained  by  securing  it  in  the  abdominal  wound,  or  it  may  be  extir- 
pated. If  the  obstruction  of  the  cystic  duct  is  a  stone  which  cannot  be 
removed,  or  a  cicatricial  stricture  or  a  tumor,  the  gall-bladder  should  be 
extirpated,  if  possible.  If  extirpation  is  impossible  or  very  difScult,  the 
alternative  is  drainage  through  the  abdominal  wound,  for  the  creation  of  a 
fistula  into  the  intestine  (cholecystenterostomy)  is  not  advisable,  because  the 
occlusion  of  the  cystic  duct  shuts  off  the  bladder  from  the  liver  and  destroys 
its  physiological  value,  and  septic  infection  of  the  bladder  might  be  the 
result  of  connecting  it  with  the  intestine. 

If  the  calculus  is  in  the  common  duct,  the  bladder  can  be  opened  and 
sometimes  the  calculus  can  be  removed  by  pushing  it  back  into  the  bladder 
through  the  cystic  duct,  by  crushing  it  with  forceps,  or  by  breaking  it  up 
with  the  needle.  As  a  rule,  the  common  duct  will  have  to  be  incised.  After 
removal  of  the  stone  this  opening  can  be  sutured  or  a  drainage-tube  can  be 
secured  in  it.  If  the  stone  is  removed,  the  bladder  may  then  be  sutured 
and  returned  to  the  abdomen,  or  it  may  be  secured  in  the  abdominal  wound 
and  drained,  or  it  may  be  extirpated.  Should  the  obstruction  be  complete 
and  irremediable  (impacted  calculus,  tumor),  a  fistula  should  be  formed 
between  the  bladder  or  the  common  duct  and  the  intestine,  or  the  bladder 
may  be  drained  externally,  but  the  latter  will  result  in  complete  loss  of  the 
bile.  If  the  obstruction  is  found  to  be  irremediable  a  fistula  should  be 
made  between  the  duct  and  the  bowel.  If  this  is  impossible,  the  duct  can 
be  drained  externally  by  inserting  a  tube  in  the  duct  and  bringing  it  out  of 
the  abdominal  wound,  or,  the  omentum  may  be  arranged  so  as  to  make  a 
funnel-shaped  cavity  around  the  wound  in  the  duct,  which  is  lightly  packed 
with  gauze.  These  methods  of  drainage  are  so  effective  that  it  is  seldom 
necessary  to  suture  the  duct.  In  such  cases,  if  there  should  j^rove  to  be 
serious  disease  of  the  bladder,  ulceration,  abscess,  or  tumor,  the  organ 
should  be  extirpated. 

McBurney  has  successfully  removed  a  calculus  from  the  common  duct 
by  incising  the  duodenum  and  stretching  or  incising  the  intestinal  orifice  of 
the  duct,  and  the  writer  has  adopted  a  similar  treatment  in  a  case  of  a  small 
tumor  of  the  duodenum  obstructing  the  duct,  in  which  the  tumor  was  in 
the  duodenal  mucous  membrane  on  one  side  of  the  papilla.  Finally,  in 
cases  of  tumor  of  the  gall-bladder,  or  hydrops,   or  empyema,   the  organ 


OPERATIONS  UPON  THE  GALL-BLADDER.  925 

should  be  extirpated  if  possible ;  but  if  the  adhesions  are  very  strong, 
hydrops  and  empyema  may  be  treated  by  drainage  through  the  abdominal 
wound.     Cholecystenterostomy  should  never  be  performed  in  these  cases. 

The  various  methods  of  operating  upon  the  bladder  and  duct  may  be 
formulated  as  follows : 

1.  Cholecystotomy. — The  bladder  may  be  incised  immediately,  after 
protecting  the  peritoneal  cavity  with  gauze  or  sponges.  It  was  formerly 
considered  dangerous  to  open  the  bladder  in  the  free  peritoneal  cavity,  and 
it  was  therefore  sutured  in  the  abdominal  wound,  or  gauze  was  packed  down 
in  the  abdominal  wound  ;  a  delay  of  from  twenty-four  to  forty-eight  hours 
was  made  in  order  to  allow  adhesions  to  form  before  the  bladder  was 
opened  ;  but  this  operation  in  two  acts  is  now  seldom  considered  necessary. 

2.  Cholecystostomy. — This  consists  in  securing  the  bladder  in  the 
wound  after  it  has  been  opened.  The  edges  of  the  incision  in  the  bladder 
may  be  sutured  to  the  parietal  peritoneum  at  the  edges  of  the  abdominal 
wound  ;  or  a  stiff  tube  may  be  secirred  in  the  opening  in  the  bladder  by  a 
ligature  tied  over  the  edges  around  the  tube.  The  abdominal  wound  should 
be  sutured  except  at  one  angle  in  which  the  gall-bladder  is  secured. 

3.  Cholecystendyse. — When  the  bladder  is  healthy,  and  there  is  no 
obstruction  in  the  biliary  passages,  it  is  possible  to  suture  the  organ  and 
drop  it  back  into  the  abdomen.  This  proceeding,  also  called  "ideal  chole- 
cystotomy," secures  iirimary  union  of  the  entire  wound  and  saves  the  patient 
from  the  liability  to  a  permanent  and  annoying  fistula,  for  in  a  few  cases 
cholecystostomy  is  followed  by  a  fistula  discharging  bile  and  mucus.  The 
suturing  of  the  bladder  is  suitable  for  comparatively  few  cases,  but  appears- 
to  be  a  safe  procedure. 

4.  Cholecystectomy. — Extirpation  of  the  gall-bladder  was  first  sug- 
gested because  gall-stones  are  formed  in  that  organ,  and  it  was  supposed 
that  its  removal  would  effect  a  permanent  cure.  It  is  true  that  stones  are 
formed  in  the  ducts  and  in  the  liver  also,  but  this  occurs  so  rarely  that  it 
need  scarcely  be  taken  into  account.  On  the  other  hand,  relapses  after  the 
ordinary  methods  of  treatment  are  certainly  not  common,  and  the  removal 
of  the  gall-bladder  adds  to  the  danger  of  the  operation.  But  if  the  gall- 
bladder is  the  seat  of  diffuse  suppuration,  a  deep  ulcer,  or  a  tumor,  it  is 
desirable  that  it  should  be  removed.  The  organ  is  dissected  free  with  the: 
finger,  for  it  is  usually  very  adherent  in  these  cases,  then  the  cystic  duct  is- 
ligatedand  divided.  The  mucous  membrane  of  the  stump  is  to  be  destroyed 
by  cauterization.  Partial  removal  of  the  gall-bladder  is  an  excellent 
method  of  treating  cases  in  which  the  ulcer  or  the  tumor  is  limited  to  the 
fundus.  When  the  gall-bladder  is  very  adherent  and  difficult  to  remove, 
the  outer  walls  can  be  divided  and  the  mucous  membrane  shelled  out  like 
the  lining  of  a  cyst.     (Mayo.) 

5.  Cholecystenterostomy. — When  there  is  a  permanent  obstruction  in 
the  common  duct  it  is  absolutely  necessary  to  secure  an  outlet  for  the  bile, 
which  may  be  accomislished  by  making  a  permanent  external  fistula  by 
cholecystostomy  ;  but  to  avoid  the  loss  of  the  bile  it  is  preferable  to  make  an 
opening  between  the  gall-bladder  and  the  bowel,  as  high  up  as  possible. 
This  may  be  done  after  the  manner  of  a  gastro-enterostomy  by  suturing  the 


926 


OPERATIONS  UPON  THE  GALL-BLADDER. 


edges  of  a  small  incision  in  the  gall-bladder  to  a  similar  incision  in  the  looj) 
of  jejunum  chosen.  But  a  better  method  is  the  use  of  the  Murphy  button, 
the  insertion  of  which  will  be  described  with  gastro-enterostomy,  page  933. 
(Pig.  759.)     The  operation  by  suture  has  had  a  mortality  of  thirty  per 


Insertion  of  the  Murphy  hutton  for  cholecystenterostomy. 


cent. ,  whereas  Murphy  has  collected  forty-seven  cases  in  which  the  button 
was  used,  with  only  two  deaths.  There  are,  however,  two  objections  to  the 
Murphy  button, — first,  that  the  opening  is  very  small  and  circular  and  may 
contract,  obliteration  having  been  known  to  take  place  in  less  than  six 
months ;  secondly,  that  the  button  may  slip  back  into  the  gall-bladder 
when  it  becomes  detached,  instead  of  falling  into  the  intestine,  and  may 
there  form  a  foreign  body.  The  first  objection  can  hardly  be  met,  but  the 
second  might  possibly  be  prevented  by  making  the  intestinal  half  of  the 
button  larger  than  that  in  the  gall-bladder.     (Lilienthal.) 

6.  Choledochotomy. — Choledochotomy  consists  in  making  an  opening 
in  the  common  duct.  When  this  opening  is  sutured  we  speak  of  choledo- 
chendyse.  When  it  is  connected  with  the  intestine  we  speak  of  a  choledochen- 
ter ostomy.  The  depth  at  which  the  common  duct  lies  makes  operations  upon 
it  exceedingly  difficult  in  the  majority  of  cases,  yet  it  is  often  possible  to 
suture  the  wound  in  that  duct  or  to  unite  it  with  the  duodenum,  the  duct 
being,  as  a  rule,  greatly  dilated,  even  to  the  size  of  the  thumb,  in  cases 
where  these  operations  are  necessary.  It  can  be  made  more  accessible  by 
placing  a  j)illow  under  the  patient's  loins  and  allowing  the  shoulders  and 
pelvis  to  fall  backward. 

SURGICAL   DISEASES   OE   THE   STOMACH. 

Topography. — The  position  of  the  stomach  as  usually  repi-esented  is 
not  quite  correct,  its  true  situation  being  much  more  nearly  that  known  as 


FOREIGN   BODIES  IN  THE  STOMACH.  907 

the  "foetal  position;"  that  is  to  say,  the  long  axis  is  nearly  vertical,  its 
lesser  curvature  being  directed  towards  the  right  side  of  the  body  and  the 
greater  curvature  towards  the  left.  When  the  stomach  is  distended  the 
greater  curvature  becomes  very  much  larger,  and  forms  a  pouch  extending 
upward  under  the  diajphragm  and  downward  below  the  level  of  the  pylorus. 
The  pjdorus  lies  above  the  lowest  part  of  this  pouch,  making  with  the  duo- 
denum an  cr>  trap.  The  pylorus  in  the  empty  condition  of  the  organ  is 
situated  just  undei"  the  border  of  the  ribs  and  the  liver,  a  trifle  to  the  right 
of  the  middle  line.  When  the  stomach  is  distended  the  pylorus  moves  to 
the  right  and  slightly  downward,  reaching  a  j)oiut  midway  between  the 
median  line  and  the  nipple-line. 

Gastroptosis. — The  attachments  of  the  stomach  may  become  loosened, 
so  that  the  organ  lies  with  the  lesser  curvature  near  or  below  the  umbilicus, 
and  the  greater  near  the  pubes.  The  pylorus  may  remain  near  its  normal 
situation  or  may  also  descend.  This  condition  is  followed  by  disturbances 
of  digestion,  extreme  emaciation,  and  neurasthenia.  A  general  enteroptosis 
may  accompany  it.  Treatment. — A  median  laparotomy  above  the  umbil- 
icus, followed  by  drawing  up  the  stomach  and  securing  it  by  Lembert 
sutures  passed  so  as  to  secure  its  anterior  wall  to  the  parietal  peritoneum, 
has  given  permanent  relief  when  the  condition  was  serious  enough  to 
demand  surgical  treatment. 

Foreign  Bodies. — Foreign  bodies  may  enter  the  stomach,  weak- 
minded  persons  frequently  swallowing  such  articles  as  jack-knives  and 
spoons.  Hysterical  women  have  been  known  to  swallow  hair,  which  forms 
a  ball  in  the  stomach  similar  to  the  hair-balls  so  often  found  in  cattle,  the 
latter  swallowing  the  hair  after  licking  their  coats.  These  foreign  bodies 
may  be  retained  for  a  long  time  without  discomfort,  but  they  are  apt  to  pro- 
duce ulceration  by  pressure  upon  some  part  of  the  stomach  wall,  or  to  become 
lodged  in  the  pylorus  and  obstruct  that  opening.  Such  bodies  can  easily  be 
removed  by  the  operation  of  gastrotomy,  and  this  shoiild  be  performed  at 
once  in  case  they  are  too  large  to  pass  through  the  bowel. 

Ulcer. — Ulcer  of  the  stomach  may  occur  at  any  age,  but  is  most  frequent 
about  the  twentieth  year.  It  is  twice  as  common  in  women  as  in  men.  It 
is  usually  situated  on  the  posterior  wall,  but  those  ulcers  which  perforate 
seem  to  be  situated  chiefly  on  the  anterior  wall,  especially  near  the  lesser 
curvature.  The  ulceration  may  cause  fatal  hemorrhage,  or  perforation 
of  the  wall  of  the  stomach  and  peritonitis.  In  some  cases  there  is 
great  thickening  of  the  base  of  the  ulcer,  due  chiefly  to  a  deposit  of  fibrin 
on  the  peritoneal  side,  but  usually  there  is  no  thickening.  In  a  considerable 
proportion  of  cases  carcinoma  develops  in  old  ulcers,  especially  those  with 
thick  bases.  The  ulcers  vary  greatly  in  size,  from  a  pin's  head  to  some 
inches  in  diameter. 

Sjrtnptoms  and  Diagnosis. — The  symptoms  of  gastric  ulcer  are  intense 
localized  pain  in  the  stomach,  increased  by  the  presence  of  food  ;  vomiting, 
particularly  the  vomiting  of  bright  blood  ;  loss  of  digestive  power ;  and 
ansemia.  The  hemorrhage  is  usually  small  in  quantity,  but  frequently 
repeated.  In  some  cases  a  large  artery  is  opened,  causing  abundant  hemor- 
rhage, which  may  be  immediately  fatal.     There  is  marked  hyperacidity  of 


928  TREATMENT   OF  ULCERS   OF  THE  STOMACH. 

the  stomach,  and  its  motility  is  impaired,  probabl3'^  by  spasm  of  the  pylorus. 
Some  cases  of  extensive  ulceration  have  absolutely  no  symptoms ;  in  fact, 
perforation  into  the  peritoneal  cavitj^  may  take  place  without  any  previous 
symptoms  of  gastric  trouble  (in  eight  j)ev  cent,  of  the  cases  according  to 
Weir  and  Foote),  but,  as  a  rule,  there  are  sufficient  symptoms  to  make  a 
diagnosis  possible.  When  the  gastric  symptoms  are  clear  and  the  patient 
feels  a  sudden  acute  pain  in  the  epigastrium,  often  associated  with  severe 
collai)se,  with  or  without  vomiting,  which  is  followed  by  local  tenderness, 
rise  of  temperature,  and  the  development  of  tympanites,  the  diagnosis  of 
perforation  is  easy.  Vomiting  is  present  in  about  two-thirds  of  the  cases. 
The  duluess  on  percussion  over  the  liver  may  be  lost,  owing  to  the  escape 
of  gas  into  the  peritoneal  cavity.  (See  page  900.)  The  pain,  however,  may 
first  be  felt  in  any  other  part  of  the  abdomen,  and  even  the  tenderness  may 
be  more  marked  in  the  iliac  region  than  in  the  epigastrium.  Occasionally 
profound  septic  poisoning  accorapauies  very  mild  local  symptoms,  but,  as  a 
rule,  perforation  of  the  stomach  ijroduces  a  frank  general  peritonitis  or  a 
localized  abscess,  and  peritoneal  sepsis  occurs  less  frequently  than  after 
intestinal  perforation.  The  perforation  may  take  place  in  that  part  of  the 
stomach  not  covered  by  peritoneum,  and  an  extraperitoneal  abscess  may 
form  under  the  diaphragm  or  between  the  diaphragm  and  the  liver.  These 
cases  naturally  run  a  slower  course,  and  if  the  diagnosis  can  be  made  before 
septicaemia  sets  in,  a  cure  may  be  expected.  A  few  cases  of  perforation  of 
the  stomach  have  recovered  without  oiieration.  The  i^rognosis  after  oper- 
ation depends  altogether  upon  the  interval  of  time  which  elapses  between 
the  perforation  and  the  lajjarotomy.  Weir  has  shown  that  when  the  oper- 
ation was  done  within  twelve  hours  the  majority  of  cases  were  saved,  but  in 
later  operations  only  about  one-fifth  recovered. 

Treatment. — Surgical  treatment  may  be  necessitated  by  profuse  hemor- 
rhage, by  repeated  small  hemorrhages,  or  by  perforation.  A  surgical  cure 
may  also  be  undertaken  when  medical  treatment  has  failed,  and  it  has  been 
very  successful  when  the  ulcer  has  caused  stenosis  of  the  pylorus.  In  such 
cases  gastro-enterostomy  relieves  the  stenosis  and  lessens  the  hyperacidity, 
but  a  relapse  may  take  place,  Mikulicz  having  seen  three  relapses  in  fifty 
cases  operated  by  himself.  Excision  of  the  ulcer  is  to  be  recommended 
whenever  permanent  thickening  can  be  felt  around  it,  on  account  of  the 
danger  that  cancer  may  develop.  Operation  has  been  urged  for  hemorrhage, 
but  it  has  often  proved  impossible  to  find  the  ulcer  in  these  cases  after  the 
stomach  has  been  opened.  The  stomach  caa  be  exj^osed  by  a  median  in- 
cision above  the  navel,  and  a  transverse  incision  at  right  angles  to  the  first 
through  the  left  rectus  muscle  may  be  added  later  if  necessary  in  order  to 
obtain  sufficient  room.  When  perforation  occurs  the  openijig  will  usually 
be  found  high  up  on  the  lesser  curvature.  The  posterior  wall  may  be  exam- 
ined by  tearing  through  the  mesocolon.  When  the  iierforation  is  found,  it 
should  be  closed  with  Lembert  sutures.  It  is  unnecessary  to  excise  the 
edges  of  the  ulcer,  and  the  condition  of  the  patient  rarely  allows  a  pro- 
longed operation.  The  abscess  must  be  thoroughly  washed  out  and  drained, 
and  if  general  peritonitis  is  present  it  must  be  treated  as  already  described. 
The  best  method  of  examination  for  an  obscure  bleeding  ulcer  consists  in 


STENOSIS   OF  THE  PYLORUS. 


929 


making  an  incision  in  the  anterior  wall  after  the  stomach  has  been  exposed 
and  turning  out  of  this  opening  every  portion  of  the  stomach  in  succession 
by  pressure  with  the  finger  on  the  opposite  side.  The  patient  is  usually 
very  ansemic  and  feeble,  and  the  operation  must  be  comjileted  as  rapidly  as 
possible.  The  bleeding  points  should  be  ligated  or  sutured.  In  some  cases 
the  tissues  are  hard  and  friable,  and  the  cautery  must  be  relied  upon,  as 
ligatures  will  not  hold. 

Stenosis  of  the  Pylorus. — Narrowing  of  the  pylorus  may  be  con- 
genital, or  caused  by  external  compression  by  tumors  or  adhesions,  by  cica- 
tricial contraction  due  to  healed  lalcers  on  the  inner  surface,  or  by  the 
growth  of  tumors  in  the  stomach  wall  at  this  point.  There  may  also  be  a 
spasmodic  contraction  of  the  sphincter  muscle.  Mechanical  dilatation  of 
the  stomach  often  results,  unless  the  stricture  is  malignant,  when  the  short 
duration  of  life  does  not  allow  time  for  dilatation  to  develop.  The  symptoms 
of  simple  stenosis  of  the  pylorus  are  merely  those  of  obstruction,  as  shown  by 
vomiting,  usually  coming  on  some  little  time  after  a  meal,  and  occasionally 
recurring  at  regular  intervals  of  two  or  three  days.  The  ejected  matter 
consists  of  food,  and  sometimes  contains  undigested  particles  of  food  taken 
several  days  previously.  The  vomiting  is  pre- 
ceded bj'  signs  of  discomfort  and  fulness  in  the 
stomach,  but  there  is  no  nausea,  and  the  patient 
looks  iipon  it  as  a  relief 

Treatment. — The  treatment  of  pyloric  stric- 
ture dejaends  upon  the  cause.  Loreta's 
method  consists  in  stretching  the  pylorus  by 
performing  a  laparotomy,  invaginating  the  stom- 
ach wall  with  the  finger,  and  forcing  the  latter 
through  the  sphincter.  The  immediate  effects 
of  this  operation  are  excellent,  but  subsequent 
contraction  takes  place  in  the  great  majority  of 
cases.  Heineke  and  Mikulicz  introduced  an 
operation  known  as  pyloroplasty,  which  is 
useful  when  the  stomach  walls  are  thin  and  the 
duodenum  and  stomach  can  be  brought  easily  in 
contact.  Pyloroplasty  is  performed  by  incising 
the  pylorus  in  the  direction  of  its  longitudinal 
fibres  (Fig.  760,  A),  pulling  the  edges  of  this 
incision  apart  (B)  and  uniting  them  in  an  oppo- 
site direction  (C),  so  that  the  two  ends  of  the 
longitudinal  incision  are  united  in  the  centre, 
and  the  middle  points  of  its  upper  and  lower  lips 

become  the  upper  and  lower  angles  of  the  wound  when  sutured,  the  longi- 
tudinal incision  thus  being  converted  into  a  transveise  one.  When  the 
pylorus  is  obstructed  by  old  adhesions  the  latter  may  be  separated  when 
laparotomy  has  been  performed, — gastrolysis.  For  cases  iii  which  there  is 
a  tumor  or  limited  inflammatory  thickening  of  the  wall  of  the  stomach  and 
pylorus,  a  resection  of  the  parts  gives  excellent  results.  For  all  other 
cases  gastro-enterostomy  is  the  best  method  of  treatment.     The  mortality 


Pyloroplasty 


930  TUMORS   OF  THE  STOMACH. 

from  resection  is  very  liigh,  although  in  the  hands  of  the  best  operators  it 
has  been  steadily  reduced.  The  mortality  from  gastroenterostomy  is  reason- 
ably low,  a  large  number  of  the  deaths  being  caused  by  the  weak  condition 
of  the  patient  at  the  time,  Mhich  can  be  avoided  by  early  operation. 

Dilatation  of  the  Stomach. — The  result  of  pyloric  stenosis  is 
usually  dilatation  of  the  stomach,  and  this  may  be  so  extreme  that  the 
greater  curvature  descends  to  the  pubes.  The  pylorus  may  retain  its  origi- 
nal position  or  may  be  dragged  down  with  the  heavy  organ.  The  walls  of 
the  stomach  may  be  greatly  hypertrophied,  and  large  jaeristaltic  waves  can 
often  be  seen  through  the  abdominal  wall,  which  is  thin  on  account  of  the 
emaciation.  Treatment. — Removal  of  the  cause  of  the  pyloric  obstruction 
or  the  performance  of  gastro-enterostomy  will  generally  be  followed  by  a 
return  of  the  stomach  to  normal  size.  But  if  this  does  not  occur  the  dis- 
tention may  be  treated  by  folding  a  longitudinal  strixj  of  the  anterior  wall 
of  the  stomach  into  the  interior  of  the  organ,  and  securing  it  in  that  posi- 
tion by  a  series  of  sutures. 

Hour-Glass  Stomach. — In  some  rare  cases  the  condition  known  as 
hour-glass  contraction  of  the  stomach  exists  as  the  result  of  cicatricial  con- 
traction of  a  circular  ulceration  in  the  centre  of  the  organ,  so  that  the 
cardiac  and  pyloric  portions  of  the  stomach  are  separated  by  a  narrow  stric- 
ture, barely  admitting  the  finger.  For  the  relief  of  this  condition  an  operation 
simila;r  to  pyloroplasty  may  be  done,  but  Wolffler  recommends  making  an 
anastomotic  opening  between  the  two  parts  of  the  stomach,  gastro-anastomosis. 

Tum.ors. — Benign  tumors  of  the  stomach  are  mere  curiosities  on 
account  of  their  rarity,  but  a  chronic  inflammation  in  the  neighborhood  of 
the  pylorus  may  produce  such  thickening  of  the  stomach  wall  in  that  situa- 
tion as  to  simulate  a  cancer.  This  fibrous  deposit  may  make  the  wall  of  the 
stomach  two  inches  in  thickness,  and  may  interfere  with  the  movements  of 
the  pylorus  by  its  rigidity  and  produce  obstruction.  The  diagnosis  may  be 
very  difficult,  even  when  the  new  tissue  has  been  cut  into  and  insj)ected.  If 
its  benign  nature  appears  certain  it  is  unnecessary  to  remove  the  pylorus,  as 
a  gastro-enterostomy  will  relieve  the  symptoms,  but  in  cases  of  doubt  it  is 
better  to  resect  that  part.  Cicatricial  thickening  of  the  pylorus  may  also 
simulate  malignant  disease.  The  malignant  tumors  of  the  stomach  are 
sarcoma  and  carcinoma. 

Sarconia. — Only  a  few  cases  of  sarcoma  have  been  observed,  but  this 
disease  may  be  suspected  whenever  the  tumor  reaches  a  considerable  size 
before  it  affects  the  general  health,  is  situated  on  the  greater  curvature  and 
not  near  the  pylorus,  and  occurs  in  comxjaratively  young  individuals. 

Carcinoma. — Carcinoma  is  most  frequently  situated  in  the  neighbor- 
hood of  the  pylorus,  where  even  a  small  tumor  may  produce  obstruction. 
It  also  appears  at  the  cardiac  orifice  or  near  either  cnrvatiire.  The  pyloric 
tumors  are  very  sharply  limited  towards  the  duodenum,  which  is  seldom 
involved.  Ulceration  occurs,  and  may  cause  death  by  hemorrhage.  The 
disease  involves  the  glands  comparatively  early,  and  forms  metastases  in 
the  liver  later. 

Symptoms  and  Diagnosis. — The  principal  symptoms  of  cancer  of  the 
stomach  are  the  presence  of   a  tumor,   with  vomiting  when  the  tumor 


CARCINOMA  OF  THE  STOMACH.  931 

obstructs  the  pylorus,  the  vomiting  taking  l^U^ce  some  little  time  after  eat- 
ing, and  occixsionally  at  regular  intervals,  and  the  vomited  matter  contain- 
ing undigested  particles  of  food  eaten  hours  or  days  previously.  Pain  may 
or  may  not  be  present.  There  may  be  in  the  later  stages  vomiting  of  a 
coffee-ground  matter,  which  is  the  remains  of  partially  digested  blood.  In 
order  to  obtain  a  cure  by  operation  the  diagnosis  must  be  made  very  early 
in  the  disease ;  and  yet  this  is  exceedingly  difficult,  because  secondary 
infection  occurs  while  the  tumor  is  still  small  and  out  of  reach  under  the 
ribs,  and  because  pain  and  vomiting  may  not  occur  until  the  disease  is  well 
advanced.  The  tumor  in  cancer  of  the  pylorus  when  first  discovered  usually 
seems  about  the  size  of  a  small  hen's  egg  and  is  more  or  less  fixed,  but  it  can 
sometimes  be  moved  through  a  considerable  area,  being  more  readily  i^ushed 
up  than  drawn  down.  The  surface  may  be  nodular  or  smooth.  Hydrochloric 
acid,  which  is  a  natural  constituent  of  the  contents  of  the  stomach,  is  dimin- 
ished or  absent  in  cancer,  but  this  sign  is  not  invariable,  and  it  is  also  found 
in  other  diseases.  The  presence  of  lactic  acid  in  the  stomach,  associated 
with  the  absence  of  hydrochloric  acid,  adds  to  the  certainty  of  the  diagnosis. 
To  ascertain  these  facts,  "test-meals"  of  certain  foods  are  given  and  the  con- 
tents obtained  by  the  stomach-tube  for  analysis.  Ulcer  of  the  stomach 
resembles  cancer  in  some  of  its  symptoms,  but,  as  a  rule,  the  diagnosis  can 
be  made  by  the  fact  that  the  patient  with  ulcer  is  usually  under  forty  years 
of  age,  by  the  presence  of  acute  pain,  by  the  absence  of  obstructive  vomiting,  — 
the  vomiting  being  of  an  irritable  type  and  taking  xilace  immediately  after  eat- 
ing,— and  by  the  occurrence  of  bright  blood  instead  of  coffee-ground  material 
in  the  vomited  matter.  There  will  also  be  tenderness  over  the  stomach  and 
an  absence  of  tumor,  unless  perforation  has  taken  place  and  produced  an 
inflammatory  mass  of  omentum  and  adhesions.  The  diagnosis  may  be 
impossible  when  cancer  develops  in  the  indurated  base  of  an  ulcer.  The 
symptoms  of  carcinoma  of  the  stomach  may  be  closely  simulated  by  chronic 
iniiammation  due  to  gall-stones.  An  exploratory  laparotomy  should  be  under- 
taken in  doubtful  cases  without  waiting  for  time  to  settle  the  diagnosis,  as  it 
will  then  be  too  late  to  remove  the  tumor.  It  is  possible  that  the  exami- 
nation of  the  stomach  by  a  minute  electric  lamp,  which  is  passed  down  by 
an  oesophageal  bougie,  so  that  the  light  shall  shine  through  the  abdominal 
wall,  may  be  of  use  in  the  diagnosis  of  tumors  of  the  stomach,  but  as  yet  no 
progress  has  been  made  in  this  direction. 

Treatment. — The  risk  of  resection  for  malignant  disease  is  very  great, 
and  so  few  patients  have  remained  free  from  recurrence  that  gastro-enter- 
ostomy  offers  almost  as  much  hope  of  prolonging  life,  as  it  relieves  the 
obstruction,  which  is  the  most  urgent  symptom.  But  the  results  of  resection 
show  a  steady  improvement.  The  mere  extent  of  the  disease  is  not  impor- 
tant, for  the  entire  stomach  has  been  successfully  removed,  the  duodenum 
being  united  to  the  oesophagus.  The  removal  of  the  parts  must  be  free, 
cutting  half  an  inch  from  the  diseased  tissue  on  the  duodenal  side,  and  two 
inches  or  more  on  the  gastric  side.  The  main  obstacle  to  success  is  the 
disease  in  the  lymphatics,  beginning  first  in  the  glands  along  the  lesser  cur- 
vature. In  cancer  of  the  stomach,  therefore,  resection  should  be  strictly 
limited  to  tumors  having  no  extensive  secondary  disease  in  the  glands. 


932 


GASTROSTOMY. 


Tumors  of  the  greater  curvature  offer  a  better  prognosis  than  those  of  the 
pylorus,  provided  no  injury  is  done  to  the  blood-supply  of  the  colon. 

Operations. — G-astrotomy. — This  consists  in  incision  of  the  stomach 
for  the  removal  of  a  foreign  body  or  exploration  of  its  interior,  and  is  per- 
formed by  doing  a  median  laparotomy  and  making  an  incision  on  the 
anterior  surface  of  the  stomach  parallel  with  the  greater  curvature,  but 
sufficiently  far  away  from  it  to  avoid  the  arterial  branches.  The  incision 
is  closed  by  two  or  three  tiers  of  sutures,  the  first  through  all  the  coats, 
inverting  the  edges,  the  second  through  peritoneum  and  muscle,  and  a 
Lembert  suture  outside  if  necessary.     We  employ  a  continuous  suture. 

Gastrostomy. — In  cases  of  stricture  of  the  oesophagus  a  permanent 
Oldening  may  be  made  in  the  stomach  for  the  introduction  of  food  and  the 
prolongation  of  life,  and  this  operation  is  called  gastrostomy.  Of  the 
many  methods  recommended  we  shall  describe  only  two.  The  simplest 
method  is  to  make  a  small  oblique  incision  through  the  abdominal  wall, 
parallel  to  the  ribs  and  a  finger's  breadth  distant  from  them.  The  peri- 
toneum is  sutured  to  the  skin  around  this  opening.  The  anterior  wall  of 
the  stomach  is  picked  up  and  two  stout  loops  of  silk  passed  in  the  thick- 
ness of  the  wall,  but  not  entirely  through  it,  within  half  an  inch  of  each 
other.  While  an  assistant  holds  the  stomach  in  the  wound  by  these  loops 
the  peritoneal  coat  of  the  stomach  is  sutured  to  the  serous  membrane  of  the 
abdominal  wall.  The  stomach  is  allowed  to  form  adhesions  to  the  abdomi- 
nal wall  before  it  is  incised,  the  opening  being  delayed  for  twenty-four 
hours,  if  the  patient's  condition  allows.  The  great  objection  to  the  simple 
method  of  gastrostomy  is  the  difficulty  of  closing  the  opening  in  the 
stomach  by  a  pad,  resulting  in  irritation  of  the  skin  in  the  neighborhood  by 
the  gastric  juice. 

A  better  method  of  forming  the  fistula  is  that  devised  by  Stamm.  A 
vertical  incision  is  made  through  the  rectus  muscle,  the  stomach  is  drawn 
out,  and  a  minute  opening  made  in  the  latter.      A  No.  15  F.  catheter  is 

passed  into  this  opening,  and  a  purse- 
string  suture  of  fine  silk  is  placed 
around  the  opening  at  a  distance  of  a 
quarter  of  an  inch.     This  suture  when 


Fig.  761. 


Gastrostomy  by  Stamm's  method.    One  suture  has  Section  through  tube  and  stomach  wall, 

been  tied  and  the  second  is  in  place  ready  to  tie. 

tied  inverts  that  part  of  the  stomach  wall  near  the  catheter.  (Fig.  761.)  A 
similar  suture  is  placed  at  the  same  distance  outside  of  the  first,  and  a  third 
may  be  added  if  desired.     The  stomach  is  then  fixed  in  the  abdominal  wound 


GASTRO-ENTEROSTOMY. 


933 


by  sutures  in  the  usual  way,  closing  it  ai'ound  the  catheter  as  tightly  as  pos- 
sible. The  intention  of  this  operation  is  to  produce  an  internal  nipple-like 
projection  (Fig.  762)  of  the  stomach  wall  around  the  catheter,  so  that  when 
the  stomach  is  distended  the  pressure  within  will  close  the  canal  by  valvular 
action.  The  results  obtained  by  this  method  are  excellent.  The  catheter  may 
be  removed  at  the  end  of  a  week,  and  introduced  afterwards  only  at  the  time 
of  feeding,  but  iu  some  cases  there  is  difSculty  in  reinserting  it.  The 
leakage  from  the  sinus  when  the  catheter  is  out  is  very  slight  and  is  easily 
absorbed  by  a  dressing,  no  pad  being  required.  Gastrostomy  can  be  per- 
formed with  local  antesthesia.  If  it  is  done  by  Stamm's  method  a  spon- 
taneous closure  of  the  fistula  will  occur  when  the  tube  is  i)ermanently 
removed,  which  is  of  advantage  when  the  necessity  for  it  is  only  temporary. 

Gastro-Enterostomy. — Gastro- enterostomy  consists  in  making  an  oj)en- 
ing  between  the  stomach  and  the  intestine,  and  is  employed  in  cases  where 
there  is  great  pyloric  obstruction.  It  may  be  performed  by  Murphy's  button 
or  by  suture,  and  the  opening  may  be  made  on  the  anterior  or  the  posterioi- 
wall. 

Anterior  Operation  with  Murphy's  Button. — The  stomach  is  ex- 
posed by  a  median  incision,  or  by  an  incision  through  the  left  rectus  muscle, 
or  at  the  outer  border  of  the  latter.  When  the  stomach  is  very  much 
retracted  it  may  be  necessary  to  add  to  this  a  transverse  incision  in  either 
direction,  according  to  circumstances.  The  stomach  is  found  and  drawn 
into  the  wound,  a  point  being  selected  upon  its  anterior  surface  free  from 
blood-vessels  and  far  from  the  disease.  A  loop  of  small  intestine  is  drawn 
up  in  the  lower  angle  of  the  wound  and  a  point  selected  about  three  feet 
from  the  beginning  of  the  jejunum,  this  interval  being  necessary  in  order  to 
allow  the  looj)  to  pass  downward  behind  the  transverse  colon,  around  the 
latter,  and  then  upward  in  front  to  the  stomach  without  compressing  the 
bowel.  It  is  important  to  select  carefully  the  point  for  the  anastomosis,  for 
if  the  opening  is  made  too  far  down  in  the  intestine  the  result  may  be  dis- 


FiG.  763. 


Fig.  764. 


Application  of  sutures  for  the  i 
the  Murphy  button.    (Dunn.) 


Murphy  button  inserted  and  ready  to  be  joined  in  intes- 
tinal anastomosis.     (After  Von  Frey.) 


astrous  from  lack  of  nutrition.  The  chosen  loop  of  bowel,  from  six  to 
twelve  inches  long,  is  isolated  by  two  strips  of  gauze  passed  through  the 
mesentery  and  tied  around  the  gut  at  each  end,  the  contents  of  the  loop 
being  squeezed  out  thoroughly  before  the  gauze  strips  are  tied.     A  small 

60 


934  GASTEO-ENTEROSTOMY. 

incision  is  then  made  in  tlie  stomacli  while  an  assistant  compresses  the  organ 
with  his  fingers  so  that  none  of  its  contents  shall  escape.  A  straight  needle 
armed  with  stout  silk  is  passed  so  as  to  make  a  continuous  suture,  including 
the  entire  thickness  of  the  stomach  wall  and  circumscribing  this  opening- 
close  to  its  edge,  or  this  suture  may  be  placed  before  the  incision  is  made. 
(Fig.  763.)  One-half  of  the  Muriihy  button  is  then  slipped  into  the  incision, 
and  the  thread  adjusted  so  as  to  draw  the  edges  tightly  around  the  stem  of 
the  button,  and  tied.  A  similar  incision  is  made  in  the  bowel  on  the  side 
away  from  the  mesenteric  border,  and  the  other  half  of  the  button  inserted 
after  passing  a  purse-string  suture  around  the  edges,  as  before.  (Fig.  764.) 
The  two  halves  of  the  button  are  then  pressed  firmly  together,  the  bowel 
being  placed  so  that  the  direction  of  its  peristalsis  is  the  same  as  that  of  the 
stomach,  and,  finally,  a  Lembert  continuous  suture  of  fine  silk  is  run  around 
the  opening  in  order  to  make  it  perfectly  secure.  The  gauze  strips  are 
removed  from  the  loop  of  bowel,  the  organs  replaced,  and  the  abdominal 
wound  closed. 

Operation  by  Suture. — The  steps  of  the  operation  by  suture  are  the 
same  up  to  the  exposure  of  the  stomach  and  the  isolation  of  the  loox3  of 
bowel.  The  latter  is  held  in  proper  position  close  to  the  stomach  at  the 
point  chosen  for  the  opening,  and  a  continuous  Lembert  suture  at  that  point, 
more  than  two  inches  in  length,  holds  the  two  in  position.  With  a  sharp 
knife  an  incision  two  inches  long  is  made  through  the  serous  and  muscular 
coats  of  the  stomach  and  of  'the  gut,  and  the  edges  on  the  side  near  the  line 
of  suture  are  united  by  a  second  continuous  stitch.  The  mucous  membrane 
is  then  divided  for  the  same  distance,  and  a  continuous  suture  of  fine  silk 
secures  the  edges  of  the  gastric  mucous  membrane  to  that  of  the  intestine, 
first  on  the  distal  side  of  the  opening  and  then  on  the  proximal.  The 
muscular  coats  of  the  two  organs  are  then  united  on  the  proximal  side  of 
the  wound,  and,  finally,  the  Lembert  sutures  of  the  serous  surface  are 
continued  completely  around  the  opening. 

Operation  by  Rubber  Ligature. — McGraw  has  used  the  following 
method  with  success :  The  stomach  and  intestine  are  exposed  and  sutured 
together  by  a  continuous  Lembert  suture  for  a  space  about  three  inches  long. 
A  stout  needle  threaded  with  a  round  rubber  ligature  about  one-eighth  of 
an  inch  in  diameter  is  made  to  transfix  the  stomach  and  bowel  walls,  taking 
a  bite  two  and  one-half  inches  long  parallel  to  the  suture.  The  ends  of  the 
rubber  ligature  are  tied  in  a  half  hitch  and  drawn  very  tight  over  a  stout 
silk  thread  which  is  tied  firmly  around  them,  and  then  the  second  half  of 
the  knot  is  tied  and  secured  with  another  knot  of  the  silk.  The  ends  of  the 
ligatures  are  cut  short  and  another  line  of  Lembert  sutures  completes  the 
circle  around  the  point  of  union.  The  rubber  ligature  cuts  its  way  through 
in  two  or  three  days,  the  edges  of  the  organs  uniting  meanwhile,  and  an 
opening  two  inches  or  more  in  length  results. 

Posterior  Operation. — Von  Hacker  has  recommended  making  the 
opening  in  the  posterior  wall  of  the  stomach,  in  order  to  avoid  bringing  the 
small  intestine  in  a  loop  around  the  transverse  colon.  In  this  method,  after 
the  stomach  has  been  exposed,  the  transverse  colon  is  drawn  out  of  the 
abdominal  wound,  thrown  upward  over  the  chest,  and  covered  with  a  warm, 


EESEOTION   OF  THE  STOMACH.  935 

moist  towel.  The  operator  tlieii  selects  a  portion  of  the  mesocolon  which  is 
free  from  blood-vessels  where  it  covers  the  posterior  wall  of  the  stomach, 
and  tears  in  it  an  opening  about  three  inches  in  diameter,  exposing  the 
stomach.  The  edges  of  the  torn  peritoneum  are  retracted  by  two  or  three 
sutures  in  the  stomach  wall.  The  bowel  is  united  to  the  stomach  by  button 
or  suture,  as  already  described.  This  method  has  the  further  advantage  of 
lessening  the  liability  to  vomiting,  because  as  the  patient  lies  on  the  back 
the  food  passes  backward  by  gravity  into  the  intestine  through  the  opening 
in  the  posterior  wall  of  the  stomach. 

"  Vicious  Circle." — One  of  the  principal  dangers  of  gastro-enterostomy 
is  the  tendency  to  the  formation  of  a  "vicious  circle,"  the  contents  of  the 
stomach  passing  in  a  reverse  direction  on  entering  the  bowel  and  filling  the 
loop  towards  the  pylorus  instead  of  going  on  down  the  bowel.  This  is  most 
common  after  the  anterior  operation,  and  results  in  obstruction,  vomiting, 
and  death  by  inanition.  It  can  be  overcome  by  suturing  two  or  three  inches 
of  the  bowel  above  the  opening  (the  afferent  loop)  to  the  wall  of  the  stomach. 
A  surer  method  is  to  divide  the  bowel  comi^letely  and  insert  the  distal  end 
into  the  stomach  and  the  proximal  end  into  the  distal  loop  of  bowel  about 
six  inches  from  the  anastomotic  oi^ening  (Eoux's  Y-method).  Or  a  lateral 
anastomosis  can  be  made  between  the  afferent  and  efferent  loop  of  bowel  as 
they  hang  side  by  side  below  the  stomach  after  the  gastro-enterostomy  has 
been  completed. 

Resection. — Resection  of  the  stomach  wall,  not  including  the  pylo- 
rus, is  a  comparatively  easy  procedure,  the  tumor  being  cut  away  freely, 
the  vessels  caught  and  ligated  in  the  usual  way,  and  the  wound  closed  with 
continuous  or  interru^jted  sutui'es  of  fine  silk.  The  edges  are  drawn  together 
with  a  suture  including  all  the  coats.  A  musculo-pieritoneal  suture  is  applied 
over  tins  and  a  Lambert  suture  may  be  added  for  security.  The  part  of  the 
stomach,  wall  removed  should  be  elliptical  in  shape,  and  the  long  axis  may 
be  placed  either  longitudinally  or  transversely. 

Pylorectomy. — The  pylorus  and  diseased  portion  of  the  stomach  are 
completely  isolated  by  a  series  of  double  ligatures  passed  through  the  mesen- 
tery above  and  below.  An  assistant  shuts  off  the  pylorus  from  the  rest  of 
the  stomach  by  pressure  with  the  fingers,  while  another  assistant  comj)resses 
the  duodenum,  a  long,  narrow  clamj)  is  placed  on  each  side  of  the  portion 
to  be  removed,  and  the  latter  is  excised  between  these  clamps  and  the 
assistants'  fingers.  The  clam^js  and  tumor  being  removed,  the  edges  of  the 
circular  incisions  are  united.  On  the  posterior  wall  the  serous  layers  must 
first  be  brought  in  contact,  then  the  muscular  layers,  and  finally  the  mucous 
layer,  all  sutures  being  tied  on  the  inside.  Interru]Dted  sutures  of  fine  silk 
are  generally  used,  although  some  surgeons  employ  catgut  and  a  continuous 
stitch.  The  mucous  membrane  suture  is  then  contiiiued  on  the  anterior  side 
of  the  wound,  completing  the  circle,  followed  by  completion  of  the  suturing 
of  the  muscular  and  serous  layers.  The  bowel  and  stomach  are  then  released 
and  the  abdominal  wound  closed.  If  the  line  of  resection  through  the 
stomach  passes  some  distance  from  the  pylorus,  or  if  the  removal  of  the 
diseased  tissues  requires  an  oblique  incision  of  the  stomach  wall,  the  opening 
in  the  stomach  will  be  much  larger  than  that  in  the  duodenum,  and  before 


936 


DISEASES  OF  THE  INTESTINES. 


Fig.  765. 


the  circular  suture  described  is  made,  the  opening  in  the  stomach  should  be 
reduced  by  sutures  until  it  is  of  proper  size  to  unite  with  the  duodenum. 
Kocher  closes  the  oijening  in  the  stomach 
completely  and  makes  another  small  opening 
in  the  posterior  wall,  to  which  he  unites  the 
duodenum.  (Fig.  765.)  This  method  is  easier 
in  i)ractice,  especially  if  Murphy's  button  be 
employed  for  the  union. 

Combined  Resection  and  Gastro-En- 
terostomy. — In  cases  of  extensive  resection, 
and  even  in  ordinary  cases,  it  is  often  easier 
to  invaginate  the  cut  ends  of  the  stomach  and 
duodenum  and  close  them  entirely.  A  rapid 
method  of  resection  is  that  of  Doyen.  A 
heavy  clamp  is  placed  across  the  duodenum 
and  the  stomach  in  healthy  tissue.  Two  other 
clamps  are  placed  between  these  and  the  dis- 
eased part.  The  parts  are  divided  between 
each  j)air  of  clamps  close  to  the  outer  ones, 
and  the  diseased  portion  is  removed  with  its 
clamps.  The  outer  clamps  are  then  removed 
and  the  crushed  edges  overhanded  with  a  con- 
tiniious  silk  suture.  The  crushed  part  is  then 
invaginated  into  the  healthy  part  and  a  layer 
of  Lembert  sutures  applied  over  it.  The 
remaining  portion  of  the  stomach  is  then 
united  to  the  jejunum,  as  in  the  ordinary  operation  for  gastro-enterostomy. 
The  results  of  this  method  are  far  better  than  those  of  circular  suture. 

Gastric  Fistula. — It  may  be  necessary  to  close  a  gastric  fistula  which 
has  been  pi'oduced  by  the  external  opening  of  abscesses  communicating  with 
the  organ,  by  accidental  injuries,  or  by  operation.  If  the  fistula  is  small  or 
made  by  the  Stamm,  Kader,  or  Witzel  method,  it  may  close  spontaneously. 
To  close  it  by  operation  the  abdomen  must  be  opened,  the  stomach  freed,  the 
edges  of  the  opening  in  the  latter  inverted  and  sut\ired,  and  the  abdominal 
wound  closed  after  cutting  away  its  edges  until  healthy  tissues  are  reached. 

Feeding  after  Operations  on  the  Stomach. — Before  any  operation 
upon  the  stomach  is  performed,  the  organ  should  be  thoroughly  washed  out 
with  the  tube.  In  the  after-treatment  of  these  cases  feeding  by  the  mouth 
is  suspended  and  rectal  alimentation  employed  for  fortj' -eight  hours.  There 
is  seldom  any  vomiting  when  feeding  by  the  mouth  is  resumed,  provided  the 
food  be  given  in  small  quantities  at  first  and  limited  to  sterilized  milk  or 
peptonized  milk  and  water.    Solid  food  may  be  given  in  a  week  or  ten  days. 


Kocher's  pylorectomy :  stomach  closed, 
duodenum  ready  for  implantation. 


DISEASES  OF  THE  INTESTINES. 

Foreign  Bodies. — Foreign  bodies  which  have  been  swallowed  may 
lodge  in  the  intestines,  as  well  as  large  gall-stones  or  concretions  of  inspis- 
sated f£eces.  Forks,  knives,  spoons,  and  tooth-brushes  have  been  removed 
by  operation  either  directly  from  the  intestine  or  from  abscesses  which  had 


ULCERATION   OF  THE  INTESTINES.  937 

been  formed  by  peiforatiou  of  the  bowel.  When  small  sharp  objects  have 
been  swallowed,  snch  as  nails  or  pins,  the  best  treatment  is  to  feed  the 
patient  on  large  quantities  of  some  food  which  will  make  bulky  fteces  and 
form  a  bolus  around  the  object  and  carry  it  safely  through  the  canal  without 
danger  of  perforation,  potato  being  the  best  material  for  this  purpose.  Intu- 
bation tubes  are  often  swallowed,  but  usually  pass  without  trouble.  The 
larger  foreign  bodies,  gall-stones,  and  concretions  may  give  rise  to  intestinal 
obstruction,  or  may  perforate  the  intestinal  wall  and  cause  peritonitis,  either 
local  or  general.  If  an  abscess  is  formed,  the  foreign  body  may  make  its 
way  through  the  abdominal  wall  spontaneously  and  recovery  ensue.  As 
soon  as  the  presence  of  these  objects  is  known  they  should  be  removed  from 
the  bowel  by  laparotomy  and  incision. 

Ulceration. — Yarious  inflammatory  conditions  cause  ulceration  of  the 
intestinal  nuicous  membrane  with  the  common  consequences  of  hemorrhage, 
perforation,  and  secondary  stricture.  Ulcer  of  the  duodenum  resembles 
gastric  ulcer,  but  is  more  frequently  latent,  running  its  course  with  little  or 
no  sign  until  sudden  hemorrhage  or  perforation  occurs.  The  ulcer  is  usu- 
ally situated  on  the  anterior  wall  and  in  nine-tenths  of  the  cases  it  is  in  the 
first  part  of  the  duodenum.  Perforation  occurs  in  from  one-half  to  two- 
thirds  of  the  cases,  and  usually  opens  the  peritoneal  cavity.  The  disease  is 
four  times  as  common  in  man  as  in  woman.  Perforation  leads  to  a  local  or 
general  peritonitis,  and  less  frequently  to  an  extra-peritoneal  subphrenic 
abscess.  Prompt  laparotomy  is  necessary  to  save  life.  (See  page  915.) 
Typhoidal  ulcers  cause  j)erforative  peritonitis  in  nearly  seven  per  cent,  of 
the  cases  of  typhoid  fever  (Fitz).  In  some  cases  the  perforating  ulcer  has 
been  found  in  the  vermiform  appendix  or  the  caecum,  instead  of  the  ileum, 
and  more  than  one  ulcer  may  perforate  at  once.  The  symptoms  may  be  well 
marked,  but  are  often  obscvu-e  in  the  beginning.  They  are  abdominal  pain, 
local  tenderness,  collapse,  vomiting,  abdominal  distention  and  rigidity,  addi- 
tional fever,  and  a  leucocytosis  which  is  characteristic  by  its  steady  increase 
from  hour  to  hour,  reaching  15,000  to  20,000.  The  patient's  condition  is 
often  very  bad  from  the  original  disease,  but  an  early  laparotomy  offers  fair 
chance  of  recovery  (twenty  per  cent.,  Keen).  (See  page  915.)  Local  anses- 
thesia  can  often  be  employed.  The  perforation  may  be  closed  by  sutures  or 
the  injured  loop  wrapped  in  gauze  and  the  wound  left  open.  There  are  four 
cases  on  record  in  which  recovery  followed  resection  of  the  affected  loop 
when  extensive  disease  was  present.  Ulcerative  colitis  and  dysentery 
may  also  result  in  intestinal  hemorrhage  or  perforative  peritonitis,  and 
demand  surgical  interference. 

Tubercular  Inflammation. — This  may  cause  perforation  or  may  form 
solid  tumors  made  up  of  the  thickened  wall  of  the  bowel  and  of  the  peritoneal 
adhesions,  especially  in  the  ileo-ctecal  region.  It  is  often  localized  and  can 
be  cured  by  resection  of  the  affected  bowel.  The  tubercles  may  be  subserous 
or  may  develop  first  in  the  submucous  coat.  The  symptoms  are  those  of  stric- 
ture even  from  the  first,  with  attacks  of  colic  and  constipation.  Diarrhceal 
discharges  are  not  seen  in  this  form  of  tuberculosis.  The  treatment  consists 
of  laparotomy  with  resection  of  the  affected  loop.  Intestinal  anastomosis  or 
exclusion  may  be  useful  as  palliatives  or  as  a  iireliminary  to  resection. 


938  TUMORS  OF  THE  INTESTINE. 

Stricture. — When  ulcers  of  the  bowel  heal,  a  stricture  may  be  pro- 
duced by  cicatricial  contraction  or  by  surrounding  adhesions,  and  this  occurs 
most  frequently  in  the  neighborhood  of  the  ileo-csecal  valve  as  a  result 
of  typhoid  fever,  tuberculosis,  or  syphilis.  These  strictures  produce  intes- 
tinal obstruction,  usually  of  a  rather  chronic  type,  which  can  be  relieved  by 
such  operations  as  making  an  artificial  anus,  resecting  the  diseased  loop  of 
bowel,  or  making  an  intestinal  anastomosis  by  uniting  a  loop  of  the  bowel 
above  to  one  below  the  point  of  stricture,  so  that  the  contents  of  the  bowel 
may  descend  without  passing  through  the  narrowed  portion,  or  exclusion  of 
the  affected  loop. 

Tumors. — The  benign  tumors  of  the  bowel  are  usually  polypoid.  They 
may  be  adenomata,  growing  from  the  mucous  membrane,  or  fibromata, 
originating  from  the  submucous  coat.  Polypi  are  occasionally  multiple, 
and  occur  in  any  part  of  the  bowel.  If  large,  they  may  cause  obstruction, 
and  even  a  small  polypus,  by  dragging  on  the  wall  of  the  bowel  during 
peristalsis,  may  form  an  intussusception.  If  they  are  recognized,  they  should 
be  removed,  with  thorough  excision  of  the  base  from  which  they  grow. 

Sarcoma. — Sarcoma  is  rare,  but  occurs  in  both  the  large  and  the  small 
intestine,  although  more  frequently  in  the  latter.  It  is  found  in  young 
persons,  forming  tumors  of  considerable  size,  running  a  i-ather  rapid  course, 
and  resulting  in  intestinal  obstruction,  cachexia,  and  death.  A  very  early 
operation  may  offer  some  hope  of  cure,  but  early  diagnosis  is  difficult. 

Carcinoma. — Carcinoma  of  the  bowel  is  most  common  in  the  neighbor- 
hood of  the  ileo-csecal  valve,  at  the  flexures  of  the  colon,  and  in  the  sigmoid. 
It  occurs  in  elderly  persons  and  in  two  forms.  In  one  variety  the  tumor  is 
large,  making  a  considerable  mass,  which  becomes  adherent  to  the  surround- 
ing parts,  but  may  not  greatly  obstruct  the  caliber  of  the  bowel.  In  the 
other  form  the  mass  is  very  small,  and  when  the  bowel  is  exposed  no  tumor 
may  be  seen,  the  intestine  looking  as  though  a  string  had  been  tied  around 
it,  but  on  compressing  tlie  bowel  between  the  fingers  a  small  hard  mass  is 
felt.  The  diseased  wall  of  the  gut  is  found  on  section  to  be  thickened  circu- 
larly, greatly  reducing  the  caliber  of  the  bowel.  These  tumors  are  of  slow 
growth,  and  do  not  involve  the  glands  early.  In  both  forms  the  symptoms 
are  usually  those  of  chronic  constipation  or  intestinal  obstruction.  There 
may  be  intermittent  diarrhoea  and  discharge  of  pus  and  blood.  Pain  may 
be  present,  with  colicky  exacerbations.  Cachexia  finally  sets  in,  and  death 
occurs  about  two  years  after  the  first  symptoms,  and  sometimes  sooner.  If 
an  early  diagnosis  cau  be  made  before  the  glands  are  infected,  the  tumor 
may  be  excised.  After  that  time  the  obstruction  may  be  relieved  by  making 
an  intestinal  anastomosis  or  an  artificial  anus. 

Fecal  Fistula. — A  fecal  fistula  is  an  opening  between  the  bowel  and 
the  external  parts  {external  fistula),  or  between  the  bowel  and  some  of  the 
hollow  viscera,  such  as  the  vagina  or  the  bladder,  or  another  loop  of  intes- 
tine {internal  fistula^.  These  openings  are  the  result  of  accidental  wounds, 
of  inflammation  with  sloughing  (appendicitis),  of  ligatures  applied  in  lapa- 
rotomies, and  most  frequently  of  strangulated  hernise,  with  sloughing  of 
the  bowel  and  sac.  The  internal  variety  usually  requires  some  plastic 
operation  in  the  vagina,  or  an  extensive  laparotomy  with  suture  of  both  the 


FECAL  FISTULA. 


939 


intestine  and  the  other  organ  involved.  In  the  external  fistulie,  unless  the 
opening  is  large,  there  is  a  strong  tendency  to  spontaneous  cure  by  cica- 
tricial contraction,  although  the  process  is  a  slow  one.  The  main  obstacle 
to  closure  is  the  existence  of  a  bend  in  the  bowel  at  the  point  of  the  fistula, 
so  that  the  alferent  and  efferent  loops  lie  side  by  side,  with  a  spur  between 
them  which  prevents  the  contents  of  the  afferent  loop  from  passing  directly 
into  the  efferent,  and  forces  them  to  issue  by  the  fistula.     (Fig.  7C6.)     The 


Fig.  766. 


Fic4.  767 


Fig.  768. 


Fecal  fistula  with  spur.  Double-barrelled  fecal  fistula.  Lateral  fecal  fistula. 

A,  A',  abdominal  wall ;  B,  B',  bowel ;  F,  F',  fecal  fistula  ;  S,  spur. 


worst  cases  are  those  seen  after  strangulated  hernia,  as  a  complete  loop  of 
bowel  usually  sloughs  in  such  cases,  leaving  two  openings  into  the  ends  of 
the  gut  as  they  lie  side  bj'  side.  (Pig.  767.)  When  the  bowel  is  opened  by 
an  abscess  which  has  eroded  its  wall,  a  lateral  opening  results  (Fig.  768), 
and  the  spur  is  not  well  marked,  so  that  spontaneous  cure  is  the  rule.  Fis- 
tulse  of  the  small  intestine  are  less  likely  to  heal  than  those  of  the  large. 
If  the  opening  leads  to  a  part  of  the  intestine  very  high  up  there  will  be 
marked  loss  of  nutrition,  because  the  food  goes  to  waste,  but  otherwise  the 
symptoms  are  limited  to  the  annoyance  and  the  irritation  of  the  surrounding 
skin  by  the  discharge.  When  the  loop  of  bowel  involved  lies  deep  in  the 
abdomen  and  the  sinus  is  long  and  narrow,  there  is  very  apt  to  be  retention 
of  the  discharge,  with  a  liability  to  the  formation  of  abscesses  or  diffuse 
suppuration  about  it,  a  condition  which  is  most  frequently  seen  as  a  result 
of  appendicitis  with  abscess.  If  there  is  a  permanent  obstruction  to  the 
bowel  beyond  the  seat  of  the  fistula,  the  latter  becomes  an  artificial  anus, 
and  cannot  be  closed  until  the  distal  obstruction  is  remedied.  Fecal  fistula 
is  rarely  seen  as  the  direct  result  of  tuberculous  or  cancerous  disease  of  the 
intestine  involving  the  abdominal  wall. 

Treatment.— The  treatment  of  fecal  fistula  should  be  expectant  at  first, 
protecting  the  skin  by  ointments  and  cleanliness,  and  keeping  the  external 
orifice  of  the  sinus  open,  so  that  it  will  close  from  the  bottom,  in  order  to 
avoid  inflammation  by  retention  of  the  discharge.  If  the  external  orifice 
should  close  and  the  patient  begin  to  have  fever,  even  if  there  is  no  local 
sign  of  abscess,  a  careful  watch  should  be  kept  to  evacuate  the  pus  at  the 


940 


TREATMENT  OF  FECAL  FISTULA. 


earliest  possible  moment.     In  cases  with  much  irritation  of  the  skin  the 
patient  may  be  kept  submerged  in  the  permanent  bath. 

If  the  fistula  shows  no  tendency  to  heal,  or  frequently  relapses,  it  must  be 
closed  by  operation.     The  first  and  often  the  only  necessary  step  is  the 

destruction  of  the  spur.  Dupuytren's 
enterotome  (Fig.  769)  is  an  instrument 
devised  for  this  purpose,  consisting  of  a 
forceps,  one  branch  of  which  is  introduced 
in  each  end  of  the  bowel,  and  the  handles 
are  then  slowly  axjproximated  with  a 
screw,  being  tightened  daily  until  they 
cut  their  way  through  the  adjacent  walls, 
adhesions  meanwhile  forming  around 
them,  so  that  the  peritoneal  cavity  is  not 
opened  in  the  process.  When  the  two 
loops  of  bowel  lie  close  together,  this  in- 
strument acts  admirably  ;  but  if  the  angle 
between  them  is  open,  the  tension  may 
prevent  the  adhesions  from  forming  suffi- 
ciently rajjidly,  and  peritonitis  may  re- 
sult, or  another  loop  of  bowel  may  lie  in 
the  angle  and  may  be  caught  by  the 
clamp.  By  incising  the  abdominal  wall 
sufficiently  to  expose  the  intestinal  ends, 
dividing  the  spur  by  open  incision,  and 
suturing  the  mucous  membrane  at  the 
edges  of  the  latter  across  the  raw  surfaces 
so  as  to  prevent  recontraction,  the  spur  can 
be  removed  without  invading  the  peritoneum.  A  better  method  is  to  open  the 
peritoneal  cavity  near  the  fecal  fistula  and  to  make  an  anastomosis  between  the 
afferent  and  efferent  loops  a  short  distance  from  the  external  opening,  thus 
establishing  the  circiilation  of  the  intestinal  contents  above  the  spur.  When 
the  spur  has  been  disposed  of  by  section  or  anastomosis,  the  external  orifice 
may  be  closed  by  any  of  the  ordinary  plastic  operations  for  such  openings, 
but  it  will  usually  heal  spontaneously.  A  more  radical  method  is  resection, 
the  entire  external  orifice  being  circumscribed  by  an  incision  some  distance 
from  its  edges,  the  abdomen  opened,  and  the  two  adherent  ends  of  bowel 
drawn  out  together  and  cut  away,  the  open  ends  of  the  gut  being  then 
united  as  in  intestinal  resection  and  the  abdominal  wound  closed  as  usual. 
This  operation  is  generally  very  difficult,  on  account  of  the  numerous 
adhesions  and  the  danger  of  peritoneal  infection  from  the  open  fecal  fistula, 
but  some  form  of  open  operation  is  now  j)referred  to  the  enterotome. 

Operations. — Enterotomy. — If  it  is  simply  desired  to  remove  a 
foreign  body  from  the  intestine,  a  laparotomy  is  done,  and  the  loop  of 
bowel  is  incised  along  the  border  opposite  the  mesentery.  The  foreign  body 
is  removed,  and  the  wound  is  closed  with  Lembert  sutures. 

Enterostomy. — If  it  is  necessary  to  make  an  artificial  anus,  the  opening 
should  be  made  as  low  down  as  possible  and  just  above  the  obstruction 


Dupuytren's  enterotome  applied.    (Agnew.) 


COLOSTOMY.  941 

which  it  is  desired  to  relieve.  The  small  intestine  may  be  opened  near  the 
ileo-ciEcal  valve,  but  not  above  that  point,  lest  the  absorption  by  the  bowel 
above  the  opening  be  not  snificient  to  support  life. 

Jejunostomy. — In  some  cases  of  incurable  ob.struction  of  the  pylorus 
or  duodenum  which  cannot  be  treated  by  gastroenterostomy,  a  loop  of  the 
jejunum  has  been  secured  in  an  abdominal  wound,  so  that  the  patient  may 
be  fed  in  a  similar  manner  to  that  emj)loyed  after  gastrostomy.  The  ojiera- 
tion  is  rare  and  not  very  successful.  It  is  known  as  jejunostomy,  and  resem- 
bles gastrostomy  in  the  methods  of  its  performance. 

Colostomy. — Lumbar  Operation. — The  eistraperitoneal  or  old  opera- 
tion of  colostomy  (formerly  called  colotomy)  is  done  in  the  lumbar  regions 
upon  the  ascending  or  the  descending  colon.  An  incision  is  made  parallel 
to  and  one  inch  below  the  last  rib,  extending  outward  from  the  edge  of  the 
quadratus  lumborum.  This  is  deepened  until  the  fat  in  the  neighborhood 
of  the  kidney  is  exposed  in  the  wound.  The  iinger  then  searches  for  the 
bowel,  which  will  usually  be  found  distended  in  these  cases,  owing  to  the 
obstruction  ;  the  peritoneum  is  pushed  aside  if  it  comes  in  sight,  and  the 
bowel  is  secured  by  a  loop  of  silk  on  a  curved  needle,  which  is  passed 
through  the  part  not  covered  with  peritoneum.  The  bowel  is  drawn  into 
the  wound,  where  it  is  sutured  to  the  skin  and  incised. 

The  intraperitoneal  operation  is  done  upon  the  ciscum,  the  transverse 
colon,  or,  most  frequently,  the  sigmoid  flexure.  Iliac  Operation. — The 
sigmoid  flexure  may  be  opened  by  several  methods,  the  simplest  being  that 
of  an  oblique  incision  parallel  to  Poupart's  ligament,  about  half-way  between 
the  anterior  superior  spine  of  the  ilium  and  the  middle  line.  The  peri- 
toneum is  incised  and  sutured  to  the  skin  around  the  edge  of  the  opening, 
making  an  aperture  in  the  abdominal  wall  an  inch  and  a  half  in  length. 
If  this  opening  is  made  by  the  split-muscle  method  (McBurney )  there  is  a 
tendency  to  the  formation  of  an  external  sphincter.  The  loop  of  the  sig- 
moid is  drawn  up  to  the  wound  and  sutured  by  continuous  Lembert 
stitches  to  the  peritoneal  margin.  If  there  is  no  need  of  haste,  a  delay  of 
twenty-four  hours  before  incising  the  bowel  will  allow  strong  adhesions  to 
form.  If  it  is  necessary  to  incise  the  bowel  at  once,  additional  care  must  be 
taken  to  make  the  stitches  very  close,  so  that  there  shall  be  no  danger  of 
infecting  the  peritoneum  with  fteces.  A  better  method  is  to  draw  a  loop  of 
the  bowel  out  of  the  abdominal  wound  and  pass  a  strong  gla.ss  rod  or  di-ain- 
age-tube  through  its  mesentery,  so  that  the  glass  rod  supports  the  weight  of 
the  intestine.  A  few  sutures  are  made  to  secure  the  bowel  to  the  margin  of 
the  opening,  and  also  to  unite  the  two  limbs  of  the  loop  under  the  rod.  The 
intestine  is  cut  across  upon  the  rod  in  twenty-four  hours,  no  anaesthetic  being 
required. 

Enterectomy,  or  Resection. — To  remove  a  tumor  of  the  bowel,  the 
loop  containing  it  is  isolated  by  two  strips  of  gauze  tied  around  the  bowel 
some  distance  from  the  part  to  be  resected,  after  expressing  the  contents  of 
the  loop.  The  mesenteric  attachment  of  the  portion  to  be  removed  is  then 
tied  off  by  several  silk  or  catgut  ligatures.  The  part  to  be  excised  is  seized 
with  a  long  clamp  on  each  end,  and  the  bowel  divided  beyond  these  clamps. 
If  the  tumor  is  situated  near  the  end  of  the  small  intestine  or  in  the  lai-ge 


942 


ENTERECTOMY. 


iutestine,  the  two  euds  of  the  bowel  may  be  secured  in  the  abdominal  wound 
and  an  artificial  anus  made.  This  is  the  best  procedure  if  the  patient  is 
very  feeble,  or  if  the  operation  is  a  verj'  tedious  one  with  severe  hemorrhage 
or  great  shock.  Otherwise  it  is  best  to  unite  the  eads  of  the  intestine.  This 
may  be  done  by  a  circular  suture  ijassing  through  all  the  coats,  inverting 
the  edges,  and  the  serous  coat  united  over  this  with  Lembert  sutures. 
(See  page  907.)  Or  a  lateral  anastomosis  may  be  made,  both  ends  of  the 
bowel  being  closed  by  a  continuous  suture,  a  slit  at  least  three  inches 
long  being  made  on  the  side  opposite  the  mesenteric  border  in  each  end 
of  the  bowel,  and  the  edges  of  these  openings  united  in  the  same  way  as 
in  gastroenterostomy.  Doyen's  crushing  method  may  be  employed,  the 
bowel  being  crushed  at  the  points  to  be  sutured  by  a  forceps  with  jaws 
half  an  inch  broad,  applied  transversely,  and  ligatures  tied  around  the 
intestine  in  the  grooves  thus  made.  The  portion  of  the  bowel  to  be  removed 
is  cut  away  and  a  purse-string  suture  is  applied  so  as  to  invaginate  each 
ligated  end.  A  lateral  anastomosis  is  then  made.  Finally,  the  ends  may 
be  united  by  a  Murphy's  button.  With  a  needle  threaded  with  coarse  silk  a 
continuous  suture  is  made  around  each  end  of  the  bowel,  passing  tlirough 
the  entire  thickness  of  its  wall  close  to  the  cut  edge.  Half  of  the  button  is 
inserted  in  each  end,  and  the  thread  of  this  suture  is  drawn  tightly  around 


Fig.  770. 


W^' 


End  to  end  union  with  a  Murphy's  button,  bowel  drawn  out  and  wound  covered  with 
gauze.  The  halves  o£  the  button  secured  in  the  bowel.  One  half  is  in  the  hand  ready  for 
reunion ;  the  other  half  is  still  held  by  the  forceps  used  while  applying  the  suture. 


its  neck.  (Fig.  770).  The  two  halves  are  then  joined,  and  a  continuous 
Lembert  suture  is  applied  outside  of  all.  Various  devices  to  be  placed 
inside  of  the  bowel,  or  forceps  to  hold  the  ends,  haA^e  been  suggested  as  aids 
in  intestinal  suture,  but  none  has  achieved  much  poi)ularity. 


APPENDICITIS.  943 

Intestinal  Anastomosis. — In  some  cases  it  is  not  x)ossible  to  remove 
the  diseased  bowel,  and  a  "short  cut"  may  then  be  made  around  the  point 
of  obstruction  by  forming  an  anastomosis  in  which  an  opening  in  the  bowel 
above  is  united  to  a  similar  opening  in  the  bowel  below,  exactly  as  in  the 
case  of  gastro-enterostomy,  either  by  sutures  or  by  a  Murphy's  button.  The 
method  by  sutures  is  better,  because  it  allows  a  much  larger  opening  to  be 
made,  and  there  is  a  tendency  for  all  such  orifices  to  contract.  The  incisions 
in  the  bowel  should  be  three  or  four  inches  long,  and  should  be  made 
opposite  to  the  mesenteric  attachment. 

Intestinal  Exclusion. — Intestinal  exclusion  is  useful  when  a  part  of 
tlie  bowel  is  diseased  by  a  cicatricial  stricture  or  multiple  fistulfe  or  some 
such  condition  which  is  neither  malignant  nor  tuberculous.  In  such  a  case 
the  bowel  may  be  divided  above  and  below  the  point  of  disease  and  the 
proximal  and  distal  ends  united,  so  as  to  re-establish  the  continuity  of  the 
gut.  Both  ends  of  the  diseased  loop  may  then  be  closed  after  irrigating  it 
thoroughly,  or,  preferably,  one  end  may  be  left  open  and  secured  in  the 
abdominal  wound.  In  this  way  the  circulation  of  the  intestinal  contents 
goes  on  entirely  through  the  healthy  bowel,  and  the  diseased  part  is  relieved 
from  function  and  from  irritation.  The  general  health  is  restored,  and  a 
local  cure  may  be  obtained.  It  is  said  that  the  excluded  part  of  the 
intestine  atrophies  so  completely  that  it  is  perfectly  safe  to  close  both  ends 
of  the  isolated  loop. 

DISEASES   OF   THE   VERMIFORM   APPENDIX. 

Anatomy. — The  normal  appendix  is  about  three  and  a  quarter  inches 
long,  and  is  attached  to  the  cfficum  just  behind  its  blunt  extremity.  In  the 
foetus  the  caecum  is  funnel-shaped  and  continuous  with  the  appendix  at  its 
apex,  and  this  arrangement  occasionally  i)ersists  in  adult  life.  The  appendix 
may  be  from  seven  to  nine  inches  in  length,  or  it  may  be  only  half  an  inch 
long,  or  even  absent  altogether.  It  is  normally  an  intraj)eritoneal  organ, 
and  very  rarely  is  it  found  behind  the  peritoneum.  It  has  a  short  mesentery 
which  runs  behind  the  csecum  towards  the  ileo-csecal  valve.  The  appendix 
is  usually  coiled  up  behind  and  a  little  to  the  inner  side  of  the  caecum,  but 
its  position  is  very  variable.  It  has  even  been  found  extending  across  the 
body,  so  that  its  tip  lay  on  the  left  side  of  the  middle  line,  and  abscesses 
have  been  caused  by  it  in  this  situation.  The  ctecum  and  the  appendix 
may  lie  high  up  near  the  liver,  as  in  the  foetus.  Whatever  its  position,  its 
base  is  always  in  connection  with  the  anterior  longitudinal  band  of  the 
colon  which  runs  down  over  the  ca?cum,  and  this  can  be  used  as  a  guide  to 
the  appendix. 

Pathology. — The  vermiform  appendix  consists  of  two  layers  of  muscle, 
longitudinal  and  circular,  covered  externally  with  peritoneum  and  inter- 
nally with  a  mucous  membrane  resembling  that  of  the  ciecum,  except  that  it 
is  very  rich  in  lymphoid  tissue.  In  the  diseased  state  the  first  change  is  a 
catarrhal  one,  consisting  simply  of  congestion  of  the  mucous  membrane, 
thickening,  and  an  increase  of  secretion.  Foreign  bodies  are  frecxuently 
found  in  the  cavity  of  the  appendix,  which  should  normally  be  empty. 
They  are  almost  invariably  hardened  masses  of  fceces,  biit  occasionally  in 


944  VARIETIES   OF  APPENDICITIS. 

their  centre  will  be  found  a  true  foreign  body,  such  as  a  pin  or  the  seed  of  a 
fruit.  Strictures  are  frequent,  and  adhesions  often  fix  the  organ  in  a  bent 
position.  In  rare  cases  the  distal  part  of  the  apisendix  is  entirely  shut  off 
by  the  obliteration  of  the  lumen,  and  a  cyst  is  formed  which  may  be  of  large 
size.  Ulcerative  inflammation  is  also  common,  and  may  result  in  perfora- 
tion. The  tip  of  the  appendix  or  any  part  of  its  wall  may  become  gan- 
grenous, or  the  entire  organ  may  slough. 

Appendicitis  is  more  common  in  men  than  in  women,  and  occurs  before 
the  thirtieth  year  in  three-quarters  of  the  cases,  although  it  may  occur  at 
any  age.  The  causes  of  appendicitis  are  not  fully  understood.  In  some 
cases  it  would  seem  that  ulceration  had  resulted  in  a  cicatricial  stricture,  or 
adhesions  had  bent  the  organ,  and  the  stagnation  of  its  contents  due  to 
these  causes  had  j)roduced  a  fecal  concretion,  which,  in  its  turn,  excited 
ulceration  or  sloughing  of  the  wall.  In  others  the  sloughing  appears  to  be 
the  result  of  the  intensity  of  the  inflammation.  The  inflammation  is  due  to 
bacterial  infection,  either  by  the  colon  bacillus  or  the  ordinary  pyogenic 
germs,  and  occasionally  by  the  tubercle  bacillus.  It  is  probable  that  con- 
stii)ation  and  chronic  gastrointestinal  disturbance  also  act  as  predisposing 
causes  by  exciting  catarrhal  inflammation.  Injury  by  a  direct  blow  has 
occasionally  resulted  in  perforation  of  the  appendix,  and  when  adhesions 
exist,  severe  muscular  effort  may  injure  it  by  sharp  flexion  or  traction. 
Some  believe  that  rheumatism  may  cause  inflammation  of  the  appendix,  on 
account  of  the  large  amount  of  lymjihoid  tissue,  as  in  the  tonsil.  The 
ai^pendix  is  frequently  found  in  herniiB,  on  the  left  side  as  well  as  the  right, 
and  may  become  inflamed  in  this  situation. 

Varieties  of  Appendicitis. — There  are  several  clinical  varieties  of 
appendicitis:  Colic  of  the  appendix  is  characterized  by  sharp  attacks 
of  pain,  accompanied  by  vomiting,  prostration,  and  tenderness  in  the  region 
of  the  apj)endix.  Early  inspection  of  the  parts  has  shown  that  there  may 
be  no  inflammatory  change  in  the  tissues  of  the  organ.  These  attacks  are 
apparently  the  result  of  obstruction  due  to  adhesions  or  stricture. 

The  treatment  of  this  condition  in  a  first  attack  should  be  simply  pallia- 
tive. If  the  attacks  were  frequent,  however,  and  did  not  yield  to  medical 
treatment,  removal  of  the  appendix  would  be  advisable. 

Simple  Appendicitis. — The  mild  cases  of  appendicitis  present  the 
lesions  of  catarrhal  inflammation,  sometimes  with  extension  of  the  infec- 
tion into  the  deeper  ijarts  of  the  appendix  wall  but  without  suppuration  or 
gangrene,  and  sometimes  with  superficial  ulceration  of  the  mucous  mem- 
brane. Adhesions  may  form  externally  owing  to  peritoneal  irritation,  and 
a  palpable  mass  may  thus  be  produced,  but  the  tumor  is  not  of  large  size, 
being  made  up  only  of  omentum  or  intestine  adherent  to  the  appendix. 
These  lesions  may  all  disappear  by  resolution,  the  ulcers  healing  and  the 
adhesions  being  absorbed.  The  cure  is  frequently  incomplete,  for  strictures 
may  be  produced  internally  or  adhesions  may  persist  which  will  be  likely  to 
result  in  recurrent  attacks  later.  On  the  other  hand  the  lesions  may  extend . 
and  cause  suppuration,  gangrene,  or  perforating  ulcers  with  their  conse- 
quences as  described  below.  The  term  "  resolving  appendicitis "'  is  therefore 
not  quite  correct  as  applied  to  these  cases. 


SIMPLE  APPENDICITIS.  945 

Symjytoms. — This  form  usually  begins  with  a  sudden  sharp  pain  in  the 
abdomen,  generally  referred  to  the  right  iliac  fossa,  but  the  pain  may  begin 
gradually  with  slight  soreness  in  that  region.  There  is  abdominal  tender- 
ness and  distinct  muscular  rigidity,  generally  sharply  localized  to  the  same 
neighborhood,  and  a  tumor  may  be  felt  in  some  cases.  The  tumor  will  usu- 
ally be  small,  soft,  and  indistinct  in  its  outlines  unless  previous  attacks  have 
occurred  and  left  a  mass  of  adhesions.  There  may  be  vomiting,  fever,  even 
a  chill,  and  slight  leucocytosis  may  be  present.  The  presence  of  inflamma- 
tory symptoms  distinguish  the  attacks  from  aj)pendicular  colic,  and  their 
rapid  yielding  to  treatment  shows  that  the  appendicitis  is  not  of  the  severe 
type.  But  at  the  moment  of  the  onset,  and  until  the  symptoms  do  yield,  it 
is  impossible  to  say  that  the  inflammation  will  not  extend  beyond  the  appen- 
dix and  produce  a  local  abscess,  although  acute  perforation  and  general 
peritonitis  do  not  begin  in  this  gradual  way. 

Treatment. — It  has  been  shown  that  it  is  more  dangerous  to  remove  the 
inflamed  appendix  during  the  acute  attack  than  after  it  has  subsided  and 
the  infectious  material  has  somewhat  lost  its  virulence.  Every  effort  should 
therefore  be  made  to  secure  resolution.  The  patient  is  to  be  confined  to  bed 
in  the  dorsal  position  with  an  ice-bag  applied  over  the  aj^pendix.  i^o  solid 
food  is  to  be  given  and  only  a  limited  amount  of  fluids.  Some  advocate 
giving  nothing  wliatever  by  the  mouth  and  relying  upon  rectal  alimentation 
(Ochsner),  but  this  weakening  method  should  not  be  ijushed  to  an  extreme. 
Sufficient  codeine  should  be  given  to  enable  the  patient  to  endure  the  pain, 
but  not  enough  to  entirely  prevent  pain,  lest  the  symptoms  be  made  obscure. 
The  bowels  may  be  moved  by  glycerin  suppositories  or  small  enemata,  but 
no  laxatives  given  by  the  mouth,  and  the  use  of  the  bed-pan  must  be  insisted 
upon.  Some  counsel  giving  a  jsurge  at  the  beginning  of  the  attack,  and  this 
treatment  will  sometimes  abort  the  disease,  but  we  have  often  seen  abscesses 
and  even  fatal  perforation  as  a  direct  result  of  this  treatment,  and  consider 
it  too  dangerous. 

When  the  pain  and  tenderness  and  the  fever  have  subsided,  cautious 
attempts  to  return  to  a  normal  diet  may  be  allowed.  The  tenderness  may 
persist,  and  the  patient  should  be  kept  in  bed  until  it  disappears.  If  it 
lasts  long  after  the  other  symptoms,  removal  of  the  appendix  should  be 
undertaken.  In  any  case  after  one  sharp,  well-marked  attack  of  simple 
appendicitis  the  patient  should  be  advised  to  have  the  appendix  removed 
in  ten  days  after  recovery,  because  of  the  great  danger  of  recurrence.  If 
there  is  no  improvement  of  the  symptoms  within  a  few  hours  of  beginning 
treatment,  and  if  resolution  is  not  complete  within  two  or  three  days,  it 
should  be  considered  that  the  case  is  no  longer  simj)le  appendicitis,  and 
the  operation  is  to  be  undertaken.  The  signs  of  su^ipuration  are  described 
below,  and  their  appearance  indicates  that  immediate  surgical  interference 
is  necessary. 

Appendicitis  with  Abscess. — In  this  variety  an  ulcer  develops,  or  the 
appendix  wall  is  slowly  penetrated  bj^  bacteria,  and  supijurates  or  sloughs, 
leading  to  a  localized  peritonitis,  the  infection  occurring  so  slowly  that 
adhesions  have  time  to  form.  In  the  rare  cases  in  which  the  aijpendix  is 
extraperitoneal  or  adherent  to  the  parietal  peritoneum  and  perforation  takes 


946  SUPPURATIVE  APPENDICITIS. 

]3lace  at  that  point,  an  extraperitoneal  abscess  may  be  formed  and  tlie  peri- 
toneal cavity  may  escape.  Symptoms. — The  attack  may  begin  acutely  with 
pain  and  tenderness  and  vomiting  ;  or  it  may  begin  verj'  gradually,  with  a 
little  tenderness  in  the  iliac  region,  some  constipation,  or  diarrhoea  and  a 
general  feeling  of  malaise.  The  pain  increases,  vomiting  sets  in,  and  the 
temperature  rises,  occasionally  with  a  chill.  The  temj)erature  may  be  very 
high,  and  there  may  even  be  a  chill  in  cases  without  abscess,  or  there  may 
be  no  fever  when  suppuration  has  occurred.  Leucocytosis  is  generally 
present  in  these  cases,  but  it  is  sometimes  unaccountably  wanting.  It  is  as 
uncertain  a  symjDtom  of  supijuration  as  the  fevei',  unless  the  count  reaches 
20,000.  A  very  valuable  sign  is  the  rigidity  of  the  right  rectus  muscle 
as  compared  with  the  left,  as  it  is  seldom  found  in  other  conditions,  except 
in  peritonitis  about  the  gall-bladder.  In  some  cases,  even  without  gen- 
eral peritonitis,  the  entire  abdomen  is  rigid.  Sometimes  there  is  vesical 
tenesmus  or  retention,  or  j)ain  shooting  down  the  thigh.  The  right  thigh  is 
held  flexed  in  order  to  relieve  pressure,  and  there  may  be  retraction  of  the 
testicle.  Occasionally  a  tumor  can  be  found  at  the  first  examination,  and  its 
presence  is  an  encouraging  sign,  for  when  there  are  no  limiting  adhesions 
no  tumor  forms.  The  tumor  can  sometimes  be  made  more  evident  by  for- 
ward pressure  in  the  loin  by  the  hand,  and  occasionally  it  can  be  felt  in 
the  rectum  and  not  anteriorly,  but  rectal  evidence  is  exceptional  until  late. 
The  vomiting  may  be  very  slight  or  absent,  or  it  may  be  very  j)ersistent, 
obstinate  vomiting  being  a  sign  of  general  peritonitis  or  profound  sepsis. 
An  abscess  should  be  suspected  when  the  pain  continues  in  spite  of  moderate 
doses  of  morphine,  when  vomiting  and  fever  persist  or  return  after  a  tempo- 
rary cessation,  especially  when  a  distinct  tumor  can  be  felt.  The  temjjera- 
ture  is  an  uncertain  guide,  but  a  rapid  pulse  is  a  reliable  sign  of  suppura- 
tion. The  symptoms  may  increase  until  the  abscess  bursts  or  is  incised,  or 
they  may  siibside,  the  pus  becoming  encapsulated.  If  the  abscess, is 
neglected,  it  may  open  externally,  or  into  any  of  the  neighboring  organs 
(intestine,  bladder,  ureter,  uterus),  or  may  form  subphrenic  abscesses  and 
discharge  through  the  lung.  Most  commonly,  however,  general  peritonitis 
develops  by  the  sudden  giving  way  of  the  adhesions  surrounding  the  pus, 
or  by  a  more  gradual  spread  of  the  infection  to  the  neighboring  jieritoneum. 
In  these  conditions  pyremia  often  follows,  and  it  is  by  uo  means  necessary 
that  the  abscess  around  the  appendix  should  be  unusually  large  or  infectious 
to  produce  this  result,  as  we  have  seen  cases  in  which  the  secondary  abscesses 
were  the  first  indication  of  disease  noticed,  the  appendicitis  having  given  no 
recognizable  symptoms.  Eecovery  is  rare  in  these  neglected  cases,  espe- 
cially if  peritonitis  or  pyjemia  develops. 

Diagnosis. — Gastro-Enteritis. — The  localized  pain  and  tenderness  and  the 
great  prostration  of  appendicitis  would  be  absent.  The  symptoms  of  gastro- 
enteritis can  generally  be  brought  under  control  within  a  shorter  time.  The 
vomiting  is  apt  to  be  more  violent  in  the  gastric  attacks.  There  would  be 
no  leucocytosis.  Fecal  impaction  in  the  ctecum  is  said  to  resemble  appen- 
dicitis, but  it  would  appear  to  be  a  very  rare  condition  according  to  our 
modern  experience,  and  the  same  is  true  of  typhlitis.  In  gall-stone  colic  there 
will,  as  a  rule,  be  a  history  of  previous  similar  attacks,  of  jaundice,  or  of 


DIAGNOSIS   OF  APPENDICITIS.  947 

gall-stones  found  in  the  stools ;  the  i)aia  is  felt  to  shoot  backward  to  the 
right  shoulder,  and  the  collapse  from  the  pain  is  usually  greater.  There 
would  be  no  iliac  tenderness.  In  cholecydiUs  the  tumor  formed  by  the  gall- 
bladder is  rather  higher  up  than  the  mass  felt  in  appendicitis,  and  it  can 
usually  be  felt  as  a  tense  round  cyst,  unless  there  is  a  peritoneal  abscess 
around  it,  while  the  tumor  of  the  appendicular  abscess  is  more  irregular, 
rather  doughy,  and  less  distinct  in  outline.  Vomiting  is  usually  more 
marked  in  cholecystitis.  Benal  colic  may  sometimes  resemble  appendicitis, 
but  the  previous  history,  the  reduction  in  the  quantity  of  urine,  and  the 
pain  running  down  the  ureter  will  give  the  clue,  and  there  will  be  no  tumor 
in  the  ileo-cfecal  region.  A  tumor  of  a  kidney  which  was  low  down,  and 
j)articularly  a  floating  kidney  in  which  the'  ureter  had  become  twisted,  and 
some  cases  of  pyonephrosis,  might  give  rise  to  doubt,  but  a  thorough  exami- 
nation of  the  tumor  should  settle  the  diagnosis,  the  kidney  tumor  being 
higher  up  and  more  easily  reached  from  the  back,  and  generally  being 
movable  upward  towards  the  diaphragm.  Obscure  cases  of  typlioid  fever 
may  sometimes  be  confounded  with  appendicitis,  especially  as  pain  in  the 
ileo-caecal  region  is  a  common  symptom  in  the  early  stages,  but  the  pain  is 
less  acute,  and  the  presence  of  an  eruption  on  the  abdomen  and  the  charac- 
teristic temperature  record  should  prevent  confusion.  Biaphragmatic  pleu- 
risy, or  a  small  foci^s  of  pneumonia  at  the  base  of  the  right  lung  may  cause 
pain  in  the  right  side  of  the  abdomen  and  may  closely  simulate  beginning 
appendicitis  until  the  typical  local  signs  and  symptoms  develop  and  correct 
the  error.  Salpingitis  and  right  ovarian  abscess  may  simulate  aj)pendicitis, 
the  appendix  may  lie  in  the  pelvis  and  produce  an  abscess  there,  or  inflam- 
mation may  spread  from  it  to  the  tube  and  ovary  or  vice  versa.  It  may  be 
impossible  to  distinguish  between  these  conditions.  The  history  may  assist 
if  it  records  previous  symptoms  of  intestinal  or  of  genital  disease.  But 
operation  is  generally  required  in  any  case. 

Prognosis. — The  prognosis  depends  upon  the  variety  of  the  appendicitis. 
In  the  ordinary  form  it  has  been  estimated  that  out  of  seven  cases  severe 
enough  to  be  marked  by  the  presence  of  a  tumor,  five  will  resolve  under 
medical  treatment,  one  will  form  an  abscess  which  will  require  an  operation, 
and  one  will  have  a  general  pex-itonitis  and  die.  But  all  the  cases  of  abscess 
will  not  be  saved  by  this  late  operation,  so  that  the  mortality  would  be  even 
greater  than  one  case  in  seven,  and  the  prognosis  under  our  present  methods 
of  early  operation  is  much  better  than  this  estimate.  Ultimate  recovery  is 
not  always  obtained  in  those  cases  which  are  supposed  to  have  recovered 
under  medical  treatment,  as  fecal  fistulte  may  result  from  the  bursting  of  an 
abscess  externally  when  it  already  connects  with  the  bowel,  or  pytemia  may 
develop  from  abscesses  even  after  they  have  discharged  themselves  into  the 
bowel  or  externally,  and  in  many  cases  recurrence  takes  place. 

Treatment. — The  only  treatment  of  appendicitis  with  abscess  is  imme- 
diate operation.  The  pus  is  to  be  discharged  as  soon  as  its  presence  is 
certain,  for  there  is  constant  danger  that  the  abscess  may  burst  or  that  gen- 
eral septic  infection  may  take  place.  Pus  will  be  found  at  the  end  of  forty- 
eight  hours  in  the  majority  of  cases.  Delay  is  certain  to  result  in  more 
extensive  adhesions,  greater  damage  to  the  surrounding  parts,  and  loss  of 


948  TREATMENT  OF  SUPPURATIVE  APPENDICITIS. 

strength  to  the  patient.  The  best  incision  for  reaching  abscesses  in  ai^pen- 
dicitis  is  an  oblique  one  parallel  to  the  fibres  of  the  external  oblique 
aponeurosis,  placed  just  inside  of  the  anterior  superior  spine  of  the  ilium, 
or  above  Poupart's  ligament,  according  to  the  situation  of  the  tumor.  (Fig. 
751,  c.)  The  incision  should  be  made  where  the  tumor  is  most  j)rominent, 
and  yet  should  give  access  to  the  base  of  the  appendix.  When  the  abscess 
is  very  large  or  extends  back  in  the  loin,  a  counter-opening  here  may  be 
of  advantage  for  drainage,  the  anterior  incision  being  sutured  wholly  or 
in  part. 

Small  abscesses  can  be  successfully  treated  through  the  McBurney 
incision.  After  the  incision  has  been  made  the  wound  should  be  carefully 
deepened  until  the  iieritoneum  is  opened,  and  then  if  adhesions  are  found 
they  should  be  cautiously  separated  until  pus  is  reached.  If  the  general 
cavity  is  opened,  it  must  be  pj'otected  by  xaacking.     (See  page  915. ) 

If  possible,  the  appendix  should  be  removed,  as  it  may  cause  recurrence 
or  form  a  persistent  sinus  in  the  wound.  The  mesentery  of  the  apiDcndix  is 
transfixed  with  a  ligature  close  to  the  base  of  the  ajipendix  and  ligated  and 
divided.  The  aiiijendix  can  then  be  removed  by  invagination  of  the  stump 
as  described  below.  In  some  cases  this  procedure  may  be  impossible,  on 
account  of  the  adhesions  and  alteration  of  the  walls  of  the  appendix  and  the 
caecum,  or  great  haste  may  be  necessary  because  the  j)atient  is  in  collapse, 
and  the  aj)peudix  is  then  to  be  ligated  at  its  base  and  cut  away,  the  mucous 
membrane  of  the  stumj)  being  destroyed  by  the  thermo-cautery  or  pure 
carbolic  acid,  and  the  little  cavity  filled  with  iodoform  powder.  But  if  the 
patient's  condition  is  so  bad  that  it  is  dangerous  to  prolong  the  operation  by 
a  search  for  the  axjpendix,  or  if  the  removal  of  the  latter  necessitates  break- 
ing down  adhesions  and  opening  the  general  j)eritoneal  cavity  when  it  is 
well  shut  off,  it  is  safer  to  leave  it  and  simply  to  pack  the  wound. 

The  treatment  of  the  wound  is  the  same  as  for  all  intraperitoneal  abscesses. 
(See  page  914. )  The  cavity  of  the  abscess  is  to  be  cleansed  by  dry  sponging, 
irrigation  being  likely  to  spread  the  infection,  and  therefore  dangerous.  The 
packing  is  then  removed  carefully,  so  as  not  to  allow  prolapse  of  any  intestine, 
and  replaced  with  a  small  amount  of  gauze  for  drainage,  or  rubber  tubes  may 
be  inserted  beside  the  gauze.  If  the  wound  is  large,  it  should  be  partly  closed 
with  silkworm-gut  sutures.  In  the  after-treatment  the  gauze  drainage  is 
changed  every  two  or  three  days.  Peroxide  of  hydrogen  will  be  found 
useful  to  detach  adherent  gauze  and  for  irrigation  of  the  abscess  cavity.  If 
there  is  much  discharge,  a  drainage-tube  may  be  necessary  instead  of  gauze. 
The  bowels  should  be  moved  by  enema,  as  purgatives  by  the  mouth  are 
likely  to  open  the  wound  at  the  base  of  the  appendix.  Fluid  food  is  neces- 
sary until  the  bowels  move.  If  vomiting  is  troublesome,  the  stomach-tube 
should  be  emi^loyed.  The  wound  should  be  kept  rather  widely  open  by 
packing  until  the  deeper  jjarts  have  healed  ;  otherwise  a  troublesome  sinus 
is  apt  to  persist  for  months. 

A  fecal  fistula  may  form  in  the  wound  as  the  result  of  perforation  of  the 
intestinal  wall  by  the  suppurative  process,  making  the  cavity  of  the  bowel 
communicate  with  the  abscess.  Should  this  occur,  the  wound  must  be  widely 
opened,  thoroughly  cleaned,  and  packed  to  its  full  extent.     Healing  by 


VARIETIES   OF  APPENDICITIS.  949 

granulation  will  usually  take  place,  and  finally  the  fistula  will  be  obliterated. 
If  it  should  not,  an  operation  will  be  necessary,  but  it  should  be  post- 
poned for  several  months.  Hernia  is  very  common  after  operations  for 
appendicitis,  especially  in  cases  with  abscess  in  which  the  wound  has  been 
packed,  for  the  wide  scar  is  a  weak  one  and  easily  stretches.  After  every 
operation  for  aijpendicitis,  unless  performed  by  the  McBurney  method,  the 
patient  should  wear  an  abdominal  belt,  fitted  with  a  hard  rubber  plate 
secured  directly  over  the  scar,  for  at  least  a  year.  If  the  abdominal  wall 
shows  signs  of  weakness,  the  belt  should  be  continued,  or  the  old  scar  may 
be  excised  and  the  wound  sutui'ed  as  in  the  operation  for  veutral  hernia. 

Acute  Perforation  of  the  Appendix. — Perforation  results  from  ulcera- 
tion, gangrene,  or  over-distention  of  an  appendix  with  an  impassable  stric- 
ture. The  symptoms  are  generally  very  sudden  in  their  onset,  the  pain 
being  intense,  the  vomiting  persistent,  and  the  tenderness  great.  A  general 
peritonitis  usually  follows,  although  in  some  eases  the  acute  symptoms  may 
subside  and  a  localized  abscess  may  result.  Some  cases  of  perforation  also 
result  in  peritoneal  septicwnvia,  which  produces  death,  with  symptoms  of 
profound  toxic  poisoning,  such  as  vomiting,  diarrhoea,  and  prostration, 
ending  in  collapse,  without  much  pain  or  tenderness,  and  occasionally  with- 
out distention  or  rigidity  of  the  abdomen.  Symptoms. — The  first  symptom 
in  the  ordinary  cases  with  peritonitis  is  usually  pain,  often  with  great  col- 
lapse, and  the  vomiting  may  set  in  immediately  after  or  may  be  delayed. 
Abdominal  rigidity  and  tympanites  soon  develops.  The  pain  may  be  gen- 
eral over  the  abdomen  or  may  be  referred  at  first  to  the  region  of  the 
stomach  or  elsewhere  instead  of  to  the  iliac  region,  although  it  speedily 
becomes  localized  in  the  latter  place.  In  some  unusual  cases  it  remains 
constantly  upon  the  left  side  of  the  abdomen  or  high  up  in  the  epigastric 
region.  The  tenderness,  however,  is  usually  most  marked  from  the  first  in 
the  region  of  the  ajjpendix,  and  is  generally  most  acute  at  McBurney' s  point, 
which  is  situated  on  a  line  from  the  anterior  superior  spinous  i^rocess  of  the 
ilium  to  the  umbilicus,  two-thirds  of  the  distance  from  the  former,  a  point 
corresponding  fairly  well  with  the  usual  situation  of  the  base  of  the  appen- 
dix. The  leucocytosis  is  variable,  being  present  in  the  frank  suppurative 
cases,  but  often  absent  when  the  patient  is  in>  too  severe  collapse  or  too  septic 
to  react  to  the  bacterial  toxines.  The  ordinary  signs  of  peritonitis  are  observed 
in  these  cases,  and  unless  promptly  treated  death  is  almost  inevitable. 

These  cases  are  sometimes  diflicidt  to  recognize,  as  they  may  begin  with 
the  symjjtoms  of  an  ordinary  gastroenteritis,  but  general  peritonitis  may  be 
suspected  from  the  rapid  loss  of  strength,  the  sudden  development  of  shock, 
the  beginning  tympanites,  or  the  violent  vomiting.  No  tumor  is  found,  as 
a  rule,  and  pain  is  not  a  reliable  symptom  in  these  cases,  being  in  some 
instances  very  severe,  in  others  very  slight.  The  presence  of  severe  pain 
usually  indicates  a  better  prognosis,  for  pain  is  frequently  absent  in  cases  of 
peritoneal  septicaemia. 

Treatment. — If  an  operation  can  be  performed  early  some  of  these  cases 
can  be  saved.  A  median  incision  should  be  made  and  the  diagnosis  verified. 
It  may  be  necessary  to  add  an  incision  over  the  appendix  to  reach  that  organ, 
for  it  should  be  remo\'ed  in  every  case.     The  abdomen  should  be  thoroughly 

61 


950  VAEIETIES   OF  APPEJy'DICITIS. 

cleansed  and  drained  as  described  on  page  915.  In  some  cases  the  imme- 
diate shock  of  the  perforation  will  be  so  great  that  it  will  be  necessary  to 
postpone  operation  until  reaction  is  obtained  if  reaction  is  possible.  In 
thoroughly  septic  individuals  ojieration  is  useless. 

Chronic  Appendicitis. — This  occurs  in  several  varieties.  The  symp- 
toms may  begin  acutely  and  then  quiet  down  to  slight  tenderness  and  attacks 
of  pain,  and  perhaps  constipation,  with  or  without  a  tumor.  If  all  symptoms 
disappear  and  other  attacks  follow  after  a  completely  free  interval,  the  cases 
are  called  recurrent.  If  the  patient  is  never  entirely  well  and  has  numerous 
exacerbations,  the  case  is  known  as  relapsing  appendicitis.  In  both  varieties 
removal  of  the-  appendix  is  advisable  in  well-marked  cases.  The  lesions 
found  in  these  cases  are  various,  such  as  adhesions,  thickening  of  the  wall 
of  the  appendix,  empyema,  encapsulated  abscesses,  and  fecal  concretions. 

Treatment. — Eemoval  of  the  appendix  is  necessary  for  these  conditions. 
The  incision  is  best  made  by  the  McBurney  method,  through  the  fibres  of 
the  external  and  internal  oblique,  without  dividing  them.  (See  page  904.) 
Before  separating  the  adhesions,  gauze  or  sponges  should  be  packed  around 
the  inflammatory  mass  so  as  to  protect  the  free  xjeritoneal  cavity.  Adherent 
omentum  is  ligated  and  divided  and  the  appendix  isolated.  It  may  be  very 
difficult,  or  even  imj)ossible,  to  find  the  appendix,  and  in  some  cases  it  is 
absent,  having  been  destroyed  by  the  former  acute  inflammation  or  atrophied 
by  a  chronic  process.  We  have  found  the  appendix  entirely  detached  from 
the  cffiGum,  with  no  trace  of  its  base,  but  distended  with  pus.  The  wound 
can  be  enlarged  if  necessary  by  dividing  the  internal  oblique  fibres. 


4- 


iyniej^i?*- 


A,  iuversion  of  stump  of  appendix,  suture  ready  to  tie  ;  B,  surface  of  Ciecum  after  tying  suture. 

A  ligature  is  passed  through  the  mesentery  of  the  appendix  and  tied, 
and  that  membrane  divided.  A  fine  silk  purse-string  Lembert  suture  is 
applied  around  the  base  of  the  appendix  but  not  tied.  A  clamp  with  jaws 
over  a  quarter  of  an  inch  wide  is  applied  to  the  base  of  the  appendix  so  as  to 


INTESTINAL  OBSTRUCTION.  951 

criisli  it.  Two  fine  catgut  ligatures  are  then  applied  at  each  border  of  the 
deep  groove  thus  made,  and  the  appendix  divided  between  them  and  removed. 
The  stumj)  is  then  invaginated  by  pushing  it  into  the  caecum  with  some 
blunt  instrument  and  the  purse-string  suture  is  tied.  (Fig.  771.)  A  second 
purse-string  suture  can  be  applied  for  greater  security.  Some  sui-geons 
prefer  to  cut  the  appendix  across,  closing  the  distal  end  with  a  clamp  or 
ligature,  and  compressing  the  proximal  end  with  the  fingers,  and  then  to 
invaginate  the  stump  into  the  CEecum  and  secure  the  whole  with  a  purse-string 
Lembert  suture.  The  latter  method  is  difficult  when  the  tissues  are  thickened, 
and  there  is  a  liability  to  the  escape  of  fecal  contents.  In  some  cases  neither 
procedure  may  be  possible,  and  the  appendix  is  then  to  be  ligated  and  cut 
away.  Even  by  this  incomplete  method  primary  union  of  the  wound  may 
be  obtained.  When  the  appendix  has  been  removed,  any  gianulating  sur- 
face should  be  curetted,  and  the  wound  may  be  closed  without  drainage  if  it 
is  possible  to  remove  all  the  infected  tissue  ;  otherwise  a  small  drain  should 
be  inserted.  The  wound  is  closed  with  buried  sutures  of  chromicized  catgut 
or  with  through  and  through  sutuies  of  silkworm-gut.  The  after-treatment 
is  that  usual  in  laparotomy. 

INTESTINAL   OBSTRUCTION. 

In  the  condition  known  as  intestinal  obstruction  there  may  be  simply 
a  mechanical  occlusion  of  the  lumen  of  the  bowel,  or  the  occlusion  may 
be  accompanied  by  strangulation  of  the  gut,  and  in  some  cases  there  may 
be  strangulation  without  occlusion,  as  when  the  ctecum  or  the  appendix  is 
strangulated.  Intestinal  obstruction  may  be  compared  to  ordinary  hernia, 
which  may  be  obstructed  or  strangulated,  or  both. 

Varieties. — Clinically,  we  divide  the  cases  of  intestinal  obstruction  into 
acute,  subacute,  and  chronic,  and  in  the  subacute  and  chronic  varieties  we 
recognize  a  complete  and  an  incomplete  obstruction,  for  in  some  cases  a 
small  amount  of  material  is  able  to  pass  by  the  seat  of  obstruction.  Intes- 
tinal obstruction  is  the  result  of  various  conditions  : 

(1)  Paralysis. — Paralysis  of  the  bowel  maybe  caused  by  peritonitis,  by 
compression  in  a  strangulated  hernia,  or  by  a  severe  blow.  It  may  be 
general  or  limited  to  a  small  loop  of  the  bowel,  and  in  the  latter  case  the 
obstruction  may  not  be  complete,  for  the  contents  of  the  intestine  may  be 
pushed  through  the  paralyzed  loop  by  the  active  bowel  above.  Some  cases 
of  inflammation  of  the  bowel  wall  appear  to  be  accompanied  by  paralysis 
and  serious  interference  with  the  fecal  movement. 

(2)  Fecal  Impaction. — If  the  contents  of  the  bowel  are  allowed  to 
accumulate,  a  hard  mass  is  formed  which  is  very  difficult  to  break  up. 
These  collections  are  most  frequently  found  in  the  rectum,  but  also  occur 
in  the  sigmoid  flexure  and  the  csecum.  In  extreme  instances  the  entire 
large  intestine  may  be  distended  with  fteces,  and  the  patient  has  been  known 
to  go  without  a  movement  of  the  bowels  for  several  weeks. 

(3)  Foreign  Bodies  and  Gall-Stones. — A  foreign  body  may  be  swal- 
lowed, or  a  large  gall-stone  may  perforate  the  gall-bladder  or  ducts  when 
adherent  to  the  bowel,  and  enter  the  latter.  Gall-stones  are  said  to  ijerforate 
the  large  intestine  most  frequently,  but  they  also  enter  the  small  intestine, 


952 


INTESTINAL  OBSTRUCTION. 


particularly  the  duodenum,  and  may  cause  obstruction.  Over  one  hundred 
operations  in  cases  of  obstruction  due  to  gall-stones  are  on  record.  A  gall- 
stone may  become  impacted  in  any  part  of  the  small  intestine,  but  most 
frequently  at  its  narrowest  portion,  the  ileo-csecal  valve.  Gall-stones  some- 
times accumulate  layers  of  fecal  matter  as  they  lie  in  the  bowel,  and  thus 
constitute  the  larger  number  of  enteroliths,  although  the  latter  have  been 
known  to  form  about  various  foreign  substances.  Enteroliths  may  attain 
such  a  large  size  as  to  distend  the  bowel.  Obstruction  has  also  been  caused 
in  children  by  masses  of  round  worms.  Foreign  bodies  in  the  intestine  may 
perforate  its  wall  and  cause  a  general  peritonitis  or  an  abscess,  and  recovery 
has  followed  the  removal  of  foreign  bodies,  such  as  a  foi'k  or  spoon,  from 
such  abscesses. 

(4)  Stricture. — This  consists  in  a  reduction  of  the  lumen  of  the  bowel 
by  various  causes.  There  may  be  a  congenital  narrowing  at  some  part  of 
the  bowel  where  the  junction  of  the  diiferent  loops  takes  place  in  foetal 
life.  The  stricture  may  be  cicatricial,  owing  to  the  healing  of  some  ulcer 
or  inflammatoiy  process.  The  narrowing  may  be  due  also  to  tumors  out- 
side of  the  bowel  pressing  upon  it  or  growing  into  its  lumen.  Among 
causes  of  stricture  we  include  hsematoceles  formed  in  the  wall  of  the  bowel 
beneath  the  mucous  membrane,  inflammatorj^  thickening  of  the  bowel  wall, 
and  external  hsematoceles  or  abscesses. 

(5)  Bands. — Obstruction  may  be  caused  by  bands  of  organized  lymph 
formed  in  peritonitis^  which  pass  across  the  abdomen  from  one  organ  to 

another  or  to  the  abdominal  wall.  A  loop  of 
bowel  may  be  caught  under  such  a  band  or  sur- 
rounded by  it,  and  either  simple  occlusion  or 
strangulation  may  result.     (Fig.  772.) 

(6)  Adhesions. — Adhesions  may  form  be- 
tween the  bowel  and  the  abdominal  wall  or  some 
of  the  viscera,  which  may  directly  compress  the 
bowel  or  hold  it  in  a  bent  position,  or  simply 
bind  it  down  so  as  to  impede  the  peristaltic 
movements.  We  have  seen  a  flexion  produced 
by  an  adhesion  to  inflamed  tuberculous  mesen- 
teric glands. 

(7)  Diverticula. — Intestinal  diverticula  are 
not  infrequent,  especially  Meckel's  diverticulum 
in  the  ileum,  being  the  result  of  incomplete  foetal 
changes,  and  they  may  interfere  with  the  move- 
ments of  the  bowel  as  do  the  peritoneal  bands, 
by  forming  adhesions  and  dragging  on  the  bowel 
or  binding  it  down,  or  even  surrounding  it  like 
a  cord.  The  appendix  vermiformis  may  act  in 
a  similar  fashion. 

(8)  Apertures. — There  may  be  internal  her- 
nia or  strangulation  through  a  natural  aperture 

in  the  peritoneum,  such  as  the  foramen  of  Winslow,  or  through  artificial 
openings  made  by  atrophj^  of  the  mesentery,  for  the  latter  process  may 


Fig.  772. 


Constriction  of  a  loop  of  gut  by  a 
band.    (Agnew.) 


INTUSSUSCEPTION. 


953 


produce  openings  an  inch  or  more  in  diameter.     Strangulation  may  also 
take  place  thi-ough  abnormal  openings  formed  by  adhesions  or  bands. 

(9)  Volvulus. — Volvulus  is  a  twisting  of  any  part  of  the  bowel  which 
has  a  long  mesentery,  either  the  small  intestine  or  the  sigmoid  flexure,  a 
loop  being  given  a  quarter  or  half  turn,  or  even  a  complete  rotation  on  its 
axis.  The  twisted  loop  is  free  at  its  centre,  but  its  ends  are  closed  by  the 
rotation,  and  its  blood-supply  may  be  shut  off  by  the  twist  in  the  mesen- 
tery so  that  gangrene  results.  Volvulus  occurs  four  times  as  often  in  males 
as  in  females,  and  appears  to  be  more  common  in  certain  races,  notably 
the  Eussians,  in  whom  the  sigmoid  flexure  probably  has  an  unusually  long 
mesocolon. 

(10)  Intussusception. — In  intussusception  a  portion  of  the  bowel 
becomes  invaginated,  or  "telescoped,"  into  that  immediately  below  it, 
like  the  inverted  finger  of  a  glove.  Intussusception  occurs  in  both  the 
large  and  the  small  intestine,  but  is  most  frequent  at  the  ileo-caecal  valve. 
In  some  cases  a  polypus  hanging  in  the  bowel  may  drag  the  wall  of  the 
latter  inward  during  i^eristaltic  action,  but  in  the  majority  of  cases  intussus- 
ception is  due  to  an  irregular  peristaltic  movement.  Invagination  of  the 
bowel  can  be  produced  in  animals  by  applying  an  electrode  to  the  bowel, 
the  part  where  the  current  is  strongest  becoming  firmly  contracted,  and  the 
neighboring  part  can  be  seen  to  creep  up  over  it,  as  it  were,  by  peristaltic 
action,  indicating  that  the  active  part  of  the  process  is  taken  by  the  outer 
layer  rather  than  by  the  inner.  In  such  an  invaginated  loop  there  are 
three  layers,  the  innermost  layer  being  contracted  intestine,  the  middle  layer 
being  turned  inside  out  over  the  former,  and  the  two  together  forming  the 
invaginated  part  or  intnssusceptum.      (Fig.   773.)      The  intussusceptum  is 


Frozen  section  of  intussusception  of  the  dying  (diagrammatic)  :  *'.S,  sheath  ;  Icm,  intussusceptum  ; 
.1,  apex,  MM,  mesentery,  and  N,  neck  of  intussusceptum. 

contained  in  a  third  layer,  which  retains  its  natural  position  but  is  dis- 
tended by  the  invaginated  gut  and  its  mesentery.  This  outermost  layer  is 
called  the  intussuscipiens,  or  sheath.  Intussusception  is  frequently  found 
after  death  in  children  who  have  died  of  nervous  or  intestinal  diseases.  This 
form  is  called  intussmception  of  the  dying,  and  the  invagination  is  li'equently 
directed  upward  against  the  normal  peristaltic  movement,  whereas  in  life 
we  find  the  apex  of  the  intussusception  almost  invariably  directed  towards 
the  anus.  The  intussusception  may  be  only  an  inch  or  so  in  length,  or  it 
may  involve  the  entire  lai-ge  intestine  and  most  of  the  small,  and  the  ileo- 
C£ecal  valve  may  protrude  from  the  anus. 


954 


INTUSSUSCEPTION. 


lu  the  ileo-cJBcal  region  there  are  two  varieties  of  intussusception, — the 
ileo-csecal  and  the  ileo-colic.  If  the  valve  remains  intact  and  is  pushed 
forward  into  the  colon  at  the  head  of  the  intussusception,  we  have  the  ileo- 
ccecal  form.  The  ctecum  may  be  inverted  with  the  valve  (Fig.  774,  2),  or 
the  inversion  may  begin  with  the  junction  of  the  colon  and  the  caecum,  the 

Fig.  774. 


Varieties  of  intussusception :  1,  ileo-colic  ;  2,  ileo-caecal,  ordinary  form ;  3,  ileo-csecal,  rare  form.    /,  ileum, 
AC,  ascending  colon ;  vv,  ileo-csecal  valve ;  C,  caecum  (inverted  in  Fig.  2) ;  VA,  vermiform  appendix. 

caecum  and  the  ileum  then  advancing  together  without  inversion  and  form- 
ing the  intussusceptum  as  they  lie  side  by  side  (Fig.  774,  s).  This  last 
variety  is  very  rare.  In  the  ileo-colic  form  the  valve  remains  in  place,  but 
opens,  and  the  lower  part  of  the  ileum  is  inverted  through  it  into  the  colon 
(Fig.  774,  i).  The  ileo-csecal  form  is  the  most  common  of  all.  S'ext  in  fre- 
quency comes  intussusception  of  the  small  intestine,  then  that  of  the  large 
intestine,  and  finally  the  ileo-colic.  Over  one-half  of  the  cases  of  intussus- 
ception occur  in  children  under  eleven  years  of  age,  and  three-quarters  of 
these  cases  are  of  the  ileo-csecal  variety.  In  rare  instances  there  are  more 
than  three  layers  of  the  bowel,  a  second  intussusception  forming  outside  of 
the  first,  so  that  there  may  be  as  many  as  six  layers  instead  of  three. 

The  first  change  that  occurs  in  a  case  of  intussusception  is  interference 
with  the  circulation  of  the  intussusceptum,  its  blood-vessels  being  strangu- 
lated at  the  neck  of  the  tumor.  (Edema  and  swelling  take  place,  which  still 
further  obstruct  the  lumen  of  the  bowel.  Adhesions  form  between  the 
opposed  serous  sui-faces,  and  ulceration  occurs  on  the  mucous  surface. 
Eeduction  of  the  intussusception  can  take  place  only  in  the  earliest  stages, 
because  even  twelve  hours  after  the  beginning  of  the  attack  the  adhesions 
and  swelling  may  prevent  it.  If  the  strangulation  is  long  continued,  the 
intussusceptum  will  die  and  slough  away.  If  the  slough  does  not  separate 
until  the  adhesions  around  the  neck  are  strong,  no  peritonitis  is  set  up,  and 
the  slough  passes  off  by  the  bowel,  the  lumen  of  the  canal  being  thus  restored. 
This  happy  termination,  however,  is  rare,  for  the  adhesions  are  seldom 
so  complete  as  to  prevent  peritonitis  when  the  slough  separates,  and  the 
swollen  intussusceptum  may  cause  perforation  of  the  wall  of  the  sheath  and 


INTESTINAL  OBSTRUCTION.  955 

result  in  peritonitis.  If  the  slougli  separates  safely,  the  cure  may  not  be 
complete,  for  a  cicatricial  stricture  may  form  at  the  neck  of  the  invagination 
and  cause  chronic  obstruction.  In  some  cases  the  strangulation  is  not  severe 
enough  to  cause  sloughing,  but  the  adhesions  prevent  reduction,  and  the 
fecal  movement  is  restored  by  a  canal  which  opens  through  the  centre  of 
the  intussusception  by  partial  sloughing  or  ulceration,  and  the  condition  of 
chronic  intussxi,sception  is  produced,  which  may  last  for  months  or  years,  but 
is  usually  fatal  in  the  end. 

Symptoms. — In  acute  intestinal  obstruction  with  strangulation  the  patient 
is  suddenly  taken  with  pain  in  the  abdomen  and  vomiting,  and  falls  into 
a  condition  of  collapse.  The  onset  is  abrupt,  the  pain  severe,  the  con- 
stipation absolute.  The  vomiting  becomes  more  and  more  violent,  the  con- 
tents of  the  stomach  first  being  voided,  then  bile,  and  finally  fecal  matter 
from  the  upper  intestine  rejected  by  antiperistalsis.  The  pulse  is  imper- 
ceptible, there  is  cold  perspiration,  and  the  patient  is  very  restless.  The 
pain  may  be  slight  or  very  severe,  and  it  is  generally  localized  at  the  seat 
of  the  obstruction.  There  is  no  movement  from  the  bowels,  not  even  gas 
being  j)assed.  There  may  be  retention  of  urine,  but  more  frequently  the 
secretion  is  suppressed. 

In  the  subacute  form  the  symptoms  come  on  more  slowly,  but  in  a  few 
hours  reach  the  same  intensity.  The  vomiting  may  be  very  violent  or  may 
amount  only  to  regurgitation,  the  latter  being  the  rule  in  cases  of  chronic 
obstruction.  It  will  be  the  first  symptom  when  strangulation  is  present, 
and  will  begin  late  when  there  is  a  simple  mechanical  obstruction  to  the 
lumen  of  the  bowel,  especially  if  the  obstruction  is  low  down.  It  is  not 
usually  accompanied  by  nausea.  Pain  is  an  unimportant  sign,  although 
colicky  pain  is  generally  present  in  acute  strangulation.  The  pain  may  be 
situated  anywhere  in  the  abdomen,  but  occasionally  there  is  localized  ten- 
derness at  the  ijoint  of  obstruction.  Tympanites,  by  which  we  understand 
distention  of  the  abdomen  with  tympanitic  resonance,  is  the  most  constant 
of  the  local  signs.  The  distention  is  due  to  paralysis  of  the  bowel  and  the 
decomposition  of  the  fluids  contained  in  it.  It  has  been  shown  that  this 
paralysis  first  becomes  evident  and  is  most  marked  in  the  strangulated  loop, 
so  that  by  an  early  examination  a  tumor  formed  by  the  distended  looj)  of 
intestine  may  be  felt  and  the  exact  situation  of  the  obstruction  can  be  deter- 
mined, especially  in  volvulus  or  in  strangulation  by  bands.  Eectal  move- 
ments and  even  the  passage  of  gas  are  suspended,  but  in  intussusception 
there  is  a  discharge  of  mucus  and  blood  from  the  rectum,  with  tenesmus. 

The  temperature  in  intestinal  obstruction  is  low,  and  may  be  subnormal. 
Auscultation  gives  little  clue  to  the  seat  of  the  obstruction,  but  in  some 
cases  the  peristaltic  wave  can  be  heard  moving  towards  the  obstruction, 
becoming  louder  as  it  approaches  that  point  and  then  ceasing.  The  peri- 
staltic movements  may  be  seen  through  the  abdominal  wall,  especially  in 
cases  of  chronic  obstruction  with  great  hypertrophy  and  distention  of  the 
bowel.  They  can  occasionally  be  stimulated  by  laying  a  cold  hand  upon  the 
skin  or  slapping  it  with  a  wet  towel.  A  tumor  is  present  in  some  cases, 
.  generally  being  formed  by  a  strangulated  loop,  a  volvulus,  or  an  intussus- 
ception. 


956  DIAGNOSIS  OF  INTESTINAL  OBSTRUCTION. 

In  the  chronic  form  of  obstruction  the  passages  may  gradually  diminish 
in  size  and  frequency,  or  constipation  may  exist  for  some  weeks  or  months 
beforehand,  so  that  the  bowel  becomes  accustomed  to  the  obstruction.  The 
movements  may  be  of  very  small  diameter.  Constipation  and  diarrhoea  are 
apt  to  alternate.  The  general  condition  of  the  patient  in  these  cases  does 
not  suffer  at  first,  and  complete  obstruction,  without  even  the  passage  of 
gas,  has  been  known  to  exist  for  ten  days  or  a  fortnight  and  yet  be  followed 
by  recovery. 

Diagnosis. — It  is,  in  the  first  place,  essential  to  determine  whether 
strangulation  is  j)resent,  the  symptoms  of  this  condition  being  the  acute  pain 
and  the  uncontrollable  vomiting,  which  rapidly  becomes  fecal.  If  there  are 
symptoms  of  strangulation,  all  the  hernial  aj)ertures  must  be  examined,  in 
order  to  exclude  the  presence  of  strangulated  hernia.  Eectal  examination 
should  not  be  omitted  in  any  case.  Acute  peritonitis  caused  by  perforation 
sometimes  resembles  intestinal  obstruction,  but  may  be  recognized  by  the 
more  intense,  general  and  steady  pain,  the  great  abdominal  tenderness,  and 
the  rise  of  temperature  and  leucocytosis  following  the  acute  collapse.  Peri- 
tonitis not  infrequently  develops  also  in  intestinal  obstruction.  Appendicitis 
with  ijerforation  is  often  the  cause  of  intestinal  obstruction,  either  from  the 
inflammatory  paralysis  of  the  bowel  or  from  the  mechanical  effect  of  adhe- 
sions about  the  appendix,  but  the  local  symptoms  usually  overshadow  those 
of  obstruction.  Thrombosis  of  the  mesenteric  veins  and  acute  inflammation 
of  the  i^ancreas  may  also  resemble  obstruction. 

The  diagnosis  of  tlie  various  kinds  of  obstruction  must  be  made  from  the 
clinical  history  together  with  the  local  examination.  Thus,  acute  obstruc- 
tion is  most  frequently  the  result  of  intussusception,  then  of  strangulation 
by  bands  or  through  apertures,  of  volvulus,  or  impacted  foreign  bodies,  and 
rarely  of  stricture  or  paralysis.  It  should  be  noted,  however,  that  acute 
obstruction  may  suddenly  develop)  upon  a  chronic  condition,  and  a  malig- 
nant stricture  of  the  large  intestine  has  been  known  to  exist  without  symp- 
toms until  it  grew  so  small  as  to  be  blocked  by  an  apple-seed,  causing  acute 
obstruction  with  a  fatal  result.  Subacute  obstruction  is  most  frequently 
seen  as  the  result  of  foreign  bodies,  of  strictures,  of  adhesions,  and  of 
strangulation  by  bands  or  through  apertures.  Chronic  obstruction  is  most 
commonly  found  in  jjaralysis  of  the  intestine,  fecal  impaction,  stricture,  or 
adhesions.  Chronic  intussusception  is  uncommon.  Earely  we  find  chronic 
obstruction  due  to  foreign  bodies  or  incarceration  by  bands  or  through 
apertures. 

Strangulation  by  bands,  apertures,  and  diverticula  is  most  commonly 
found  in  adults,  and  with  a  history  of  preceding  peritonitis,  abdominal 
injury,  or  hernia.  The  vomiting  begins  early,  and  soon  becomes  fecal,  the 
constipation  is  absolute,  but  tympanites  does  not  become  well  marked  for 
three  or  four  days,  there  is  no  tenderness  nor  rectal  tenesmus,  and  there  may 
be  no  tumor.     The  prostration,  however,  may  be  extreme. 

In  volvulus  of  the  sigmoid  flexure  the  patient  is  generally  a  male  past 
middle  age,  with  a  history  of  constipation.  The  vomiting  is  not  marked, 
and  is  seldom  fecal.  Tympanites  begins  at  first  in  the  occluded  loop,  and 
may  be  limited  to  that  throughout,  as  has  been  shown  by  Von  Wahl,  but  it 


DIAGNOSIS   OF  INTESTINAL   OBSTRUCTION.  957 

must  be  i-emembered  that  a  distended  sigmoid  flexure  may  be  so  large  in 
these  cases  as  to  fill  the  entire  abdomen,  so  that  no  limited  tumor  can  be 
distinguished.  As  a  rule,  however,  a  tumor  is  felt  between  the  navel  and 
the  iliac  spine  or  Poupart's  ligament.  There  may  be  tenderness  in  the  left 
iliac  region  and  some  rectal  tenesmus.  Volvulus  of  the  small  intestine 
usually  caufses  more  acute  symptoms. 

Acute  Intussusception. — Acute  intussusception  occurs  in  children 
under  ten  years  of  age  in  one-half  the  cases,  and  the  majority  of  these  chil- 
dren are  under  three  years  old.  There  is  often  a  history  of  colic  or  of  the 
administration  of  purgatives.  Vomiting  is  usually  present,  becoming  fecal 
early.  Constipation  is  present  at  first,  or  diarrhoea,  but  they  soon  give 
place  to  small  frequent  passages  of  ihucus  and  blood  without  freces,  and  there 
is  tenesmus.  Tymijanites  is  rare  at  first.  The  intussusception  can  be  felt 
in  the  abdomen  as  a  sausage-like  mass,  which  is  more  or  less  fixed  when 
situated  in  the  large  intestine,  but  is  movable  when  in  the  small.  The 
tumor  will  generally  be  felt  in  the  iliac  regions  or  on  the  right  side  higher 
up.  Its  apex  can  frequently  be  reached  by  the  finger  in  the  rectum,  and 
occasionally  it  protrudes  from  the  anus. 

In  cases  of  obstruction  by  a  true  foreign  body,  the  history  will  give  a 
clue  to  the  cause.  In  gall-stone  impaction  there  will  be  an  account  of 
frequent  attacks  of  gall-stone  colic  (although  in  rare  cases  this  may  be 
absent),  and  of  an  attack  of  local  peritonitis,  marking  the  time  at  which  the 
gall-stones  entered  the  intestine.  In  some  instances  the  gall-stone  will  be 
large  enough  to  be  felt  through  the  abdominal  wall.  The  symptoms  are  of 
the  subacute  type,  and  fecal  vomiting  occurs  late.  Gas  is  frequently  passed 
Ijer  anum,  and  sometimes  the  symptoms  are  intermittent. 

Chronic  Obstruction. — Fecal  impaction  is  the  most  common  cause 
of  chronic  obstruction  in  women,  especially  when  hysteria  or  insanity  is 
present.  Constipation  and  stomach  disturbance  shall  have  preceded  the 
attack,  and  the  symptoms  develop  gradually,  although  they  may  finally 
become  as  intense  as  in  the  acute  varieties.  The  distended  bowel  may  be 
felt  distinctly,  being  doughy,  dull  on  percussion,  and  not  tender,  and  the 
mass  takes  the  impression  of  the  fingers  when  pressed  firmly  irpon  it. 

Adhesions. — Stricture. — Adhesions  and  stricture  present  chi'onic 
symptoms,  which  develops  slowly,  but  progress  steadily  to  complete  obstruc- 
tion, with  fecal  vomiting.  In  these  cases  the  abdominal  distention  is  apt  to 
be  extreme  and  fecal  vomiting  is  a  late  symptom. 

Cicatricial  Stricture. — Cicatricial  stricture  is  usually  preceded  by  some 
intestinal  inflammation,  siach  as  syphilitic  ulcers  or  dysentery.  In  stricture 
due  to  a  malignant  tumor  there  is  slowly  inci-easing  constipation,  occurring 
in  a  patient  over  middle  age,  with  gradually  increasing  attacks  of  obstruc- 
tion lasting  a  few  days  at  a  time,  with  vomiting  and  pain.  There  may  be 
alternating  diarrhoea  and  constipation.  There  is  gradual  loss  of  flesh  and 
strength,  and  the  skin  acquires  a  dull  yellowish  color.  A  tumor  may  be 
detected  in  the  malignant  cases,  and  it  is  generally  small  and  rather  uneven 
on  its  surface,  and  occasionally  tender.  Blood  and  pus  may  be  found  in  the 
movements.  The  stricture  is  often  so  low  down  as  to  be  reached  by  the 
finger  in  the  rectum. 


958  TREATMENT  OF  INTESTINAL   OBSTEUCTION. 

Chronic  Intussusception. — Chronic  intussusception  usually  has  an 
acute  beginning,  and  a  tumor  of  considerable  size  is  generally  felt  in  the 
rectum,  in  the  neighborhood  of  the  transverse  colon,  or  occasionally  in  the 
sigmoid  flexure. 

Prognosis. — The  outcome  of  intestinal  obstruction  depends  chiefly  upon 
the  existence  of  strangulation.  When  there  is  no  strangulation  the  result 
varies  in  the  different  conditions  causing  the  obstruction,  as  already  described, 
but  the  prognosis  is  in  most  cases  better  than  when  strangulation  is  present, 
spontaneous  recovery  being  almost  unknown  in  the  latter  condition.  If  the 
intestinal  strangulation  is  not  relieved,  peritonitis  is  caused  by  perforation 
of  the  affected  bowel,  or  the  penetration  of  its  wall  by  bacteria,  its  blood- 
supply  being  imj)aired  or  entirely  shut  off.  The  peritonitis  may  be  general, 
or  localized  by  adhesions.  If  adhesions  form  about  the  involved  intestine, 
ulceration  or  sloughing  may  result  in  the  formation  of  an  abscess  and  an 
external  fecal  fistula,  or  in  a  natural  anastomosis  between  the  bowel  above 
and  below  the  point  of  obstruction,  recovery  by  these  means  being  pos- 
sible, but  very  rare.  Death  may  be  caused  by  peritonitis  ;  by  exhaustion 
from  the  pain,  vomiting  and  inanition  ;  by  toxic  poisoning  from  the  decom- 
posing intestinal  contents ;  or  by  pneumonia  set  up  by  aspiration  of  the 
vomited  material.     It  may  occur  within  two  days  or  after  several  weeks. 

Treatment. — In  the  acute  form  of  intestinal  obstruction  the  cause  must 
be  removed  at  once  by  mechanical  means,  usually  by  an  oijeration.  Medical 
treatment  is  useless.  In  the  subacute  form  medical  treatment  may  be  given 
a  short  trial,  but  if  not  immediately  successful  surgical  measures  must  be 
adopted,  as  the  only  chance  lies  in  the  early  i^erformance  of  an  oiDcration, 
and  even  a  short  delay  may  be  fatal.  Gibson  found  the  mortalitj'  of  cases 
operated  upon  within  one  day  thirty-five  per  cent. ;  two  days,  thirty-eight 
per  cent. ;  and  three  days,  forty-seven  per  cent.  In  the  chronic  form,  medi- 
cal measures  often  suflice  to  keep  the  j)atient  tolerably  comfortable,  but  an 
operation  is  generally  desirable. 

Medical  treatment  should  consist  in  the  use  of  enemata ;  strong  pur- 
gatives given  by  the  mouth  should  be  especially  avoided,  except  in  chronic 
obstruction,  as  they  only  excite  unusual  peristalsis,  which  increases  the 
vomiting  and  the  distress  of  the  patient.  For  an  enema,  spirit  of  turpen- 
tine, sulphate  of  magnesium  in  large  doses,  infusion  of  the  leaves  of  senna, 
and  castor  oil  may  be  employed,  given  through  a  tube  passed  as  high  up  in 
the  bowel  as  possible  and  with  as  large  a  quantity  of  water  as  the  patient 
will  bear.     It  should  be  given  under  a  pressure  of  from  three  to  five  feet. 

Vomiting  is  frequently  relieved  by  washing  the  stomach,  and  this 
may  sometimes  be  followed  by  throwing  small  quantities  of  peptonized  milk 
or  stimulants  into  the  stomach  thi-ough  the  tube.  No  solid  food  should  be 
given,  and  only  small  quantities  of  fluids  by  the  mouth,  as  the  power  of  ab- 
sorption is  very  limited,  and  attempts  at  feeding  only  increase  the  vomiting. 

In  intussusception  an  attempt  at  reduction  by  rectal  injections  of  air 
or  fluid  is  first  to  be  made.  Water  is  to  be  preferred  for  injection,  because 
it  is  more  easily  controlled,  and  the  pressure  must  not  be  great,  because  the 
softened  wall  of  the  bowel  may  give  way.  Experience  has  shown  that  the 
pressure  of  a  column  of  water  three  feet  in  height  is  sufficient  to  reduce  the 


TREATMENT  OF  INTESTINAL  OBSTRUCTION.  959 

majority  of  reducible  intussusceptions,  and  five  feet  certainly  should  not  be 
exceeded,  as  that  pressure  has  been  known  to  produce  rupture  of  the  intes- 
tine in  experiments.  The  injection  is  given  by  inserting  the  tube,  around 
which  a  bandage  has  been  wrapped  so  as  to  make  a  plug  for  the  anus,  and 
connecting  it  with  the  bag  of  a  fountain  syringe  held  a  measured  distance 
above  the  patient  as  he  lies  in  Sims's  position  or  in  the  knee-chest  position. 
If  this  attempt  is  not  successful  after  a  thorough  trial  of  half  an  hour  with 
the  aid  of  anaesthesia,  laparotomy  for  reduction  of  the  intussusception  by 
the  fingers  becomes  necessary.  Great  care  must  be  taken  not  to  rupture 
the  bowel  wall  in  the  mauipulations.  The  only  hope  of  success  in  these 
operations  lies  in  their  early  performance, — in  less  than  twenty-four  hours 
after  the  beginning  of  the  symptoms.  If  strong  adhesions  prevent  reduc- 
tion, the  intussusception  may  be  cut  away  and  the  ends  of  the  bowel  united 
by  a  Murphy's  button  or  secured  in  the  abdominal  wound,  but  up  to  the 
present  time  no  recoveries  have  followed  resection  of  the  gut  in  chiklren, 
and  but  few  in  adults.  Sometimes  the  sheath  can  be  incised,  the  intussus- 
ceptum  cut  away,  its  layers  united  by  suture,  and  the  incision  sutured,  as 
in  Maunsell's  method  of  enterectomy.  Eeseetion  for  chronic  intussusception 
has  given  excellent  results. 

The  surgical  treatment  of  intestinal  obstruction  consists  in  laparotomy 
or  eutei'ostomy.  The  laparotomy  must  be  done,  as  a  rule,  in  an  explora- 
tory manner,  as  the  diagnosis  will  be  uncertain  both  as  to  the  cause  and  as 
to  the  situation  of  the  obstruction.  The  abdomen  is  to  be  opened  by  a 
median  incision  large  enough  to  introduce  the  hand,  in  order  to  search  for 
the  cause  of  the  obstruction.  If  a  tumor  is'  distinctly  felt  and  is  fixed  at 
one  side  of  the  belly,  a  lateral  incision  over  it  may  be  more  convenient. 
If  the  lesion  cannot  be  found  at  once,  the  csecum  should  be  examined,  for 
its  distention  proves  that  the  obstruction  is  below  it,  and  the  sigmoid  flexure 
should  then  be  examined.  If  the  csecum  is  not  distended,  the  obstruction 
must  be  in  the  small  intestine,  and  the  first  loop  of  collapsed  bowel  which 
can  be  found  is  to  be  drawn  up  into  the  wound  and  the  intestine  passed 
rapidly  through  the  fingers  until  it  leads  to  the  seat  of  obstruction.  Com- 
plete evisceration  of  the  bowel  may  be  necessary,  but  should  be  avoided,  if 
possible,  by  returning  the  parts  as  soon  as  they  are  examined.  Any  bands 
or  adhesions  which  are  found  are  to  be  separated.  Hernia  through  any  of 
the  internal  apertures  is  corrected  by  reduction,  and  intussusception  is  to 
be  treated  as  already  indicated.  A  volvulus  is  to  be  carefully  untwisted  and 
stitches  taken  in  the  mesentery  so  as  to  shorten  it  and  prevent  a  recurrence. 
In  all  these  manipulations  great  care  is  necessary  to  avoid  doing  damage 
to  the  strangulated  bowel,  especially  if  the  symptoms  have  lasted  more  than 
twenty-four  hours,  when  the  gut  becomes  very  soft  and  is  easily  torn. 

If  a  foreign  body  is  found  in  the  intestine,  an  incision  is  made  opposite 
to  the  mesenteric  attachment,  and  after  the  removal  of  the  foreign  body  the 
incision  may  be  sutured,  or  the  opening  in  the  bowel  maj'  be  secured  in  the 
abdominal  wound  by  suture,  or  it  may  be  temporarily  closed  by  clamps  and 
left  iu  the  wound  in  case  collapse  makes  it  necessary  to  save  time. 

The  great  danger  in  all  these  operations  lies  in  the  fact  that  the  patient 
is  usually  very  feeble  or  in  collapse  by  the  time  that  consent  to  operation  is 


960  DISEASES  OF  THE  PANCREAS. 

obtained.  The  operation  must,  therefore,  be  completed  as  rapidly  as  pos- 
sible. The  collapse  may  be  counteracted  by  hot  bottles  about  the  patient, 
by  elevating  the  foot  of  the  bed,  and  by  vigorous  stimulation. 

The  stomach  should  always  be  washed  out  before  the  operation  is 
begun,  as  this  will  lessen  the  danger  of  aspiration  of  vomited  fecal  mate- 
rial into  the  lungs  during  unconsciousness  from  the  ansesthetic,  and  of  a 
subseciuent  septic  iineumonia. 

If  the  cause  of  obstruction  is  such  that  it  cannot  be  removed  or  cor- 
rected, we  may  leave  it  untouched  and  open  tlie  bowel  above  it ;  or  make  an 
anastomosis  by  connecting  the  bowel  above  and  below  the  seat  of  the  obstruc- 
tion ;  or  we  may  resect  the  bowel  at  the  affected  point,  and  either  unite  the 
ends  or  secure  them  in  the  abdominal  wound.  It  will  generally  be  unwise 
to  attempt  prolonged  operations  on  these  patients,  on  account  of  their 
exhausted  condition,  so  that  anastomosis  and  union  of  the  ends  are  generally 
impracticable,  and  it  is  therefore  frequentlj^  necessary  to  adopt  the  expedient 
of  making  an  artificial  anus, — opening  the  bowel  above,  or,  in  case  of  resec- 
tion, securing  the  ends  of  the  bowel  in  the  wound.  The  simplest  method  is 
always  the  best,  and  if  there  is  no  strangulation,  and  the  obstacle  is  not 
easily  removed,  the  point  of  obstruction  should  be  left  untouched  and  an 
artificial  anus  made  above.  When  the  patient  has  recovered  his  strength, 
the  surgeon  can  perform  an  anastomosis  or  resection  of  the  affected  part  of 
the  bowel  at  a  subsequent  operation.  Sometimes  the  obstruction  disappears 
spontaneously,  and  if  this  is  the  case,  or  if  it  is  removed  by  a  subsequent 
operation,  the  artificial  anus  will  usually  close  of  its  own  accord.  Many 
cases  are  brought  to  the  surgeon  so  late  that  the  patient  is  exhausted  and  an 
extensive  laparotomy  is  out  of  the  question,  the  performance  of  a  colostomy 
being  the  only  resource.  The  opening  should  be  made  in  the  sigmoid  flexure, 
if  it  is  certain  that  the  obstruction  is  below  that  point.  Otherwise  the  abdo- 
men should  be  incised  in  the  right  iliac  region,  and  the  csecum  opened  if  it 
is  found  distended.  If  the  ciecum  is  collapsed  or  not  found,  the  most  con- 
venient distended  loop  of  bowel  is  to  be  secured  and  opened.  The  patient's 
condition  may  be  such  that  it  is  dangerous  to  administer  a  general  anaes- 
thetic, but  with  the  aid  of  cocaine  an  artificial  anus  may  be  made,  and  a 
limited  exploration  of  the  abdominal  cavity  may  be  carried  out  without 
causing  great  suffering. 

SURGICAL  DISEASES  OP  THE  PANCREAS. 

Injuries. — Although  it  is  said  that  pancreatic  juice  causes  necrosis  of 
fatty  tissues  exposed  to  its  action,  this  necrosis  is  probably  due  to  simul- 
taneous infection,  and  clean  wounds  of  the  pancreas  usually  heal  well.  The 
pancreas  has  been  known  to  prolapse  through  an  open  abdominal  wound  and 
has  been  replaced  or  removed  by  the  surgeon,  recovery  taking  xjlace  in  either 
case.  Injury  of  the  laancreas  may  be  followed  by  acute  pancreatitis  or  by 
the  formation  of  tumors,  especially  cysts. 

Heinorrhage, — Hemorrhages  take  place  in  the  substance  of  the  pan- 
creas from  unknown  causes,  usually  associated  with  pancreatitis.  The  blood 
may  collect  behind  the  peritoneum,  or  in  the  gland  itself,  and  its  quantity 
is  usually  not  very  great.     The  symptoms  are  acute  pain  in  the  abdomen, 


TUMORS  OF  THE  PANCREAS.  961 

vomiting,  aud  constipation,  and  they  closely  resemble  those  of  acute  per- 
forative peritonitis  and  intestinal  obstruction.  Death  may  be  immediate, 
and  if  the  patient  survive,  gaugreue  of  the  organ  generally  follows. 

Inflammation. — Suppurative  pancreatitis  may  result  in  the  formation 
of  small  multiple  abscesses  or  a  single  large  collection  of  pus.  The  symi^- 
toms  are  local  pain  extending  to  the  back,  vomiting,  and  constipation, 
simulating  intestinal  obstruction,  followed  by  diarrhoea.  Fever  may  appear 
on  the  second  or  third  day,  with  some  tympanites  limited  to  the  epigas- 
trium, and  progressive  emaciation.  The  course  of  the  disease,  after  the 
acute  onset,  is  generally  chronic.  The  swollen  gland  may  be  felt  in  the  epi- 
gastrium. If  death  is  postponed  the  characteristic  diarrhoea  and  vomiting 
appear,  with  fatty  globules  in  the  stools  and  vomited  matter.  There  may 
be  sugar  in  the  urine.  For  multijjle  abscesses  surgery  can  do  nothing,  but 
a  single  abscess  might  be  evacuated,  and,  if  limited  to  the  glandular  sub- 
stance, it  might  be  treated  by  extirijation  of  that  part  of  the  organ.  Chronic 
pancreatitis  may  be  caused  by  obstruction  of  the  duct  by  biliary  calculi, 
and  results  in  thickening  of  the  interstitial  connective  tissue  with  enlarge- 
ment and  hardening  of  the  gland,  which  often  resembles  carcinoma.  This 
may  disappear  when  the  biliary  obstruction  has  been  relieved. 

Gangrene. — Gangrene  of  the  pancreas  presents  symptoms  resembling 
those  of  inflammation,  and  is  followed  by  pysemia  or  peritonitis.  In  rare 
cases  recovery  has  taken  place,  the  sloughs  making  their  way  into  the  bowel. 
These  various  conditions  of  the  pancreas  cause  symjitoms  resembling  those 
of  peritonitis  or  intestinal  obstruction,  and  if  a  laparotomy  should  be  per-  ■ 
formed  for  the  symjjtoms,  and  nothing  else  be  found  when  the  abdomen  is 
opened,  the  surgeon  should  always  examine  the  region  of  the  pancreas. 
Several  cases  of  pancreatitis  with  necrosis  have  ended  in  recovery  after 
operation. 

Tumors. — Tumors  of  the  pancreas  may  be  cystic  or  solid. 

Cysts. — The  cysts  are  sujiposed  to  be  retention  cysts  from  obstruction 
in  the  duct  caused  by  a  calculus,  a  stricture  (often  of  traumatic  origin),  or  a 
neoplasm.  The  cj'sts  most  frequently  originate  in  the  tail  of  the  organ. 
They  grow  behind  the  peritoneum,  and  may  project  forward  between  the 
stomach  and  the  colon,  or  below  both  of  these  organs,  or  between  the  liver 
aud  the  stomach.  Adhesions  of  the  cyst  to  the  organs  about  it  or  to  the 
great  vessels  are  very  frequently,  although  not  invariably,  jiresent. 

A  pancreatic  cyst  forms  a  slowly  growing  tumor  in  the  abdomen,  fixed 
in  the  middle  line,  not  moving  with  respiration.  An  area  of  resonance 
usually  separates  it  from  the  liver,  although  if  the  tumor  should  come  for- 
ward between  the  liver  and  the  stomach  the  area  of  dulness  on  percussion 
over  it  would  be  continuous  wath  the  hepatic  dulness.  The  cyst  generally 
attains  the  size  of  a  man's  head,  but  may  be  much  larger.  The  symptoms 
are  those  excited  by  the  pressure  of  the  tumor,  discomfort,  vomiting,  jaun- 
dice, and  constipation,  together  with  disturbance  of  digestion  from  loss 
of  pancreatic  fluid,  aud  emaciation.     There  may  be  sugar  in  the  urine. 

Solid  Tumors. —Cancer  of  the  pancreas  is  not  common,  and  benign 
solid  tumors  are  rare.  The  symptoms  of  solid  tumors  are  due  to  the  obstruc- 
tion they  cause  to  the  common  bile-duct  and  pancreatic  duct,  preventing 


962  DISEASES  OF  THE   SPLEEN. 

the  flow  of  bile  and  pancreatic  juice  and  interfering  with  the  digestion, 
free  fat  appearing  in  the  stools.  There  may  be  symjjtoms  of  biliary  obstruc- 
tion, such  as  jaundice  and  more  or  less  pain  in  the  epigastrium  and  cachexia. 
The  tumors  are  of  small  size  and  slow  growth,  and  the  diagnosis  can  seldom 
be  made  in  time  to  permit  of  operative  treatment.  Similar  symptoms  are 
caused  by  carcinoma  of  the  duodenal  mucous  membrane  beginning  at  the 
papilla,  as  in  a  case  observed  by  us. 

Treatment. — These  tumors  require  operation,  but  the  solid  tumors  are 
seldom  recognized  in  time  for  successful  treatment.  To  remove  a  pancreatic 
cyst  the  abdomen  is  opened  by  a  median  incision.  The  wall  of  the  cyst  will 
be  found  to  be  covered  by  the  omentum  or  mesocolon,  or  possibly  the  gastro- 
hepatic  ligament.  The  posterior  layer  of  the  peritoneum  must  be  divided, 
and  then  the  cyst  wall  can  be  exposed.  An  aspirating  needle  or  trocar  is 
thrust  into  the  cyst  and  the  contents  evacuated.  The  opening  is  then  closed 
with  a  clamp,  and  the  adhesions  of  the  cyst  carefully  examined,  and  if  these 
are  not  too  strong  they  may  be  separated.  The  pedicle,  which  is  usually 
formed  by  the  tail  of  the  pancreas,  is  ligated,  or  that  part  of  the  pancreas 
from  which  it  springs  is  ligated  as  a  pedicle.  The  tumor  can  then  be  cut 
away.  If  the  adhesions  are  too  strong  for  safe  separation  the  sac  is  to  be 
drawn  out  and  sutured  in  the  abdominal  wound,  after  which  the  greater 
l^ai't  of  it  can  usually  be  removed,  and  the  remaining  cavity  of  the  cyst  is  to 
be  drained.  In  some  cases  the  anterior  jjortion  of  the  cyst  wall  can  be  cut 
away,  and  its  edges  closely  united  by  autares  after  a  drain  has  been  passed 
through  a  lumbar  wound  into  the  bottom  of  the  cyst.  The  abdominal 
wound  can  then  be  closed  completely.  The  fistula  discharges  freely  at  first 
and  irritates  the  skin.  It  slowly  closes  after  weeks  or  months.  The  old 
operation  of  securing  the  cyst  in  the  abdominal  wall  and  waiting  for  adhe- 
sions to  form  before  opening  it  for  drainage  is  not  so  satisfactory.  Complete 
excision  of  the  s"ac  is  much  more  dangerous  than  simple  drainage,  or  partial 
excision  and  drainage. 

SURGICAL  DISEASES  OF  THE  SPLEEN. 

Wandering  Spleen. — The  peritoneal  attachments  of  the  spleen  may 
be  so  elongated  as  to  allow  it  to  mo%'«  about  in  the  abdomen,  and  even  to 
descend  into  the  pelvis,  a  condition  known  as  wandering  spleen.  It  may 
give  rise  to  vague  feelings  of  abdominal  distress,  or  the  tumor  may  be  dis- 
covered accidentally.  The  j)edicle  may  become  twisted,  and  then  the  organ 
becomes  swollen  and  painful  and  gangrene  may  follow.  A  wandering 
spleen  may  be  fixed  by  a  large  pad  and  bandage,  but  this  is  seldom  very 
effective.  Eecently  attempts  have  been  made  to  secure  the  organ  in  place 
by  the  operation  of  splenopexy.  This  may  be  done  by  opening  the  abdo- 
men, dissecting  up  a  flap  from  the  parietal  peritoneum  in  the  left  hypo- 
chondrium,  and  securing  it  across  the  spleen  to  form  a  pocket  to  hold  the 
organ.  The  operation  appears  to  be  without  danger  and  to  give  good  results. 
The  displaced  si^leen  has  frequently  been  i-emoved  with  success. 

Abscess. — Suppurative  inflammation  of  the  spleen  resulting  in  abscess 
is  usually  of  metastatic  origin.  There  may  be  a  single  abscess  or  multiple 
small  foci.     The  abscesses  may  open  spontaneously  into  the  bowel  or  exter- 


DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


963 


nally,  but  the  drainage  is  incomplete,  and  unless  an  operation  is  done  the 
patient  nsually  dies  of  pyfemiai. 

Tumors. — The  spleen  may  be  enlarged  by  congestion  in  any  condition 
which  obstructs  the  portal  circulation.  It  is  liable  to  hypertrophy  in  mala- 
rial fever,  in  leukaemia,  and  also  from  unknown  causes.  In  chronic  enlarge- 
ment the  organ  usually  becomes  fibrous,  l^eoplasms  and  cysts  of  the  spleen 
are  rare,  even  sarcoma  being  uncommon.  They  give  rise  to  few  symj)toms 
except  those  caused  by  their  mechanical  effects  when  of  large  size. 

Splenectomy. — The  spleen  may  be  removed  without  danger  of  dis- 
turbing the  health,  its  functions  being  apparently  j)erfectly  supplied  by  the 
other  lymphatic  glands.  The  most  favorable  results  in  splenectomy  are 
obtained  in  cases  of  injury,  especially  when  the  spleen  is  prolapsed  through 
an  abdominal  wound.  In  operations  for  hypertrophy  of  the  spleen  and  for 
sarcoma  about  one-third  of  the  cases  die.  Secondary  enlargement  from  dis- 
ease of  the  liver  should  not  be  operated  upon.  IsTor  should  the  leuksemic 
spleen  be  removed,  as  it  has  been  found  that  the  mortality  in  these  cases  is 
very  high,  and  the  disease  of  the  blood  is  incurable.  Malarial  hypertrophy 
of  the  spleen  uswally  subsides  under  medical  treatment,  but  splenectomy 
may  be  necessary  when  the  tumors  are  large  and  of  long  standing.  The 
spleen  when  broken  down  and  sloughing  in  an  abscess-sac  has  also  been 
removed  successfully.  When  the  organ  is  large,  adhesions  may  form 
between  it  and  the  diaphragm  and  add  greatly  to  the  difficulty  of  removal. 
Splenectomy  is  done  by  an  anterior  laparotomy,  usually  requiring  a  very 
large  incision  on  account  of  the  huge  size  of  the  organ.  The  spleen  is  drawn 
out  of  the  wound,  and  a  ligature  is  passed  through  the  pedicle,  a  very  blunt 
ligature-ijasser  being  used  on  account  of  the  friable  nature  of  the  thin- 
walled  splenic  vein.  The  tumor  is  then  cut  away,  leaving  a  large  stump  of 
the  pedicle  to  prevent  the  ligature  from  slipping,  and  the  wound  is  closed. 
The  chief  dangers  of  the  operation  are  hemorrhage  and  shock,  and  second- 
ary or  intermediate  hemorrhage  from  the  pedicle  is  not  uncommon. 

THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

Physical  Signs. — Inspection. — Inspection  will  often  reveal  at  once 
the  presence  of  a  tumor.     When  there  is  ascites  and  the  patient  lies  on  the 

Fig.  775. 


back,  the  belly  bulges  equally  in  the  flanks  on  both  sides  and  is  flattened 
anteriorly.  The  presence  of  a  large  abdominal  cyst  gives  quite  a  different 
shape  to  the  body,  the  most  prominent  part  of  the  abdomen  being  in  the 


964 


DIAGNOSIS   OF  ABDOMINAL  TUMORS. 


Fig. 


middle  line,  while  the  flanks  are  comparatively  flat  (Fig.  775),  and  some- 
times one  side  is  more  distended  than  the  other.  In  ovarian  cysts  the 
swelling  is  most  prominent  in  the  lower  part  of  the 
abdomen,  and  the  solid  fibroid  tumors  of  the  uterus 

#  project  in  the  same  region,  but  often  make  a  more  dis- 
tinct and  conical  protrusion.  (Fig.  776.)  Large  fibro- 
cystic tumors  (Fig.  777)  may  resemble  ovarian  cysts. 
In  examining  the  abdomen  by  palpation  the  patient 
should  lie  upon  the  back,  with  the  shoulders  sup- 
ported on  a  pillow  and  the  knees  drawn  up  and  held 
by  an  assistant,  so  as  to  relax  the  abdominal  muscles 
thoroughly.  He  should  then  be  instructed  to  take 
several  long  breaths,  the  surgeon  gently  sinking  the 
hand  into  the  abdomen  during  expiration.  The  palmar 
surfaces  of  the  fingers  should  be  used  as  far  as  possi- 
ble, and  not  their  ends.  When  this  examination  has 
been  completed,  the  surgeon  should  turn  the  patient 
upon  each  side  and  percuss  and  palpate  the  abdomen 
in  these  positions,  as  additional  information  may 
sometimes  thus  be  obtained.  The  patient  may  also  be 
seated  upon  a  chair,  bending  forward,  with  his  folded 
arms  supported  upon  the  back  of  a  chair  in  front  of 
him,  and  his  head  resting  uj)on  his  arms,  as  in  this 
position  the  abdominal  muscles  are  relaxed,  and  grav- 
ity throws  the  organs  forward  against  the  j)alpating 
hand  as  the  sm-geon  stands  behind  the  patient  and  reaches  around  him. 
The  administration  of  an  antesthetio  is  useful  in  palpation  of  the  abdomen, 
and  sometimes  indispensable,  for  some  patients  cannot  relax  their  muscles. 

Fig.  777. 


Fibroid  tumor  of  the  uterus. 
(Case  of  Dr.  E.  Abbe.) 


Fibrocystic  tumor  of  the  uterus. 

The  immohiUty  of  retroperitoneal  and  pancreatic  tumors  is  characteristic. 
Tumors  connected  with  the  liver  move  tvith  respiration,  and  sometimes  those 
connected  with  the  kidneys  or  spleen  will  do  so,  while  tumors  of  the  uterus 


DIAGNOSIS   OF  ABDOMIiSTAL  TUMORS.  965 

and  ovaries  do  not.  Any  tumor  iu  contact  with  the  diaphragm  or  the  liver 
will  move  downward  on  inspiration,  but  if  the  tumor  is  firmly  held  down 
by  the  hand,  it  will  follow  the  ujjward  movement  of  those  organs  in  expira- 
tion only  when  directly  connected  with  them.  This  distinction  is  especially 
tiseful  in  ascertaining  whether  tumors  of  the  stomach  and  intestine  are  free 
or  adherent  to  the  liver.  Tumors  connected  with  the  intestine  and  stomach 
are  more  easily  pushed  up  than  drawn  down,  for  by  the  latter  movement 
their  mesenteric  attachments  are  put  upon  the  stretch.  Tumors  of  the 
small  intestine  and  sigmoid  flexure  may  be  moved  about,  while  those  of 
other  parts  of  the  colon  are  fixed.  Fluctuation  can  be  detected  by  laying 
one  hand  flat  upon  the  abdomen  and  tapijing  the  latter  gently  with  the 
other  at  some  distance.  In  j)ersons  with  a  very  thick  layer  of  fat  upon  the 
abdomen  it  is  well  to  have  an  assistant  hold  a  book  or  the  edge  of  his  hand 
firmly  against  the  linea  alba,  in  order  to  prevent  a  deceptive  wave  from 
crossing  in  the  adipose  tissue.  Percussion  will  give  the  outline  of  many 
tumors,  as  they  generally  present  areas  of  dulness  or  flatness.  The  relations 
of  the  tumor  to  the  liver  and  the  spleen  may  often  be  determined  by  this 
means.  The  presence  of  free  fluid  in  the  peritoneal  cavity  (ascites)  is 
detected  by  percussing  the  abdomen  while  the  patient  lies  on  the  back  and 
marking  the  line  of  dulness  caused  by  the  fluid,  and  then  turning  him  on 
Tiis  side  and  noting  the  change  which  occurs  iu  the  level  of  the  fluid,  as 
:shown  by  the  changing  line  of  dulness,  for  the  fluid  naturally  sinks  to  the 
most  dependent  part  of  the  cavity.  Auscultation  is  of  little  use  in  the 
examination  of  the  abdomen. 

Inflation  and  Injection. — Useful  knowledge  as  to  the  relations  of  a 
tumor  to  the  stomacli  or  intestines  is  gained  by  filling  those  organs  with 
fluid  or  air  through  a  tube  and  studying  by  palpation  and  percussion  the 
changes  thus  produced. 

Rectal  and  Vaginal  Examination. — Digital  examination  by  the  vagina 
or  the  rectum  should  never  be  omitted,  even  when  the  tumor  has  apparently 
no  relation  to  the  jielvic  organs.  The  entire  hand  may  be  passed  into  the 
rectum,  but  this  method  of  examination  is  too  dangerous  for  common  use, 
and  will  rarely,  if  ever,  be  necessary.  It  is  said,  however,  that  a  hand 
which  measures  nine  inches  in  circumference  may  enter  without  danger  of 
IJermanent  paralysis  or  incontinence,  and  that  although  it  produces  lacera- 
tions in  the  anal  mucous  membrane,  it  will  not  rupture  the  bowel.  The 
hand  can  be  passed  up  to  the  sigmoid  flexure,  and  the  four  fingers  made  to 
enter  this  part  of  the  bowel,  and  then  even  the  upper  part  of  the  abdomen 
may  be  reached  by  the  fingers. 

Exploratory  Puncture. — Exploration  of  the  abdominal  organs  with 
the  aspirating  needle  is  a  dangerous  ijrocedure.  Death  has  occurred  from 
hemorrhage  from  a  needle  puncture  of  the  spleen,  leakage  of  the  fluid  from 
a  needle  i)uncture  of  a  hydatid  cyst  has  produced  fatal  poisoning,  and  there 
is  constant  danger  of  infecting  the  peritoneum  and  setting  up  peritonitis  by 
fecal  extravasation  through  j)unctures  of  the  stomach  and  intestine.  The 
use  of  the  aspirating  needle,  which  should  be  most  carefully  sterilized, 
should  be  limited  to  puncture  of  the  peritoneal  cavity  and  of  the  extraperi- 
toneal surfaces  of  the  abdominal  organs. 

62 


966  DIAGNOSIS   OF  ABDOMINAL  TUMORS. 

Examination  of  Fluids. — The  fluids  obtained  should  be  analyzed 
chemically  and  their  sediment  examined  by  the  microscope.  Ascitic  fluid  is 
clear  and  has  a  specific  gravity  of  1010  to  1015.  It  has  a  small  amount  of 
albumin,  and  j)artially  clots  on  standing.  It  may  contain  fat-globules  suffi- 
cient to  give  it  a  milky  color,  due  to  rupture  of  a  lacteal  vessel  or  to  fatty 
degeneration  of  cells  in  malignant  tumors.  If  peritonitis  is  present  the  fluid 
is  cloudy,  of  higher  specific  gravity,  contains  more  albumin,  and  also  leuco- 
cytes and  endothelial  or  pus  cells.  Ascitic  fluid  is  often  found  when  there 
are  tumors  in  the  abdomen,  and  if  the  latter  are  malignant  the  fluid  is  apt  to 
be  bloody.  The  masses  of  endothelial  cells,  once  considered  a  characteristic 
sign  of  an  ovarian  cyst  when  ascitic  fluid  occurs  with  an  abdominal  tumor, 
simply  indicate  irritation  of  the  serous  membrane,  and  are  to  be  seen  with 
any  large  tumor.  The  fluid  of  an  echinococcus  cyst  is  similar,  especially  if  it 
be  infected,  but  it  has  no  albumin  in  its  normal  state,  and  contains  larger 
amounts  of  mineral  salts.  Occasionally  hooks  or  fragments  of  cyst  mem- 
brane are  found,  and  then  the  diagnosis  is  certain.  Ovarian  cystic  fluid  has 
a  specific  gravity  of  1010  to  1024,  but  it  may  be  less  or  greater.  It  may  be 
thin  or  mucoid,  or  even  colloid,  and  of  various  shades  of  yellow,  green,  or 
brown.  Paralbumin  is  a  characteristic  constituent,  and  cylindrical  epithe- 
lial cells  and  cholesterin  crystals  are  common.  Hydronephrosis  furnishes  a 
clear  fluid,  specific  gravity  1010  to  1020,  seldom  containing  albumin  or  cells 
unless  inflammation  has  set  in.  The  fluid  from  fibrocystic  tumors  of  the 
uterus  is  yellowish,  specific  gravity  1020  ;  it  forms  a  clot  at  once  and  con- 
tains no  cells  except  a  few  leucocytes.  Pancreatic  cysts  furnish  a  brown 
alkaline  fluid  which  has  jjower  to  digest  fat  and  starch. 

Conditions  resembling  Tumors.— Ascites.— Fluctuation  is  ob- 
tainable when  there  is  much  fluid.  When  the  patient  lies  on  the  back  there 
will  be  dulness  on  percussion  in  the  flanks  and  perhaps  at  the  pubes,  but 
the  central  portion  of  the  abdomen  will  be  resonant,  whereas  in  ovarian 
cysts  the  dulness  is  in  the  median  line  rising  from  the  pubes,  and  the  flanks 
are  resonant.  We  have  sufficiently  explained  the  means  by  which  free 
fluid  may  be  recognized.  A  very  thick  layer  of  abdominal  fat  may  simu- 
late a  tumor,  but  when  the  patient  lies  down  and  lifts  the  head  and  shoulders 
so  as  to  fix  the  abdominal  muscles,  the  mass  of  fat  can  still  be  freely  moved 
about,  showing  that  it  is  external  to  the  muscles.  An  accumulation  of  fat 
in  the  omentum  or  mesentery  is  not  so  easily  distinguished  from  a  tumor, 
but  rarely  forms  well-defined  masses.  Tympanites  is  unlikely  to  be  mis- 
taken for  a  tumor,  but  its  existence  frequently  masks  the  presence  of  the 
latter.  An  error  due  to  a  distended  bladder  is  easily  eliminated  by  the 
passage  of  a  catheter.  Fecal  masses  in  the  intestine  are  deceptive,  but  they 
can  generally  be  recognized  by  their  doughy  consistency,  which  allows  them 
to  be  moulded  between  the  fingers,  and  in  doubtful  cases  the  administration 
of  a  jjurgative  will  clear  up  the  difficulty.  Some  hysterical  individuals 
have  the  power  of  imitating  the  presence  of  abdominal  tumors  by  throwing 
the  muscles  into  irregular  contraction  and  forcing  the  distended  intestine 
forward  in  tumor-like  masses.  It  may  be  necessarj'  to  administer  an  anaes- 
thetic before  this  condition  cau  be  excluded,  for  with  the  muscular  relaxa- 
tion of  anaesthesia  the  so-called  "phantom  tumor"  melts  away.     Inflam- 


DIAGNOSIS  OF  ABDOMINAL  TUMOES.  967 

matory  masses,  consisting  of  adherent  omentum  and  bowel  and  solid 
peritoneal  exudate  or  encapsulated  abscesses,  often  resemble  neoplasms  of 
the  abdominal  organs,  but  can  be  distinguished  from  them  by  the  history 
of  some  previous  inflammatory  condition.  Inflammatory  masses,  as  a  rule, 
are  fixed  to  the  abdominal  wall  at  some  point ;  they  are  not  so  distinctly 
outlined  as  the  neoplasms,  are  more  irregular  in  shape,  not  so  hard,  and  are 
tender  to  pressure.  We  have,  however,  seen  a  small  abscess  surrounded 
by  omentum  which  was  freely  movable  in  the  abdomen,  and  such  movable 
abscesses  are  not  uncommon  in  tuberculous  iieritonitis.  Cold  abscesses 
often  simulate  neoplasms  in  the  abdomen  or  pelvis,  and  when  a  fluctuating 
tumor  is  found  in  the  lumbar  or  the  iliac  region,  the  spine,  the  pelvic  bones, 
and  the  hip-joints  should  be  carefully  examined,  for  evidence  of  disease 
there  will  indicate  that  the  mass  is  an  abscess.  Enlarged  mesenteric  glands 
may  be  taken  for  other  tumors,  but  their  fixed  median  situation  and  multiple 
or  nodular  character  should  reveal  their  nature. 

Diagnosis  of  the  Organ  affected. — The  most  important  thing  to 
be  determined  about  a  tumor  is  its  origin.  The  situation  which  it  occupies, 
and  its  attachments  to  the  liver,  stomach,  intestines,  uterus,  or  other  organs, 
must  be  carefully  studied  by  palpation  and  percussion,  for  in  the  majority  of 
cases  the  tumor  originates  from  the  organ  to  which  it  is  attached.  But  the 
fact  that  any  organ  may  be  displaced  from  its  natural  position  should  never 
be  overlooked,  for  a  floating  kidney  or  spleen  might  present  itself  as  a  tumor 
in  the  pelvis,  and  search  must  be  made  to  prove  that  the  organs  are  nor- 
mally situated.  In  addition  to  the  facts  already  given,  the  following  points 
will  be  of  assistance  in  the  diagnosis. 

Tumors  of  the  anterior  abdominal  wall  lie  very  superficially,  and  are 
movable  when  the  abdomen  is  relaxed,  but  instantly  become  fixed  if  the 
abdominal  muscles  are  made  tense  by  causing  the  patient  to  lift  the  head  and 
shoulders  as  he  lies  on  the  back,  or  by  making  him  cough. 

Tumors  of  the  stomach  are  very  diflicult  to  paljDate,  as  they  generally 
lie  well  up  under  the  ribs  or  the  border  of  the  liver,  but  they  become  more 
evident  if  the  stomach  is  distended  by  food  or  by  air  or  water.  A  tumor  at 
the  pylorus  moves  downward  and  to  the  right  with  distention  of  the  stomach. 
Occasionally,  however,  a  tumor  of  the  stomach  is  found  low  down  in  the 
abdomen,  owing  to  disijlacement  or  dilatation  of  the  organ.  Tumors  of  the 
spleen  are  more  or  less  freely  movable,  and  usually  retain  the  shape  of  the 
organ,  being  flat  and  sharp-edged  and  having  the  splenic  notch  well  defined 
upon  the  inner  border.  Tumors  of  the  gall-bladder  maintain  intimate 
relations  with  the  liver,  and  usually  form  pear-shaped  cystic  swellings  lying 
in  the  normal  x^osition  of  the  organ  or  extending  downward.  Tumors  of  the 
liver  are  continuous  with  that  organ,  as  shown  by  palpation  and  percussion, 
whether  they  uniformly  enlarge  the  liver  or  project  from  its  border,  and 
they  move  with  respiration.  They  may  be  cystic  or  solid,  and  the  surface 
may  be  smooth  or  nodular,  being  usually  the  latter  when  the  enlargement  is 
due  to  gumma,  cancer,  or  hypertrophic  cirrhosis. 

Tumors  of  the  kidney  are  lateral  and  extend  into  the  loin,  so  that  press- 
ure of  the  hand  in  that  region  is  transmitted  to  the  palpating  hand  in  front 
by  the  intervening  tumor.     The  tumor  usually  j)reserves  the  shape  of  the 


968  HERNIA. 

organ,  and  is  somewhat  movable,  although  it  does  not  move  with  respiration 
unless  very  large.  A  loop  of  the  colon  lies  in  front  of  the  mass,  where  it 
can  be  felt,  or  may  be  demonstrated  by  percussion  when  distended  with  gas. 
The  tumor  is  usually  firm  or  tense,  and  may  have  a  smooth  or  a  bosselated 
surface.  Urinary  symptoms  may  aid  in  making  the  diagnosis.  For  tumors 
of  the  female  genitals  we  refer  to  the  chapter  on  those  organs. 

Certain  tumors  develop  in  the  omentum  and  mesentery,  cysts  being 
rare  in  the  former  and  the  tumors  generally  being  sarcomatous,  while  in 
the  mesenterjr  cysts  and  lipomata  are  the  most  frequent.  The  cysts  may 
be  chylous  if  they  are  caused  by  rupture  of  a  lacteal  vessel,  serous  if  they 
are  of  lymphatic  origin,  or  hemorrhagic.  Fatty  tumors  and  sarcomata, 
as  well  as  masses  of  glands,  may  also  develop  in  the  retroperitoneal  space. 
Tumors  of  the  omentum  lie  in  front  of  the  intestine,  and  may  be  fixed  or 
movable.  They  lie  above  the  pelvis,  but  are  separated  from  the  liver  by 
the  large  intestine,  and  differ  in  shape  from  tumors  of  the  spleen.  These 
tumors  are  less  easily  drawn  down  than  up,  biit  they  move  with  respira- 
tion. Tumors  of  the  mesentery  resemble  tumors  of  the  kidney  in  that  they 
frequently  have  a  loop  of  bowel  crossing  in  front  of  them,  but  they  lie  in 
the  middle  line,  and  are  much  more  movable  than  renal  tumors  until  they 
have  reached  a  large  size.  Mesenteric  tumors  do  not  follow  the  respiratory 
movements. 

Retroperitoneal  Tumors. — Eetroperitoneal  tumors  (excluding  tumors 
of  the  kidney  and  of  the  pancreas)  lie  near  the  middle  part  of  the  abdomen 
and  are  fixed  in  that  situation.  They  are  more  difiicult  to  identify  than 
tumors  of  the  omentum  and  mesentery,  and  are  frequently  confounded  with 
tumors  of  the  kidney  or  of  the  pancreas.  The  retroiieritoneal  tumors  may 
be  sarcomata,  originating  from  the  bones  of  the  spine  or  the  pelvis. 

Tumors  of  the  omentum  offer  the  best  prospect  for  o]3eration,  and  may 
be  extirpated  after  multiple  ligation.  Tumors  of  the  mesentery  are  usually 
benign,  and  unless  they  are  well  encaj)sulated  cannot  be  removed  without 
great  danger  to  the  intestines,  on  account  of  the  liability  of  damage  to  the 
mesenteric  vessels,  so  that  the  operation  should  generally  be  limited  to  an 
exploratory  laparotomy.  Cysts,  however,  may  be  secured  in  the  abdominal 
wound  and  drained.  The  retroperitoneal  tumors  (excluding  renal  and 
pancreatic  tumors)  are  generally  inoperable. 


A  hernia  is  a  protrusion  of  any  of  the  viscera  from  the  cavity  in  which 
they  are  contained  through  an  opening  in  the  wall  of  that  cavity.  The  word 
"hernia"  standing  alone  is  generally  understood  to  refer  to  x^rotrusions 
through  the  deeper  parts  of  the  abdominal  wall,  but  still  covered  by  skin,  a 
condition  commonly  known  as  "rupture,"  and  we  shall  so  understand  it. 
The  term  is  limited  by  some  authors  to  a  protrusion  through  an  anatomical 
gap  in  the  abdominal  wall. 

When  one  of  the  abdominal  organs,  a  loop  of  bowel,  or  the  omentum 
protrudes  through  the  abdominal  wall,  it  stretches  some  or  all  of  the  layers 
of  the  latter,  and  usually  carries  before  it  a  pouch  of  peritoneum  which  sur- 
rounds the  protruding  part  on  every  side.     The  peritoneal  pouch  is  called 


HERNIA.  969 

the  sac  of  the  heruia,  aucl  its  narrower  part,  where  it  passes  through  the 
opening  in  the  abdomen,  is  called  the  neck. 

When  the  contents  of  a  heruia  can  be  returned  to  the  abdominal  cavity 
the  rupture  is  said  to  be  reducible,  the  term  irreducible  being  applied 
to  the  oi^posite  condition.  An  incarcerated  or  obstructed  hernia  is  an 
irreducible  hernia,  which  causes  symjjtonis  of  intestinal  obstruction.  A 
strangulated  hernia  is  one  in  which  not  only  is  the  passage  of  fteces  through 
the  protruded  bowel  interrupted,  but  the  circulation  of  the  blood  in  the 
contents  of  the  hernia  is  also  impeded  by  a  constriction  at  the  neck  of  the 
sac  or  within  the  latter. 

Etiology. — The  causes  of  hernia  are  not  fully  determined.  The  umbili- 
cus, the  inguinal  and  femoral  rings,  and  to  a  lesser  degree  the  sacro-sciatic 
notch  and  the  obturator  foramen,  remain  partially  open  until  late  in  foetal 
life,  and  sometimes  even  until  birth,  because  they  give  issue  to  important 
parts,  and  if  the  closure  of  these  openings  is  delayed  or  incomplete  they 
afford  an  opportunity  for  hernia.  The  funicular  process  leading  into  the 
tunica  vaginalis  may  remain  patent  without  the  formation  of  a  hernia,  and 
there  is  no  evidence  to  prove  that  imperfect  closure  is  necessary  for  its 
occurrence.  The  influence  of  violent  muscular  exertion  in  the  production  of 
hernia  is  generally  recognized,  but  many  authorities  deny  that  it  is  possible 
for  any  effort  to  cause  an  immediate  ]3rotrusion  through  the  normal  open- 
ings if  properly  closed,  and  they  assume  that  when  the  hernia  suddenly 
appears  after  a  severe  effort  there  has  been  some  congenital  deficiency  at 
that  point.  An  indication  of  the  effect  of  muscular  exeition  is  seen  in  the 
frequency  of  hernia  among  persons  engaged  in  laborious  occupations  and 
in  women  during  the  child-bearing  period.  In  pregnancy  there  is  the 
additional  complication  of  the  stretching  and  subsequent  atrophy  of  the 
abdominal  walls.  It  is  doubtless  from  the  constant  straining  in  micturition 
that  a  narrow  foreskin  and  rupture  ai'C  so  often  associated,  and  urethral 
stricture,  habitual  constipation,  and  pulmonary  diseases  with  persistent 
cough  result  in  the  production  of  heruia  for  similar  reasons. 

An  abnormally  long  mesentery  is  frequently  found  in  cases  of  hernia, 
but  it  is  uncertain  whether  this  elongation  is  a  cause  or  a  consequence  of  the 
protrusion.  The  subperitoneal  fat  at  the  inguinal  and  femoral  rings  is 
often  massed  into  a  considerable  tumor,  to  which  the  name  preperitoneal 
lipoma  has  been  given,  and  this  mass  may  grow  outward  and  make  trac- 
tion upon  the  peritoneum,  forming  a  peritoneal  pouch,  which  is  said  to  pre- 
dispose to  the  formation  of  hernia.  These  pouches,  however,  may  exist 
without  any  hernia,  and  hence  the  efficiency  of  this  cause  is  doubtful. 
Scars  situated  in  the  abdominal  wall  tend  to  the  production  of  hernia  by 
the  stretching  of  the  cicatricial  tissue.  Heredity  appears  to  have  a  very 
decided  influence  ui^on  the  occurrence  of  hernia,  and,  according  to  Macready, 
ruptures  in  the  grandparents  are  of  more  imj)ortance  than  those  in  the 
parents,  especially  for  the  occurrence  of  the  congenital  ^'arieties.  The 
number  of  males  affected  with  hernia  is  about  six  times  as  great  as  that  of 
females,  doubtless  owing  to  the  frequency  of  inguinal  hernia  and  the  impos- 
sibility of  the  complete  closure  of  this  canal  in  the  male.  Hernia  often 
accompanies  retention,  malposition,  or  delaj^ed  descent  of  the  testicle. 


970 


INGUINAL  HERNIA. 


Hernia  is  exceedingly  common  in  infants  under  one  year  of  age,  very 
rarely  appears  from  infancy  to  puberty,  at  puberty  again  becomes  common, 
and  this  proportion  remains  about  the  same  until  late  in  life.  Although  the 
total  number  of  cases  of  hernia  observed  in  elderly  persons  is  less,  the  occur- 
rence of  hernia  in  the  aged  is  relatively  just  as  frequent  as  earlier  in  life, 
for  the  total  number  of  old  people  in  the  population  is  proportionately  less. 
It  is  true  that  the  fibrous  tissues  are  lax  and  the  fat  is  absorbed  in  advanced 
age,  so  that  the  abdominal  wall  is  decidedly  weakened,  but  elderly  persons 
ai'e  less  subject  to  severe  muscular  effort  and  the  other  mechanical  causes 
which  produce  hernia.  The  freedom  of  early  childhood  from  hernia  is  sup- 
posed to  be  due  to  similar  reasons,  children  not  making  the  violent  efforts 
necessary  to  produce  the  trouble,  and  hernia  apijeariug  in  them  only  when 
there  is  a  congenital  weakness  of  one  of  the  abdominal  openings. 

Varieties. — The  different  anatomical  varieties  of  hernia  are  named  from 
tlie  openings  through  which  they  escape,  the  inguinal  being  by  far  the  most 
common,  and  next  being  the  femoral  and  the  umbilical.  Hernia  also  occurs 
through  the  obturator  foramen,  the  sacro-sciatic  notch,  and  the  diaphragm. 
Congenital  deficiencies  or  weak  places  occasionally  exist  in  other  parts  of 
the  abdominal  wall  where  hernia  may  afterwards  develop,  these  hernise  and 
those  which  come  through  cicatrices  being  known  as  ventral  hernise. 

Inguinal  Hernia. — Inguinal  hernia  is  nearly  tweh^e  times  as  frequent  as 
femoral,  and  is  much  more  common  in  men  than  in  women,  the  proportion 
being  ten  to  one.  In  women,  however,  inguinal  and  femoral  hernise  occur 
with  equal  frequency.  There  are  several  varieties  of  inguinal  hernia.  When 
the  testicle  has  descended  into  the  scrotum,  the  peritoneal  canal  jnay  not 
close  in  the  normal  manner,  and  different 
forms  of  hernia  depend  upon  these  varia- 
tions.    When  the  canal  remains  patent  in 


Fig.  778. 


Vaginalis 


Congenital  hernia.     (Agnew.)  Hernia  into  the  funicular  process.    (Agnew.) 

its  entire  length  and  a  hernia  takes  place,  its  contents  pass  down  into  the 
tunica  vaginalis  and  are  in  contact  with  the  testicle,  a  condition  known  as 
congenital  hernia.  (Fig.  778.)  The  adjective  "congenital"  refers  to 
the  anatomical  condition  and  not  to  the  hernia,  for  the  latter  may  not  apjiear 
until  late  in  life.  When  the  canal  is  obliterated  near  the  testicle,  remaining 
oj)en  above,  a  prolapse  into  it  is  called  a  hernia  into  the  funicular  process. 


INGUINAL  HEENIA. 


971 


(Fig.  779.)  When  the  canal  is  only  closed  above  at  the  internal  ring  and 
the  tunica  vaginalis  extends  up  to  that  point,  a  rare  variety'  of  hernia  may 
form,  in  which  the  protrusion  pushes  before  it  the  closed  end  of  the  funicu- 
lar process  and  iuvaginates  it  into  the  cavity  of  the  tunica.  A  frozen  sec- 
tion through  such  a  hernia  would  show  a  true  peritoneal  sac  to  the  hernia, 
surrounded  by  a  double  serous  layer  formed  of  the  invaginated  tunica.  This 
condition  is  known  as  encysted  hernia.     (Fig.  780.)     Some  authors  have 

also  given  the  name  infantile  hernia  to 
^'^'-  ''^'^-  both  the  funicular  and  the  encysted  form. 


Encysted  hernia.    (Agnew. ) 


Acquired  inguinal  hernia.    (Agnew.) 


The  congenital  and  funicular  varieties  appear  suddenly,  and  they  are  also 
characterized  by  a  long  and  narrow  ueck  where  the  funicular  process  has 
been  partly  closed,  which  renders  them  especially  liable  to  strangulation. 

When  the  inguinal  ring  closes  in  the  normal  manner,  but  a  hernia  devel- 
ops afterwards,  it  is  termed  an  acquired  hernia.  (Fig.  781.)  The  acquired 
varieties  of  inguinal  hernia  are  two, — first,  the  oblique,  which  descends 
through  the  inguinal  canal,  entering  at  the  internal  ring  and  passing  out  at 
the  external ;  and,  secondly,  the  direct,  in  which  the  hernia  enters  a  pouch 
of  peritoneum,  which  is  apt  to  form  in  the  centre  of  the  conjoined  tendon 
just  internal  to  the  epigastric  arterj^,  pushes  the  conjoined  tendon  before  it, 
and  mates  its  way  out  at  the  external  ring.  A  direct  hernia  may  penetrate 
the  conjoined  tendon  instead  of  pushing  it  forward,  and  it  may  also  be  situ- 
ated at  the  external  border  of  the  tendon  in  rare  cases.  An  old  oblique  her- 
nia often  cannot  be  distinguished  clinically  from  a  direct  hernia,  because  the 
dragging  of  the  protruded  bowel  pulls  the  internal  ring  downward  and 
inward  iu  line  with  the  external  ring  and  destroys  the  obliquity  of  the  canal, 
but  anatomically  the  two  are  recognized  by  the  situation  of  the  epigastric 
artery,  which  lies  internal  to  the  neck  of  the  oblique  hernia  and  external  to 
that  of  the  direct.  The  distinction  is  of  importance  clinically,  because  of 
this  relation  to  the  artery  and  because  an  oblique  hernia  is  much  easier  to 
retain  by  a  truss  thau  a  direct.  Congenital  hernia  is  necessarily  of  the 
oblique  variety. 

An  oblique  hernia  which  has  merely  passed  the  internal  ring  and  not  the 
external  and  lies  in  the  inguinal  canal  is  known  as  an  incomjjlete  hernia  or  a 
bubonocele. 


972  RELATIONS   OF  INGUINAL  HERNIA. 

A  hernia  which  lies  in  the  substance  of  the  abdominal  wall  is  called  an 
interstitial  hernia.  Interstitial  hernia  may  be  divided  into  preperitoneal, 
intermuscular,  and  subfascial.  In  the  preperitoneal  variety  the  sac  is  formed 
by  a  protrusion  of  the  peritoneum,  usually  one  of  the  natural  pouches  in  that 
membrane,  and  makes  a  bed  for  itself  in  the  extraperitoneal  fat,  between 
the  membrane  and  the  muscles.  Strangulation  may  take  place  in  such  a 
sac.  The  sac  of  the  intermuscular  variety  is  formed  bj='  a  protrusion  which 
passes  through  the  internal  ring,  and  then  leaves  the  inguinal  canal  by  pene- 
trating its  walls  without  reaching  the  external  ring,  and  makes  its  way 
into  the  substance  of  the  abdominal  wall  between  the  muscles,  usually 
lying  between  the  internal  and  the  external  oblique.  The  subfascial  hernia 
lies  under  the  deep  fascia.  Interstitial  hernia  is  most  common  in  the  ingui- 
nal variety,  and  occurs  both  in  males  and  females.  In  males  it  is  generally 
associated  with  some  anomalous  position  of  the  testicle,  and  Berger  ascribes 
it  entirely  to  congenital  malformations  of  the  inguinal  canal.  Others  con- 
sider it  the  result  of  a  narrow  external  ring  which  resists  the  passage  of  the 
hernia  and  forces  it  to  protrude  from  the  canal  elsewhere.  It  can  also  be 
produced  by  forcible  taxis  when  the  internal  ring  resists  reduction  and  the 
sac  and  its  contents  are  pushed  through  the  sides  of  the  canal.  In  these 
herniae,  especially  the  properitoneal  form,  the  sac  may  be  divided,  and  one 
part  of  it  may  lie  in  the  scrotum  or  labium.  In  hernise  which  enter  the 
canal  through  the  internal  ring,  and  then  j)enetrate  its  walls  and  become 
interstitial,  the  strangulation  may  take  place  at  the  Internal  ring  or  at  the 
opening  through  which  they  have  left  the  canal.  In  the  properitoneal  form 
the  sac  and  parietal  peritoneum  are  closely  adherent  where  they  are  in  con- 
tact, and  they  can,  therefore,  be  distinguished  from  a  hernia  which  has  been 
reduced  en  masse.  Interstitial  hernise  are  usually  situated  near  the  inguinal 
canal,  and  their  sacs  may  be  directed  towards  the  iliac  fossa,  towards  the 
anterior  wall  of  the  abdomen,  or  inward  towards  the  bladder.  In  the  intra- 
muscular form,  the  muscles  over  the  tumor  may  atrophy  and  even  disappear 
over  a  considerable  area,  and  in  these  cases  the  peritoneal  sac  may  turn 
upward  over  the  abdomen,  or  downward  over  the  anterior  surface  of  the 
thigh,  for  having  thus  become  subcutaneous  it  is  no  longer  limited  by  the 
fascial  attachments.  Treatment. — Interstitial  hernia  requires  operation  bj^  a 
free  incision  which  will  allow  of  thorough  exj^loration  of  the  anatomical 
peculiarities.  The  inguinal  form  can  be  treated  geuerallj'  by  the  Bassini 
method.  The  great  atroiihy  of  the  parts  found  in  some  cases  may  be  met 
by  overlaj)ping  the  various  layers  when  the  sutures  are  applied,  instead  of 
cutting  away  the  redundant  tissues,  and  by  drawing  the  rectus  towards  Pou- 
part's  ligament,  to  strengthen  the  wall.     (Berger.) 

Relations  of  Inguinal  Hernia. — As  an  inguinal  hernia  enlarges  it 
descends  into  the  scrotum  in  the  male  and  into  the  cellular  tissue  of  the 
labium  majus  in  the  female  (Fig.  782),  and  when  it  reaches  a  large  size  it 
may  hang  down  to  the  knees.  Double  inguinal  hernia  is  a  very  common 
occurrence.  The  relations  of  the  cord  to  the  neck  of  the  sac  in  inguinal 
hernia  are  of  considerable  importance.  The  cord  lies  behind  the  sac  in  the 
majority  of  cases,  but  it  may  be  spread  out  upon  it,  the  vas  deferens  being 
always  internal  and  the  vessels  external.    Sometimes  the  protrusion  appears 


FEMOEAL  HERNIA. 


973 


Inguinal  hernia  in  the  female. 


to  have  passed  directly  through  the  tissues  of  the  cord  separating  the  vas 
from  the  vessels.  In  congenital  herniffi  the  cord  may  be  quite  i^rominent  on 
the  inner  side  of  the  sac,  and  may  have  a  sort  of  mesentery.  It  would  be 
natural  to  suppose  that  in  direct 
hernite  the  cord  would  lie  on  the 
external  side  of  the  sac,  but  it  is 
frequently  found  on  the  inner  side 
or  spread  over  its  sui'face,  as  if  the 
protrusion  had  taken  place  through 
its  tissues.  The  relations  of  the 
testicle  to  the  sac  are  very  variable. 
In  acquired  hernia  the  gland  is 
usually  found  below  and  distinct 
from  the  sac,  and  in  the  congenital 
form  it  lies  within  the  sac,  but  gen- 
erally it  can.be  found  readily  by 
palpation.  The  coverings  of  an 
oblique  inguinal  hernia  when  com- 
plete are  the  skin,  superficial  fascia, 
intercolumnar  fascia,  cremaster 
muscle  (absent  in  the  female),  in- 
fundibular fascia,  properitoneal  fat, 
and  peritoneal  sac.  In  a  bubono- 
cele the  external  and  internal  oblique  muscles  take  the  place  of  the  inter- 
columnar and  cremasteric  fasciae.  In  a  direct  hernia  the  coverings  are  the 
skin,  superficial  fascia,  intercolumnar  fascia,  conjoined  tendon  (sometimes 
absent),  transversalis  fascia,  jiroperitoneal  fat,  and  peritoneal  sac. 

Femoral  Hernia. — Femoral  hernia  issues  by  the  femoral  ring,  is  seldom 
as  large  as  the  inguinal  variety,  and  is  found  in  women  three  times  as  often 
as  in  men.  It  is  not  often  as  large  as  the  fist,  and  is  usually  smaller  than  a 
hen's  egg.  It  is  much  more  liable  to  strangulation  than  the  inguinal  variety. 
The  protrusion  takes  place  between  the  femoral  vein  and  Gimbernat's  liga- 
ment, and  presents  in  the  upper  part  of  Scarjta's  triangle,  but  may  be  turned 
upward  over  Poupart's  ligament.  The  coverings  of  the  sac  are  the  skin,  the 
superficial  fascia,  the  cribriform  fascia,  the  sheath  of  the  femoral  vessels,  the 
femoral  septum,  the  properitoneal  fat,  and  the  peritoneal  sac.  The  epigas- 
tric artery  lies  on  the  outer  side  of  the  neck,  and  the  obliterated  hypogastric 
artery  on  the  inner  side.  There  are  rare  forms  which  pass  external  or  inter- 
nal to  these  vessels,  penetrate  Gimbernat's  ligament,  or  even  issue  external 
to  the  femoral  vessels.  In  a  certain  small  proportion  of  cases  the  obturator 
artery  has  an  abnormal  origin,  passing  above  or  anterior  to  the  neck  of  the 
sac,  and  then  descending  along  its  inner  border. 

Umbilical  Hernia. — Umbilical  heruiae  are  of  three  varieties.  Hernia 
in  the  umbilical  cord  occurs  as  a  congenital  malformation,  the  cavity  of  the 
amnion  not  being  entirely  obliterated,  and  a  portion  of  the  abdominal  organs 
remaining  in  it  as  in  the  foetus.  When  the  hernia  is  small  it  may  be  over- 
looked and  the  sac  and  its  contents  included  in  the  ligature  applied  at  birth, 
resulting  in  a  fecal  fistula.     When  the  hernia  is  large  the  sac  consists  of  the 


974  •  VENTRAL  HEEMa. 

amnion  externally  and  a  foetal  membrane  internally,  the  line  of  transition 
between  these  and  the  skin  and  parietal  peritoneum  being  very  evident  at 
the  margin  of  the  opening.  These  membranes  slough  soon  after  birth  and 
the  organs  may  prolapse  or  a  fatal  peritonitis  ensue,  but  a  spontaneous  cure 
may  follow,  the  prolapsed  parts  becoming  adherent  to  the  edges  of  the  ring 
and  covered  by  epithelium  growing  over  them  from  the  surrounding  skin. 
When  the  gap  in  the  abdominal  wall  is  very  wide  ,a  condition  of  eventration 
may  be  present  at  birth,  and  the  child  may  be  non-viable.  Treatment. — The 
parts  should  be  returned  to  the  abdominal  cavity  and  the  sac  kept  dry  and 
aseptic  with  powdered  boric  acid  and  a  gauze  dressing.  If  this  is  impossible, 
an  attempt  may  be  made  to  unite  the  edges  of  the  opening  with  sutures, 
carefully  stretching  the  abdominal  wall  with  the  fingers  to  enlarge  the 
capacity  of  the  abdomen.  The  sutures  are  verj^  likely  to  cut  out  and  the 
child  can  seldom  be  saved.  Infantile  umbilical  hernia  is  a  protrusion 
through  the  umbilical  scar  which  is  very  common  in  both  sexes  in  the  first 
weeks  of  life.  The  sac  is  formed  of  the  parietal  peritoneum  and  is  covered 
with  true  skin.  It  forms  a  small  globular  protrusion  through  a  ring  from 
one-quarter  of  an  inch  to  one  inch  in  diameter  and  contains  bowel.  It  is 
rarely  strangulated  or  irreducible.  The  tendency  is  towards  recovery,  and 
operation  is  seldom  needed.  Adult  umbilical  hernia  occurs  in  women  with 
increasing  frequency  after  the  thirtieth  year,  but  is  rare  in  men.  It  is 
generally  associated  with  obesity.  It  may  be  the  recurrence  of  infantile 
hernia,  but  often  j)rotrudes  through  an  opening  in  the  fascia  near  the  umbili- 
cus and  not  through  the  ring.  The  coverings  of  an  umbilical  hernia  are 
merely  the  skin,  the  superficial  fascia,  the  preperitoneal  fat,  and  the  peri- 
toneal sac,  and  they  are  generally  very  thin,  with  a  tendency  to  ulceration 
and  superficial  sloughing.  The  omentum  protrudes  first  into  the  sac,  fol- 
lowed almost  invariably  by  the  large  intestine,  the  omentum  covering  the 
bowel,  and  usually  being  adherent  and  irreducible.  The  tumor  may  be  so 
small  as  to  be  scarcely  perceptible,  or  it  may  attain  an  immense  size,  con- 
taining a  part  of  the  intestine.  The  sac  is  often  subdivided  by  partitions,  or 
secondary  sacs  may  be  formed  by  the  omentum  contained  in  it.  The  large 
herniae  are  frequently  obstructed,  causing  constipation  and  colicky  pains. 
The  smaller  tumors  are  liable  to  strangulation,  which  jDursues  a  more  acute 
and  fatal  course  than  in  other  ruptures.  Treatment. — For  the  treatment  of 
infantile  and  adult  umbilical  hernia,  see  pages  98-4  and  987. 

Ventral  Hernia. — This  in  the  middle  line  close  to  the  umbilical  open- 
ing is  not  very  rare.  Similar  protrusions  in  the  epigastric  region  are  pecu- 
liar in  that  they  often  consist  merely  of  a  little  mass  of  the  preperitoneal 
fat,  but  in  other  cases  there  is  a  peritoneal  sac  which  may  contain  omen- 
tum or  even  intestine.  These  hernise  are  usually  innocent,  but  may  cause 
pain  and  symptoms  simulating  some  lesion  of  the  stomach  or  gall-bladder, 
and  require  operative  treatment.  Strangulation  of  the  contents  of  the  sac 
may  also  occur.  Euptures  are  often  found  in  the  linese  semilunares  and 
in  the  line*  transversee,  showing  the  tendency  of  these  protrusions  to  take 
Ijlace  through  the  fibrous  parts  of  the  abdominal  wall  rather  than  through 
the  muscular.  Hernia  may  take  place  through  the  substance  of  the  muscles 
near  the  inguinal  rings,  however,  and  simulate  the  ordinary  inguinal  rupture. 


OBTURATOR  HERNIA.  975 

A  separation  of  the  rectus  muscles  produces  a  form  of  ventral  liernia 
which  is  almost  invariably  found  in  women,  especially  after  i^reguancy. 
The  separation  may  occur  anywhere  from  the  umbilicus  to  the  pubes,  and 
may  extend  the  entire  distance,  giving  exit  to  a  large  part  of  the  abdominal 
contents  and  to  the  pregnant  uterus.  With  this  condition  we  may  compare 
a  congenital  weakness  of  the  linea  alba  occasionally  seen  at  birth,  extending 
from  the  umbilicus  upward  to  the  ensiform  cartilage,  but  disaiipeariug  spon- 
taneously as  the  tendon  gains  in  strength  and  the  child  grows.  There  may 
be  a  congenital  deficiency  of  the  muscles  of  the  abdomen  at  any  part 
through  which  hernia  may  occur,  with  the  ordinary  characteristics  of  a 
ventral  hernia.  In  one  case  observed  by  us  in  a  young  child,  an  opening  as 
large  as  the  x:)alm  of  the  hand  was  situated  to  the  right  of  the  umbilicus, 
and  extended  backward  to  the  lumbar  region.  It  became  reduced  to  one- 
quarter  of  its  size  spontaneously  as  the  child  developed,  and  was  then  easily 
closed  by  operation. 

Lumbar  Hernia. — Hernise  occur  in  the  lumbar  region  through  the 
triangle  of  Petit  or  immediately  beneath  the  twelfth  rib  under  the  latissimus 
dorsi,  where  it  covers  the  trausversalis  fascia.  These  herniie  are  uncom- 
mon, but  they  sometimes  attain  a  large  size. 

Obturator  Hernia. — Hernial  protrusions  may  take  place  through  the 
obturator  foramen  at  its  upper  border,  the  relations  of  the  obturator  nerve 
and  vessels  to  the  neck  of  the  sac  being  variable.  These  hernite  occur 
almost  exclusively  in  women.  They  are  of  slow  formation,  and  are  very 
difficult  of  recognition,  because  of  the  small  size  of  the  tumor  and  of  its 
situation  in  the  deepest  part  of  the  thigh.  The  x>ressnre  of  the  tumor  upon 
the  obturator  nerve  occasions  the  so-called  Howship-Eomberg  symj)tom, 
which  is  very  useful  in  diagnosis, — namely,  the  pain  referred  to  the  distribu- 
tion of  the  obturator  nerve  on  the  inner  side  of  the  thigh  and  leg,  and  even 
reaching  the  great  toe.  Occasionally  a  paralysis  of  the  adductor  muscles 
supplied  by  the  nerve  has  also  been  noted.  Certain  movements  of  the  hij)- 
joint  may  cause  pain  by  the  pressure  of  the  obturator  muscles  upon  the 
tumor,  and  tenderness  may  be  detected  by  deep  pressure  in  Scarpa's  space. 
Examination  by  the  vagina  or  by  the  rectum  may  aid  in  diagnosis  by  the 
detection  of  a  loop  of  bowel  adherent  in  that  neighborhood.  Obturator 
hernia  is  frequently  complicated  by  inguinal  or  femoral  hernia,  and  if 
symptoms  of  strangulation  exist  when  the  inguinal  or  femoral  hernia  is 
evidently  not  strangulated,  search  should  be  made  for  an  obturator  hernia. 

Sciatic  Hernia. — In  rare  instances  hernia  takes  place  at  the  greater  or 
lesser  sciatic  notch  above  or  below  the  pyriformis  muscle,  forming  a  small 
tumor  under  the  gluteus  maximus,  which  may  enlarge  and  appear  below  the 
inferior  margin  of  that  muscle.  Strangulation  may  occur.  The  sac  can  be 
exposed  by  incision  directly  over  it,  or  laparotomy  may  be  done  and  the 
intestine  drawn  out  of  the  abnormal  opening. 

Perineal  Hernia. — Occasionally  the  intervals  between  the  muscular 
fibres  of  the  levator  ani  give  passage  to  i^rotrusions  which  i^ass  downward 
and  present  in  the  i^erineum,  traversing  the  ischio-rectal  space.  In  the 
male  these  are  easily  recognized,  as  they  form  a  protrusion  between  the 
middle  line  of  the  perineum  and  the  thigh,  but  in  the  female  they  may  pass 


976  PATHOLOGY   OF  HERNIA. 

into  the  posterior  or  tlie  anterior  part  of  the  labia,  where  they  may  simulate 
cysts.  Such  hernife  may  also  form  protrusions  into  the  vagina  or  even  into 
the  rectum.     They  are  very  rare  and  seldom  strangulated. 

Diaphragmatic  Hernia. — Hernial  protrusions  occur  through  the  dia- 
phragm, entering  the  chest.  They  may  be  of  traumatic  origin  and  due  to 
rupture  of  the  diaphragm,  and  are  then  usually  fatal.  They  may  also  be 
due  to  congenital  deficiencies  in  the  muscle,  or  they  may  pass  through  the 
natural  openings  in  the  diaphragm.  In  some  cases  the  stomach  and  a  large 
part  of  the  small  intestine  have  been  found  in  the  thorax  and  yet  the  patients 
have  shown  no  symptoms  of  the  displacement.  The  liver  may  enter  the 
sac.  The  possible  existence  of  such  obscure  hernite  should  be  considered  in 
cases  of  intestinal  obstruction. 

Pathology. — Contents. — The  contents  of  a  hernia  are  almost  invari- 
ably omentum  or  intestine,  although  almost  any  of  the  abdominal  organs 
may  be  found  in  unusual  cases.  The  urinary  bladder,  stomach,  ovaries, 
and  uterus  are  occasionally  met  with,  and  the  spleen  and  the  kidney  when 
in  the  floating  condition.  The  liver,  gall-bladder,  and  even  the  pancreas 
have  been  found  in  umbilical  hernise.  The  urinary  bladder  is  usually 
drawn  down  into  the  liernia  by  the  traction  of  the  peritoneum,  which  is 
dragged  down  to  form  the  sac,  and  thus  becomes  part  of  the  sac.  But  the 
intraperitoneal  portion  of  the  bladder  wall  may  also  prolapse  directly  into 
the  hernia  like  the  bowel.  Usually  only  a  small  part  of  the  bladder  is 
involved,  but  in  a  case  of  the  writer's  two-thirds  of  the  organ  was  in  the 
sac.  Urinarjr  symptoms  occur  (the  tumor  varies  in  size  with  micturition, 
or  pressure  on  it  causes  the  desire  to  urinate),  but  are  not  common,  and  the 
diagnosis  is  seldom  made  before  oiDcration.  If  strangulation  occurs  and  no 
bowel  is  involved,  intestinal  symptoms  will  be  absent.  The  protruding 
bladder  wall  is  often  thinned  and  altered  in  hernia,  and  is  not  easily  recog- 
nized. A  hernia  containing  omentum  is  known  as  an  epiplocele,  and  one 
containing  intestine  as  an  enterocele,  combinations  of  the  two  being  called 
entero-epiplocele.  The  omentum  may  form  a  bag  around  the  bowel,  or 
may  be  displaced  to  one  side  of  the  sac.  Omentum  which  has  been  long  in 
a  hernial  sac  undergoes  hypertrophy  of  its  distal  part,  owing  to  the  venous 
congestion,  and  forms  a  mass  like  a  lipoma,  while  the  neck  of  the  protrusion 
is  apt  to  be  reduced  to  a  fibrous  cord  by  the  compression.  The  omentum 
may  atrophy,  openings  appearing  in  it  through  which  a  knuckle  of  gut  may 
become  strangulated.  In  other  cases  calcification  or  cystic  degeneration 
takes  place,  but  the  cysts  which  are  most  frequently  seen  in  hernial  sacs  are 
due  to  chronic  peritoneal  inflammation,  like  those  which  form  in  the  peri- 
toneal cavity.  Omentum  is  almost  always  adherent  to  the  sac,  at  least  at  the 
neck,  and  an  epiplocele  is  generally  irreducible. 

The  intestine  is  much  less  likely  to  be  adherent,  and  is  usually  very  little 
altered  by  its  sojourn  in  the  hernia,  but  in  some  cases  its  walls  are  thick- 
ened, even  to  such  an  extent  as  to  reduce  its  caliber.  In  some  cases,  instead 
of  the  protrusion  of  a  loop  of  bowel,  only  a  part  of  the  circumference  of  the 
gut  is  protruded,  being  drawn  out  into  a  sort  of  pouch  constricted  at  its 
base.  This  condition  is  commonly  known  as  Littre's  hernia,  but  some 
contend  that  Littre's  name  should  be  limited  to  a  hernia  of  a  diverticulum. 


PATHOLOGY   OF   HERNIA.  977 

and  that  this  lateral  heruia  of  the  bowel  should  be  called  Richter's  hernia. 
The  lateral  hernia  may  be  due  to  the  adhesion  of  the  bowel  wall  to  the 
peritoneum  which  forms  the  sac,  or  to  the  omentum  or  other  contents  of  the 
hernia,  the  wall  thus  being  drawn  down  into  the  sac.  This  variety  of  hernia 
is  not  common,  but  it  is  very  liable  to  strangulation,  and  the  latter  is  difficult 
to  recognize  because  the  entii'e  lumen  of  the  bowel  is  not  involved  in  the 
constricting  ring,  hence  intestinal  obstruction  may  be  absent  or  incomplete. 
Littre's  hernia  is  seldom  found  except  at  the  femoral  ring. 

A  Meckel's  diverticulum  or  the  appendix  vermiformis  may  be  found  in 
a  hernial  sac,  and  in  the  case  of  these  organs  and  of  the  Fallopian  tube  a 
peculiar  form  of  strangulation,  known  as  retrograde  strangulation,  may 
take  place.  This  occurs  when  the  base  of  the  vermiform  appendix  or  of  the 
tube  descends  into  the  hernia  while  the  tip  remains  free  in  the  peritoneal 
cavity,  and  gangrene  of  the  tip  may  result  if  the  base  becomes  strangulated. 
When  these  organs  are  found  in  a  hernia  they  should  be  drawn  down  and 
removed  or  returned  after  they  have  been  examined  through  their  entire 
length,  lest  peritonitis  follow  from  perforation  of  the  tip.  The  bowel  in  a 
hernia  may  be  inflamed,  it  may  be  the  seat  of  tuberculosis  or  of  cancer,  and 
perforation  of  the  appendix  may  occur  just  as  it  does  in  the  peritoneal  cavity. 
Foreign  bodies  also  occasionally  find  their  way  into  the  bowel  contained  in 
the  hernial  sac,  and  they  may  perforate  the  gut  and  its  coverings,  and 
escape  externally,  after  the  formation  of  an  abscess. 

The  Sac. — The  sac  of  a  hernia  may  be  a  congenital  pouch  like  that  of 
the  congenital  inguinal  or  umbilical  hernia,  or  it  may  be  formed  at  the  same 
time  as  the  protrusion.  In  the  latter  case  it  is  made  by  the  sliding  and 
stretching  of  the  peritoneum  in  the  neighborhood  of  the  aperture  through 
which  the  hernia  escapes,  as  is  shown  by  the  converging  folds  and  wrinkles 
of  the  membrane.  The  sac  is  subject  to  certain  changes.  It  may  be  divided 
into  pouches  either  by  bands  external  to  it,  especially  in  the  femoral  region 
by  a  band  of  the  cribriform  fascia,  or  by  internal  bands  of  organized  peri- 
toneal fibrinous  exudate.  When  internal  bands  ai'e  present  the  sac  is 
frequently  found  very  much  narrowed  at  the  neck.  This  may  be  the  result 
of  inflammation,  or  it  may  be  due  to  the  natiiral  attempt  to  close  the  funicu- 
lar process  at  one  or  more  points.  The  contents  of  the  sac  may  be  free,  or 
they  may  become  adherent  owing  to  a  chronic  serous  inflammation  excited 
by  the  pressure  of  a  truss  or  by  the  impeded  circulation.  In  some  cases  one 
of  the  extraperitoneal  organs  may  be  found  in  the  sac,  the  c£ecum,  for 
instance,  slipping  down  with  the  fat  behind  it,  so  that  the  peritoneal  sac  does 
not  entirely  include  the  bowel,  that  part  of  it  which  was  extraperitoneal  in 
the  abdominal  cavity  remaining  in  the  same  relation  to  the  sac.  Such  a 
condition  as  this,  the  presence  of  adhesions,  or  the  hypertrojihy  of  the 
omentum,  already  described,  may  prevent  the  return  of  the  contents  of  the 
sac  into  the  abdomen.  Sometimes  the  neck  of  the  sac  becomes  shut  off  bj' 
an  adherent  plug  of  omentum  while  the  hernia  is  reduced,  and  serum  accumu- 
lates in  the  empty  sac  and  produces  a  hydrocele  of  the  hernial  sac.  In  some 
cases  a  sac  with  an  obliterated  neck  has  been  pushed  forward  by  another  her- 
nia developing  behind  it,  a  condition  which  must  not  be  confounded  with 
infantile  or  encysted  hernia,  although  it  may  closely  resemble  the  latter. 


978  SYMPTOMS  OF  HERNIA. 

Theory  of  Strangulation. — Strangulation  may  be  the  result  of  the 
descent  of  an  additional  loop  of  bowel  into  the  hernia,  for  the  narrow  ring 
may  be  dilated  as  the  loop  passes,  and  may  then  contract  by  its  elastic  force 
around  the  small  part  of  the  loop.  The  obstruction  to  the  passage  of  the 
contents  along  the  intestine  may  be  complete  even  when  there  is  considerable 
space  in  the  ring  by  the  side  of  the  bowel,  and  when  a  No.  IS  French  catheter 
can  be  passed  down  into  the  loop  of  gut.  As  the  strangulated  loop  is  shut 
oft'  it  becomes  distended  by  gas  developing  in  it,  by  serum  which  transudes 
in  consequence  of  the  impeded  circiilation,  or  by  additional  fecal  matter 
being  driven  into  it  from  above.  The  effect  of  this  distention  is  to  draw 
more  bowel  down  into  the  hernial  sac,  the  expanding  wall  of  the  incarcerated 
loop  pulling  on  the  intestinal  wall  above,  and  this  also  draws  down  more 
mesentery  into  the  ring  and  increases  the  pressure  at  that  point.  Complete 
obstruction  to  the  passage  of  fecal  contents  and  complete  irreducibility  may 
be  present  when  the  constriction  is  not  tight  enough  to  produce  any  mechani- 
cal disturbance  of  the  circulation  of  the  incarcerated  loop.  The  first 
changes  produced  in  the  bowel  by  strangulation  are  venous  congestion  and 
cedenia,  followed  by  cessation  of  the  circulation  and  finally  by  death  of  the 
tissues,  which  is  apt  to  begin  on  the  mucous  membrane  and  extend  outward 
to  the  serous  surface.  Before  necrosis  takes  place,  fibrin  is  thrown  out  on 
the  peritoneal  surface.  Bacteria  undoubtedly  pass  through  the  intestinal 
wall  when  the  circulation  is  stagnant,  and  may  cause  inflammation  and 
suppuration  of  the  sac,  but  the  exact  conditions  which  favor  their  passage 
are  not  yet  understood,  as  their  outward  movement  seems  to  be  independent 
of  the  duration  and  of  the  severity  of  the  constriction. 

The  constriction  may  be  caused  by  the  fibrous  ring  outside  of  the  sac  or 
by  the  neck  of  the  sac  itself,  as  the  latter  is  apt  to  become  narrowed  and 
converted  into  a  tough  fibrous  band  when  the  hernia  has  existed  for  some 
time.  In  rare  cases  the  strangulation  may  take  place  loithin  the  sac,  a  loop 
of  bowel  slipping  through  an  opening  in  the  omentum,  or  being  constricted 
by  a  diverticulum  or  a  band  of  peritoneal  adhesions.  Strangulation  is 
rarely  seen  in  a  hernia  containing  no  intestine. 

Symptoms. — The  symptoms  of  a  reducible  hernia  are  the  existence  of 
the  hernial  swelling,  occasionally  local  pain  or  discomfort,  or  merely  a  feel- 
ing of  weakness,  and  a  tendency  to  constipation  owing  to  the  obstruction  to 
the  bowels  caused  by  their  protrusion.  A  hernia  tends  to  increase  in  size, 
the  ligamentous  structures  about  the  neck  of  the  sac  stretching  and  more  of 
the  abdominal  contents  being  constantly  prolapsed.  The  beginning  of  the 
formation  of  a  hernia  has  sometimes  been  marked  by  pain  in  the  groin,  the 
testicle,  the  back,  or  the  abdomen  before  any  protrusion  has  been  noticed. 
In  children  a  rupture  even  of  large  size  may  leave  no  trace  after  reduction, 
and  it  may  be  difficiilt  to  prove  that  the  ring  is  larger  than  normal,  so  that 
two  surgeons  examining  the  child  on  different  occasions  might  give  opposite 
opinions  as  to  the  existence  of  a  hernia.  Inguinal  and  femoral  heruife  are 
more  common  on  the  right  side.  A  very  large  scrotal  hernia  draws  on  the 
skin  in  all  directions,  even  depriving  the  penis  of  its  covering,  so  that  the 
organ  disappears  under  the  skin,  leaving  at  its  normal  situation  a  depression 
which  looks  like  the  umbilicus.     (Fig.  783.) 


DIAGNOSIS   OF  PIERNIA.  979 

The  hernial  tumor  varies  in  size  from  a  scarcely  perceptible  swelling  to 
one  twice  the  size  of  a  man's  head,  the  largest  being  of  the  umbilical  and 
inguinal  varieties.  The  tumor  is  covered  with  normal  skin  not  adherent  to 
the  sac,  but  the  skin  may  be  very  thin,  or  ulcerated  by  the  pressure  of  a 
truss  or  bandage,  large  portions  sometimes  sloughing, 
with  great  danger  of  infection  of  the  contents  from  Fm.  Ts:;. 

the  resulting  suppuration.     The  tumor  may  be  soft      r-r^ —      ^-  -^ 

and  compressible  ;  or  firm  and  doughy  if  it  contains 
omentum,  or  if  the  bowel  is  filled  with  fecal  matter  ; 
or  it  may  be  tense  if  there  is  any  constriction  at  the 
ring.  It  often  disappears  spontaneously,  or  at  least 
diminishes  in  size,  when  the  patient  lies  down. 
There  is  a  distinct  imijulse  to  be  felt  in  the  swelling 
when  the  patient  coughs.     Impulse   on   coughing  j    f 

is  easily  obtained  in  a  large  hernia  by  grasping  it  1  / 

with  the  hand  and  directing  the  patient  to  cough, 
when  an  exijansile  distention  of  the  sac  will  be  felt. 
In  a  bubonocele  it  is  recognized  by  invaginating  the 
scrotum  and  passing  the  finger  into  the  inguinal  canal, 
so  that  when  the  j)atlent  coughs  the  impulse  of  the 
tumor  will  be  felt  against  the  tip  of  the  finger ;  but 
this  impulse  must  not  be  confounded  with  the  con- 
traction of  the  muscles  around  the  invaginating  finger. 
Scrotal  herniiB  when  weighed  in  the  hand  are  light, 
the  swelling  is  soft  and  compressible,  and  fluctuation 
is  seldom  jjresent  unless  there  is  free  fluid  in  the  sac. 
If  the  hernia  includes  bowel  containing  gas,  resonance 
on  percussion  is  evident.     When  the  hernia  is  reduced  ^"fclTof  d"  ElTbbe!)"'''' 
the  contents  slip  back  rather  suddenly,  and  are  gen- 
erally easily  kept  back  by  pi-essure  over  the  ring.     When  the  hernia  is  very 
small  only  an  indefinite  swelling  may  be  felt,  no  distinct  tumor  being  detected, 
aud  yet  when  pressure  is  made  a  sense  that  something  yields  and  slips  back, 
as  in  the  reduction  of  a  hernia,  will  enable  the  diagnosis  to  be  made.     The 
hernial  swelling  is  not  translucent,  with  rare  exceptions  in  children.     It  is 
usually  pyriform  in  shape,  except  the  umbilical  variety,  biat  the  neck  is 
rather  thick  and  can  be  traced  directly  to  one  of  the  hernial  openings.     If  a 
scrotal  hernia  is  allowed  to  return  after  reduction,  the  swelling  can  be  seen 
to  begin  above  and  descend  towards  the  bottom  of  the  scrotum,  and  the 
patient  will  often  say  that  the  swelling  appeared,  first  in  the  groin  and 
descended  later  into  the  scrotum.     (For  the  complications  of  strangulation, 
incai^ceration,  and  inflammation  of  hernia,  see  page  989.) 

Diagnosis. — The  diagnosis  of  hernia  may  be  simple  or  very  difficult. 
The  principal  conditions  with  which  it  is  apt  to  be  confounded  are  the 
various  forms  of  tumor,  especially  enlarged  lymphatic  glands,  tumors  of  the. 
testicle  or  cord,  lipoma  situated  over  the  femoral  or  inguinal  rings,  hydro- 
cele of  the  tunica  vaginalis  or  of  the  cord,  cysts  of  Cowper's  glands  or  of 
the  vulvo- vaginal  glands,  and  hydrocele  of  an  old  hernial  sac. 

The  tumors  which  are  liable  to  be  mistaken  for  hernia  are  not  reducible, 


980 


DIAGNOSIS   or  HERNIA. 


have  no  impulse  on  coughing,  are  firm  to  the  touch,  and  feel  heavy  when 
lifted  in  the  hand  ;  fluctuation  is  not  usually  detected,  and  there  is  no  reso- 
nance on  percussion.  Tumors  may  be  painful,  and  pressure  may  cause  some 
increase  of  pain.  Even  if  there  should  be  a  prolongation  running  up  towards 
the  groin  the  upper  limit  can  generally  be  reached,  and  usually  the  tumor  is 
more  or  less  ovoid  or  globular.  The  patient  will  often  relate  that  the  swell- 
ing was  first  noticed  in  the  lower  part  of  the  scrotum. 

Hydrocele. — Hydrocele  and  cystic  tumors  may  or  may  not  be  reducible 
according  as  the  opening  through  the  funicular  process  has  remained  open 
or  not,  but  they  are  generally  irreducible.  If  the  hydrocele  is  reducible 
a  distinct  impulse  on  coughing  may  be  present,  and  an  imitation  of  this 
sensation  is  sometimes  produced  in  an  irreducible  hydrocele  when  a  pro- 
longation of  its  sac  extends  well  up  into  the  inguinal  canal,  where  it  can  be 
grasped  by  the  abdominal  muscles.  Weighed  in  the  hand,  the  hydrocele 
or  cystic  tumor  feels  of  medium  weight,  but  considerably  heavier  than  a 
hernia.  It  is  elastic  to  the  touch,  fluctuation  is  distinct,  and  there  is  abso- 
lute flatness  on  percussion.  If  reduction  can  be  made,  it  is  diiiicult  to  keep 
the  sac  empty  by  pressure  upon  the  ring,  for  the  fluid  slips  through  under 
the  flngers.  If  reduction  is  allowed  to  take  place  spontaneously  in  such  a 
hydrocele,  by  having  the  patient  recline  upon  his  back,  the  reduction  is  very 
slow,  while  a  reducible  hernia  under  the  same  circumstances,  when  it  once 
begins  to  move,  usually  slips  back  quickly.  The  hydrocele  is  almost  inva- 
riably translucent,  and  hernia  is  very  rarely  so,  the  exceptions  occurring  in 

children,  in  whom  the  light  sometimes 
passes  imperfectly  through  a  hernia.  If 
the  neck  can  be  felt  it  is  generally  thin, 
although  we  have  seen  some  cases  in 
which  it  was  the  size  of  the  finger  or 
thumb.  The  patient  will  generally  state 
that  the  swelling  was  first  noticed  in  the 
lower  part  of  the  scrotum.  Hydrocele 
and  hernia  may  coexist  on  the  two  sides. 
(Fig.  78i.)  As  Macready  points  out,  the 
method  of  distinguishing  between  con- 
genital hydrocele  and  hernia  by  the 
greater  ease  with  which  the  latter  is  re- 
tained after  reduction  is  of  little  practical 
importance,  because  the  diagnosis  must 
generally  be  made  in  children,  and  in 
children  a  hernia  when  reduced  is  very 
apt  not  to  return  at  once,  even  if  the  ring 
be  large  and  the  hernia  of  considerable 
size,  and  the  test  therefore  cannot  be 
applied.  A  congenital  hydrocele,  more- 
over, does  not  always  come  down  at  once  after  reduction.  The  diagnosis 
between  hydrocele  and  hernia  is  less  difficult  than  would  appear  at  first, 
because  irreducible  enteroceles,  which  alone  could  be  confounded  with 
hydrocele,  are  rare,  irreducible  hernise  being  usually  omental.     Hydrocele 


Right  inguinal  hernia  and  left  hydrocele, 
showing  the  difference  in  the  necli  of  tlie 
tumors. 


DIAGXOSIS   OF   HERNIA.  981 

of  a  hernial  sac  is  very  difficult  to  differentiate  from  irreducible  hernia 
except  by  its  translucency  and  by  exploratory  aspiration.  In  women  a 
hydrocele  in  the  canal  of  Nuck  is  easily  recognized,  because  a  bubonocele 
in  women  is  rarely  irreducible. 

Varicocele. — The  swelling  of  varicocele  may  be  reduced  by  pressure, 
but  without  any  sense  of  distinct  slipping  back.  If  the  jjatient  lies  down 
the  swelling  becomes  reduced,  but  very  slowly,  and  it  is  not  easj^  to  keep  it 
reduced  by  pressure  upon  the  ring  when  the  patient  stands.  The  scrotum 
feels  light,  and  the  tumor  has  the  characteristic  sensation  of  a  bundle  of 
worms.  I>ro  fluctuation  is  present,  but  there  may  be  a  decided  impulse  on 
coughing  in  certain  cases,  although  the  response  is  not  quite  so  distinct  as 
in  a  hernia  or  in  a  congenital  hydrocele.  When  the  neck  of  the  sac  is  fol- 
lowed up  towards  the  ring  it  is  found  to  become  very  narrow,  and  the  patient 
states  that  he  first  noticed  the  swelling  in  the  scrotum. 

An  undescended  testicle  in  the  inguinal  canal,  when  inflamed,  is  pain- 
ful, and  may  occasion  vomiting  and  simulate  a  strangulated  hernia.  It  can 
be  recognized  by  the  absence  of  the  testicle  on  that  side  and  by  the  peculiar 
subjective  sensation  given  by  pressure  upon  the  gland.  An  inflamed  tes- 
ticle is  apparently  often  mistaken  for  a  hernia,  but  such  an  error  can  occur 
only  from  carelessness,  the  symptoms  being  very  different.  Psoas  abscess 
may  closely  resemble  a  femoral  hernia,  esiDCcially  as  it  may  present  an 
impulse  on  coughing  and  may  be  i>artly  reducible,  but  it  usually  lies  on  the 
outer  side  of  the  femoral  vessels.  Fluctuation,  moreover,  is  distinct,  and 
another  tumor  can  often  be  felt  above  Poupart's  ligament,  fluctuation  being 
felt  from  one  to  the  other.  An  examination  of  the  spine  or  of  the  iliac 
bones  will  generally  reveal  the  inflammatory  origin  of  the  abscess.  A 
varicose  distention  of  the  upper  part  of  the  saphenous  vein  sometimes 
makes  a  ijrotrusion  in  the  femoral  triangle  resembling  heruia,  but  it  can  be 
distinguished  by  the  fact  that  it  fills  up  from  below  when  the  femoral  ring  is 
completely  occluded  by  strong  pressure. 

Diagnosis  of  the  Variety  of  Hernia. — The  aperture  through  which 
a  hernia  has  descended  is  ascertained  by  tracing  back  the  neck.  In  certain 
cases,  especially  in  stout  individuals,  it  is  difficult  to  distinguish  between 
inguinal  and  femoral  rupture,  and  in  every  such  case  the  position  of  the 
tumor  should  be  disregarded  and  only  the  position  and  direction  of  the 
neck  considered  in  making  the  diagnosis.  In  femoral  hernia  the  neck  must 
enter  below  Poupart's  ligament,  and  when  this  landmark  cannot  be  felt  the 
pubic  spine  must  be  sought,  and  a  straight  line  drawn  from  this  point  to  the 
anterior  superior  spine  of  the  ilium  will  nearly  correspond  to  its  course. 
The  pubic  spine  can  be  readily  felt  in  the  male  by  invaginating  the  scrotum, 
and  in  the  female  by  putting  the  adductors  on  the  stretch  and  searching  for 
the  spine  directly  above  their  attachment  to  the  pubes. 

Suspected  Strangulation. — In  a  doubtful  case  with  symptoms  re- 
sembling strangulation,  any  suspected  swelling  should  be  examined  by  an 
exploratory  incision,  for  an  unnecessary  operation  is  less  dangerous  than  a 
neglected  hernia.  The  surgeon  should  carefully  examine  for  the  presence 
of  obturator  and  sciatic  hernite  in  ijarticular,  which  should  be  excluded 
before  deciding  that  the  strangulation  is  internal. 

63 


982  TREATMENT  OF  HERNIA  BY  TRUSS. 

Treatment. — Hernia,  whether  reducible  or  irreducible,  can  be  treated 
by  applying  apparatus  to  retain  it  or  jjrevent  its  growth,  or  by  operation, 
and  a  radical  cure  may  be  obtained  by  either  method,  although  more 
certainly  by  operation.  A  spontaneous  cure  sometimes  takes  place  in 
infancy,  even  without  the  aid  of  a  truss,  especially  in  inguinal  hernia. 

Trusses. — A  truss  is  a  form  of  apparatus  applied  to  retain  a  reducible 
hernia  or  to  prevent  an  irreducible  one  from  becoming  larger.  A  cure  by 
a  truss  can  be  hoped  for  only  in  inguinal  hernia  in  the  young  and  in 
umbilical  hernia  in  infants.  In  from  one-sixth  to  one-fifth  of  the  cases  a 
complete  cure  may  be  obtained  by  persistent  and  intelligent  use  of  a  good 
truss,  but  a  successful  result  is  possible  only  when  the  hernia  is  entirely 
reducible,  when  the  truss  retains  it  perfectly,  and  when  the  rupture  is  never 
allowed  to  descend.  Every  time  a  hernia  which  has  been  retained  by  a 
truss  passes  through  the  canal  it  stretches  the  latter  again  and  pushes  down 
the  sac,  and  the  original  condition  returns.  Trusses  for  inguinal  and  femo- 
ral herniae  are  of  three  varieties,  all  of  them  consisting  of  two  important 
parts, — a  pad  to  press  upon  the  hernia  and  a  spring  which  passes  around 
the  body  to  hold  the  pad. 

The  Pad. — In  ordinary  cases  the  pad  should  be  broad  and  flat,  for  a 
conical  pad  forces  its  point  into  the  canal  and  tends  to  enlarge  the  latter. 
The  pad  may  be  circular  or  oval  in  shape.  It  is  usually  covered  with  soft 
leather  and  stuffed,  or  it  may  be  a  rubber  sac  filled  with  air  or  some  fluid, 
but  a  simple  pad  of  hard  rubber  or  wood  is  also  employed. 

The  Spring. — The  spring  is  of  several  varieties.  The  first  form  passes 
around  the  body  on  the  rujitured  side,  behind  the  back,  and  across  to  the 
opposite  sacro-iliac  articulation.  (Figs.  787  and  788.)  The  second  form  of 
spring  crosses  in  front  from  the  ruptured  side  to  the  opposite  and  around 
the  body  to  the  sacroiliac  articulation  upon  the  ru^jtured  side,  thus  includ- 
ing about  three-quarters  of  the  circumference  of  the  pelvis.     (Fig.  785.) 

The  third  form  is  a  spring  which  crosses 
^'^'-  '^'^-  the  front  of  the  body  and  is  open  behind, 


Fig.  786. 


Truss  for  right  inguinal  liernla,  spring  crossing  Double  truss,  spring  open  behind, 

the  body. 

its  two  ends  resting  upon  the  sacro-iliac  articulations  (Fig.  786) ;  or  a 
spring  which  is  open  in  front,  passing  around  the  body  from  behind  and 
carrying  a  pad  at  each  end,  thus  leaving  the  space  over  the  pubes  free. 
The  third  form  is  employed  for  double  hernia.  In  both  the  single  forms 
mentioned  the  spring  is  of  a  slightly  spiral  shape,  the  point  of  pressure  at 
the  back  being  decidedly  above  that  at  the  femoral  or  inguinal  ring,  and 
the  spring  should  lie  about  midway  between  the  crest  of  the  ilium  and  the 
trochanter.     The  spring  is  made  of  steel  of  low  temper,  so  that  it  can  be 


TREATMENT  OF  HERNIA  BY  TRUSS. 


983 


easily  bent  in  the  hands,  and  is  covered  with  leather,  hard  rubber,  or 
celluloid.  The  two  latter  must  be  dipped  in  hot  water  if  it  is  necessary  to 
alter  their  sha]pe.     The  spring  known  as  the  French  truss  (Fig.  787)  has 

Fig.  787. 


little  stiffness,  but  is  shaped  to  fit  the  body  exactly,  and  maintains  a  con- 
tinuous gentle  pressure  ;  while  the  German  truss  (Fig.  788)  is  very  stiff,  but 
does  not  fit  very  closely,  and  thex'efore  simply  resists  when  the  hernia  tends  to 
descend  against  the  pad.     The  strength  of  the  spring  must  be  suited  to  the 


German  truss  for  right  inguinal  hernia. 

individual  case,  a  very  light  spring  being  usually  sufficient  if  the  spring  is 
I)roperly  shaped  and  applied,  but  in  some  cases  a  very  heavy  spring  is 
necessary.  The  form  of  spring  surrounding  the  ruptured  side  of  the  body 
is  not  quite  so  efficient  as  that  which  passes  around  the  sound  side,  because 
its  support  in  the  back  is  on  the  opposite  side  and  the  pressure  is  not  so 
direct,  but  it  is  easier  to  fit  because  it  lies  naturally  in  the  fold  of  the  groin, 
and  is  therefore  very  popular.  A  truss  consisting  of  an  elastic  band  with 
a  pad  is  a  favorite  with  some,  but  it  is  much  less  efficient  and  direct  in  its 
pressure  than  the  spring  trusses,  and  should  be  limited  to  use  at  night. 

When  the  surgeon  is  fitting  a  patient  with  a  truss  he  should  reduce  the 
hernia  and  press  lightly  over  the  point  of  exit  while  the  patient  coughs  and 
makes  various  movements,  in  order  to  determine  the  amount  of  pressure 
which  will  be  necessary  to  hold  the  hernia.  Having  selected  a  spring  of  the 
proper  strength,  the  pad  is  applied  over  the  point  of  exit,  the  spring  is 
passed  around  the  body,  and  the  truss  is  secured  by  the  strap.  The  patient 
again  makes  efforts  of  coughing  and  of  stooping,  to  ascertain  if  the  truss  is 


984  TREATMENT   OF  HERNIA  BY  TRUSS. 

efficient.  But  it  should  be  remembered  that  a  pressure  that  is  readily  borne 
for  a  short  time  may  be  sufficient  to  produce  destructive  changes  in  the  skin 
at  the  point  of  contact  if  long  continued ;  therefore  the  lightest  possible 
pressure  consistent  with  retention  should  be  used  in  every  case.  It  will  fre- 
quently be  impossible  to  put  on  a  truss  which  will  retain  the  hernia  during 
coughing,  and  the  patient  must  be  directed  to  press  xipon  the  pad  with  his 
hand  whenever  he  coughs.  After  the  lapse  of  a  few  days  or  weeks,  however, 
the  truss  will  often  x^rove  sufficient  to  hold  the  hernia  even  during  coughing, 
some  contraction  of  the  ring  having  taken  place.  In  oblique  inguinal  hernia 
the  pad  should  be  placed  directly  over  the  internal  ring,  not  over  the  exter- 
nal, nor  over  the  neck  of  the  sac  still  lower  down.  In  cases  of  femoral  her- 
nia the  spring  must  be  twisted  so  that  the  pad  shall  press  directly  uj)ward 
when  the  patient  stands  erect,  as  the  femoral  ring  lies  in  a  horizontal  plane 
in  that  position.  Even  in  inguinal  hernia,  when  the  patient  has  a  prominent 
abdomen,  the  spring  must  be  twisted  so  that  the  pad  will  press  almost 
directly  upward,  and  it  is  very  difficult  in  such  individuals  -to  secure  suffi- 
cient pressure  to  retain  the  hernia.  In  thin  persons,  on  the  contrary,  the 
pad  has  a  tendency  to  ride  up  on  the  abdomen,  and  must  be  held  in  place 
by  a  perineal  strap,  which  should  pass  downward  from  the  pad  around  the 
inner  side  of  the  thigh,  and  follow  the  crease  of  the  buttock  to  the  spring 
at  a  point  near  the  trochanter  of  the  same  side.  In  very  large  and  old  her- 
nise,  i^articularljr  the  dii-ect  form,  or  those  which  were  originally  oblique 
and  have  practically  become  direct,  a  large  triangular  pad  is  sometimes 
necessary,  the  lower  apex  being  carried  down  between  the  scrotum  and 
the  thigh,  and  being  continuous  with  the  perineal  strap.  This  form  is 
called  the  rat-tailed  pad,  and  while  it  is  useful  for  herniae  of  this  kind  it 
should  not  be  employed  in  others,  for  it  applies  the  pressure  in  the  wrong 
place.  It  is  easier  to  fit  a  double  truss  than  a  single  one,  and,  if  with  a  hernia 
on  one  side,  the  other  side  is  weak,  the  patient  should  wear  the  double  truss, 
preferably  that  form  with  pads  at  each  end  of  a  spring  which  encircles  the 
body  behind,  and  a  straj)  connecting  the  ends  in  front- 
Umbilical  hernia  in  infants  can  be  treated  by  a  flat  cork  pad  placed  over 
the  navel  and  held  by  adhesive  straps,  for  no  bandage  will  hold  it  properly. 
In  older  children  and  in  adults  a  similar  pad  may  be  secured  in  the  centre 
of  a  strong  abdominal  belt  or  of  a  strong  spring  passing  around  the  body 
and  resting  on  two  wide  pads  on  each  side  of  the  spine.  As  this  hernia  is 
apt  to  occur  in  very  stout  individuals,  the  level  of  the  ring  will  be  very 
much  deeper  than  that  of  the  abdominal  surface,  and  a  conical  pad  may  be 
necessary  in  order  to  exercise  proper  pressure,  but  the  apex  of  the  pad 
should  be  so  much  larger  than  the  ring  that  it  cannot  enter  and  stretch  the 
latter. 

The  various  kinds  of  truss  described  are  suitable  for  reducible  hernia. 
In  the  irreducible  varieties  it  is  almost  impossible  to  apply  an  efficient  pad, 
but  sometimes  a  hollow  cup-shaped  i^ad  may  be  used,  being  made  to  fit  a 
cast  taken  of  the  irreducible  part  of  the  tumor,  and  this  may  be  held  in 
place  by  a  spring  or  an  abdominal  belt.  •  It  will  be  found,  however,  that 
patients  with  irreducible  scrotal  or  labial  hernia  are  generally  most  com- 
fortable with  a  cotton  bag   made  of  proper  size  to  hold  the  hernia  and 


OPERATIONS   FOR   HERNIA.  985 

exercise  slight  pressure  upon  it,  and  that  those  with  irreducible  ventral  or 
umbilical  hernia  prefer  a  simple  body  bandage. 

When  an  attempt  is  to  be  made  to  cure  a  hernia  by  a  truss  the  patient 
should  have  a  lighter  truss  to  wear  at  night,  and  should  never  go  without 
the  instrument,  even  when  in  the  bath.  In  any  case  the  patient  should  be 
instructed  how  to  adjust  the  truss,  and  should  be  told  to  remove  it  at  once  if 
he  feels  the  rupture  come  down  behind  it,  for  the  pressure  on  the  descended 
ru])ture  is  liable  to  do  damage. 

Injections  into  the  Tissues  of  the  Canal. — Prom  time  to  time  various 
other  methods  of  treating  hernia  have  been  recommended,  such  as  the  injec- 
tion of  astringent  applications  along  the  canal  or  into  the  surrounding  tissue, 
the  best  known  and  most  used  of  these  being  absolute  alcohol  and  a  tannic 
acid  solution.  In  making  these  injections  the  finger  is  placed  in  the  canal 
as  a  guide,  the  needle  is  then  made  to  pass  along  just  outside  of  the  fibrous 
tissues  forming  the  canal,  and  the  injection  is  made  at  this  jilace.  While 
cures  can  undoubtedly  be  produced  in  this  way,  the  method  is  uncertain, 
and  its  application  adds  very  much  to  the  difficulty  of  any  subsequent  oper- 
ation on  the  parts,  whether  the  operation  be  practised  on  account  of  strangu- 
lation or  to  obtain  a  radical  cure.  If  the  fullest  asepsis  is  not  maintained, 
suppuration  will  follow  the  injection,  and,  unless  the  needle  is  accurately 
guided,  the  fluid  may  be  thrown  into  the  peritoneal  cavity  ;  hence  the  method 
is  not  free  from  danger. 

Operations  for  the  Radical  Cure  of  Inguinal  Hernia. — Of  the 
operative  methods  recommended  for  the  radical  cuie  of  inguinal  hernia 
it  is  unnecessary  to  describe  more  than  four.  To  prepare  the  patient  for 
oi>eration  the  bowels  must  be  thoroughly  evacuated,  and  the  pubes,  scrotum, 
or  labia  shaved  and  sterilized  as  usual.  The  incision  is  to  be  a  free  one, 
thoroughly  exposing  the  ring  to  be  sutured,  but  it  is  unnecessary  to  make  it 
the  full  length  of  the  sac,  as  the  latter  will  readily  strip  out  of  its  loose 
cellular  bed. 

(1)  Macewen's  Method. — Macewen  opened  the  sac,  returned  the  con- 
tents, and  bluntly  dissected  a  space  between  the  peritoneum  and  the  abdom- 
inal wall  as  a  bed  for  the  sac.  He  next  passed  a  continuous  suture  back  and 
forth  through  the  sac,  entering  at  its  lower  end  and  coming  out  at  its  neck. 
The  needle  was  then  made  to  carry  the  end  of  this  suture  through  the 
abdominal  wall  above  the  internal  ring  (Fig.  789),  the  sac  was  crowded  into 
the  space  previously  dissected,  being  folded  uji  by  the  suture,  and  the  latter 
was  secured  to  the  skin.  The  conjoined  tendou  was  then  sought,  and  sutures 
passed,  uniting  it  to  Poupart's  ligament  over  the  cord,  thus  reducing  the  size 
of  the  internal  ring.  The  cord  was  allowed  to  remain  close  to  the  pubic  bone 
at  the  lower  end  of  the  opening,  and  this  was  the  weak  point  in  the  method, 
as  a  fresh  protrusion  easily  descended  along  the  cord  as  it  passed  directly 
through  the  abdominal  wall  instead  of  oblic[uely. 

(2)  Bassini's  Method. — The  anterior  wall  of  the  canal  is  incised  up  to 
the  level  of  the  internal  ring,  and  the  cord  is  drawn  upwai'd  and  outward 
so  that  it  passes  through  the  upi^er  part  of  the  wound.  (Fig.  789.)  Bassini 
frees  the  sac,  ligates  it  very  high  up,  pulling  it  down  so  as  to  draw  down 
the  peritoneum  on  all  sides  in  order  that  it  shall  be  gathered  in  at  the 


OPERATIONS  FOE  HERNIA. 


neck  of  the  sac  by  the  ligature  and  present  a  jjerfectly  flat,  smooth  surface 
internally,  "without  any  depression  or  pouch  which  might  favor  a  recur- 
rence. The  sac  is  then  cut  away. 
The  conjoined  tendon  is  then  sutured 
to  the  internal  surface  of  Poupart's 


Fig.  789. 


Bassini  incision,  cord  lield  aside.    Macewen  treat-    Bassini  operation.    Sutures  tlirough  conjoined  tendon 
ment  of  sac,  the  latter  suspended  by  the  thread.  and  Poupart's  ligament  in  place  hut  not  tied. 

ligament  (Fig.  790),  below  the  point  where  the  cord  passes  through  the 
abdominal  wall,  thus  forming  a  posterior  wall  for  the  canal.  The  cord  is 
then  laid  upon  the  sutured  conjoined  tendon,  and  the  divided  aponeurosis 
of  the  external  oblique  is  united  in  front  of  it  so  that  the  normal  oblique 
structure  of  the  canal  is  very  nearly  reproduced. 

(3)  In  Halsted's  method,  which  is  similar  to  Bassini's,  the  external 
wall  of  the  canal  is  incised  up  to  the  internal  ring,  and  the  entire  thickness 
of  the  abdominal  wall  is  divided  obliquely  for  an  inch  or  more  higher. 
The  peritoneal  opening  into  the  sac  is  sutured.  The  muscular  layers  of  the 
wound  are  united  with  mattress  sutures,  leaving  the  cord  passing  out  of  the 
upper  angle,  directly  through  both  oblique  muscles.  All  but  one  or  two  of 
the  veins  of  the  cord  are  cut  away  to  reduce  its  size.  The  skin  is  then  united 
over  the  cord,  which  lies  directly  under  it  outside  of  the  external  oblique. 

(4)  Kocher  incises  the  skin  and  fascia  and  dissects  out  the  sac.  He  then 
makes  a  small  opening  through  the  external  and  internal  oblique  muscles 
above  the  internal  ring,  incises  the  peritoneum,  and  passes  through  that 
opening  a  dressing-forceps  which  is  directed  along  the  canal  and  into  the 
sac.  The  fundus  of  the  isolated  sac  is  grasped  inside,  and  the  forceps  with- 
drawn, invaginatiug  the  sac  in  the  peritoneal  cavity  and  then  drawing  it 
out  of  the  small  upper  wound.  A  ligature  is  thrown  around  the  neck  of  the 
sac,  so  placed  as  to  include  the  edges  of  the  peritoneal  incision  and  to  close 
it  also,  and  the  sac  is  cut  away.  He  considers  this  sufficient  but  adds  that 
the  external  oblique  fascia  may  be  folded  into  the  inguinal  canal  with  a 
coujjle  of  mattress  sutures  ijassed  on  its  external  surface. 

The  most  frequently  used,  and  aijparently  the  most  efficient,  of  these 
operations  is  Bassini's.  Personally  we  prefer  to  combine  Macewen' s  treat- 
ment of  the  sac  with  Bassini's  suture  of  the  canal  whenever  possible.     In 


OPERATIONS  FOR  HERNIA.  987 

some  cases  a  ligature  cannot  be  applied,  and  it  is  necessary  to  suture  the 
peritoneal  opening. 

In  the  Female. — All  these  operations  can  be  performed  in  the  female, 
but  the  round  ligament  should  be  included  in  one  or  more  of  the  sutures 
passing  through  the  conjoined  tendon.  It  has  been  our  custom  in  small 
hernife  to  treat  the  ligament  like  the  cord  in  Bassini's  operation,  but  in 
ruptures  with  a  large  internal  ring  to  secure  it  in  the  lower  angle  of  the 
opening,  as  in  Macewen's  operation. 

Injuries  to  the  Bladder. — The  danger  of  wounding  the  bladder  in 
these  operations  should  be  emphasized.  The  sliding  down  of  the  peritoneum 
in  the  formation  of  the  hernial  sac  is  very  apt  to  draw  the  extraijeritoneal 
portion  of  the  bladder  into  the  hernia,  and  the  structure  of  the  organ  is  so 
altered  that  it  is  difficult  to  recognize  it  even  when  it  has  been  incised,  for 
it  resembles  a  thin  serous  membrane  or  a  mass  of  properitoneal  fat.  As  the 
prolapsed  portion  of  the  bladder  lies  close  to  the  neck  of  the  sac,  it  may  be 
included  in  the  ligature  or  in  the  deep  suture.  If  in  any  case  the  peri- 
toneum does  not  strip  up  readily  on  the  inner  side  of  the  neck  of  the  sac, 
or  if  the  structui-e  of  the  latter  ai^pears  unusual  in  any  way,  the  surgeon 
should  not  i:)roceed  until  he  is  satisfied  that  the  bladder  is  not  involved. 

Radical  Operations  for  Other  Hernias.— Femoral  Hernia. — The 
operation  for  the  radical  cure  of  femoral  hernia  is  not  so  satisfactory  as  that 
for  inguinal.  The  outer  wall  of  the  femoral  canal  is  formed  by  the  femoral 
vein,  and  no  suture  can  be  passed  on  that  side.  Two  methods  are  in  favor 
for  the  treatment  of  this  form.  In  the  first,  which  may  be  called  the  purse- 
string  method,  the  sac  may  be  pulled  down  and  tied  off  as  high  as  possible, 
or  it  may  be  doubled  up  and  treated  as  in  Macewen's  method.  The  femoral 
canal  is  then  held  widely  oi^en  by  lifting  Poupart's  ligament  by  a  blunt 
retractor,  and  a  small  curved  needle  threaded  with  chromicized  catgut  is 
made  to  pick  up  the  under  side  of  Poupart's  ligament,  Gimbernat's  ligament, 
and  the  sheath  of  the  pectineus.  This  suture  is  tied,  and  a  similar  suture 
is  passed  through  the  same  parts  a  little  external  to  the  first,  the  first  stitch 
being  invaginated  by  tying  the  second.  A  third  suture  may  be  passed  out- 
side of  these.  "We  have  obtained  very  good  results  with  this  method,  and 
the  operation  is  not  especially  dilficult.  Another  method  may  be  called  the 
flap  operation.  A  flap  is  formed  from  the  sheath  of  the  pectineus  muscle,  or 
from  the  muscle  itself,  turned  up  under  Poui>art's  ligament,  and  secured  by 
sutures  to  that  structure. 

Umbilical  Hernia. — The  radical  cure  of  umbilical  hernia  also  is  rather 
unsatisfactory,  because  of  the  difiiculty  of  bringing  the  edges  of  the  umbili- 
cal ring  in  contact  on  account  of  the  great  abdominal  tension.  The  contents 
are  usually  adherent  to  the  sac,  and  the  latter  must  be  opened  with  caution, 
for  fear  of  wounding  them.  We  have  found  it  best  first  to  open  the  abdo- 
men just  above  the  umbilical  ring  and  then  to  pass  the  finger  through  into 
the  sac  and  cut  down  upon  the  finger.  In  this  way  the  adhesions  can  be 
released  much  more  readily  than  if  the  sac  were  opened  directly.  When 
the  adhesions  have  been  separated  and  the  omentum  removed  as  far  as 
possible,  the  remains  of  the  sac  are  to  be  sutured  across  the  oi^ening.  The 
■edges  of  the  umbilical  ring  are  freshened,  and  if  the  circular  opening  is 


988  OPERATIONS  FOB  HERNIA. 

very  wide  a  small  wedge-shaped  piece  should  be  taken  from  the  fascia  in  the 
middle  line  of  the  abdomen  above  and  below,  in  order  to  form  an  elliptical 
opening,  which  is  easier  to  suture.  The  edges  are  then  brought  into  contact 
with  chromicized  catgut  sutures,  and,  if  the  tension  is  very  great,  silver  wire 
tension  sutures,  secured  to  lead  plates  or  buttons  at  the  ends,  are  inserted  in 
addition.  The  bowels  and  diet  of  the  patient  should  be  carefully  regulated 
beforehand,  in  order  to  diminish  the  intestinal  contents  as  far  as  possible, 
and  to  prepare  against  the  danger  of  obstruction  when  adherent  bowel  must 
be  returned.  Relapses  are  very  frequent  after  these  operations,  and  the 
patients  are  apt  to  be  stout  and  bear  operations  badly,  but  when  the  amount 
of  disability  is  considerable  an  attemj)t  should  be  made  to  obtain  a  radical 
cure.  In  ventral  hernia  following  a  laparotomy  the  old  scar  should  be 
thoroughly  excised,  and  the  wound  thus  made  closed  as  in  an  ordinary 
laparotomy  without  drainage. 

General  Considerations  in  Operations  for  Radical  Cure.— Su- 
tures.— The  asepsis  of  these  oxjerations  must  be  absolute,  not  merely  because 
of  the  danger  of  peritonitis  and  cellulitis,  but  because  even  slight  suppuration 
in  the  wound  will  jiroduce  more  cicatricial  tissue  with  a  tendency  to  stretch 
and  to  allow  of  a  recurrence.  The  material  used  for  the  deep  sutures  in 
these  operations  is  very  various.  Catgut  is  good,  and  the  chromicized  cat- 
gut can  be  made  to  resist  absorption  for  five  or  six  weeks.  Kangaroo 
tendon,  sterilized  by  boiling  in  alcohol,  is  said  to  last  a  couple  of  months, 
but  we  have  known  of  cases  in  which  it  was  absorbed  in  less  time,  even  in 
three  weeks.  Silver  wire  is  objectionable,  as  it  may  irritate  the  tissues  by 
its  hardness.  Silk  and  silkworm-gut,  especially  the  latter,  make  good  per- 
manent sutures,  but  they  are  liable  to  be  sources  of  infection  as  foreign 
bodies  later,  and  to  cause  small  abscesses.  It  is  true  that  the  latter  may  be 
due  to  bacteria  circulating  in  the  blood  and  settling  in  the  tissues  irritated 
by  the  foreign  body,  but  practically  all  these  cases  are  caused  by  deficient 
sterilization  of  the  material,  a  small  amount  of  germs  or  spores  being  left 
in  them  which  develop  weeks  or  months  after  the  wound  has  healed.  It 
should  be  remembered  that  no  permanent  suture  has  any  holding  power 
after  the  wound  has  healed,  and  is  then  invariably  found  lying  loose  in  its 
bed,  so  that  its  use  does  not  add  to  the  strength  of  the  parts.  Probably  the 
best  materials  are  kangaroo  tendon  and  chromicized  catgut. 

Results. — The  results  of  these  operations  are  best  in  oblique  inguinal 
hernia  of  moderate  size,  of  which  nearly  all  the  cases  can  be  cured  by 
Bassini's  method.  The  success  will  depend  upon  the  aseptic  healing  of  the 
wound,  and  even  a  suj)erlicial  supj)uration  is  liable  to  be  followed  by  a 
recixrrence.  While  the  majority  of  relapses  take  place  within  a  year,  no 
case  can  be  considered  a  certain  cure  until  from  three  to  five  years  have 
passed  without  recurrence.  There  is  practically  no  danger  in  the  operation 
if  carefully  ]3e.rformed  in  pro])erly  selected  cases,  the  mortality  being  esti- 
mated at  one-half  of  one  per  cent. 

Contraindications. — The  operation  for  the  radical  cure  of  hernia 
should  be  undertaken  only  under  favorable  conditions  of  health  and  strength, 
as  it  is  an  operation  of  choice.  Persons  over  sixty  years  of  age  are  gener- 
ally excluded,  but  good  results  can  be  obtained  even  in  them  with  local  or 


STRANGULATION  AND  OTHER  COMPLICATIONS.  989 

spinal  cord  aiiEesthesia.  Satisfactory  results  are  also  obtained  by  opeiations 
in  children  three  years  of  age  or  older.  We  have  operated  in  ca.ses  of 
phthisis  of  moderate  degree  and  chronic  bronchitis,  in  which  the  hernia 
was  troublesome  on  account  of  the  patient's  cough,  and  obtained  a  good 
result.  The  presence  of  cough  during  convalescence,  however,  jeopardizes 
the  success  of  the  operation.  Obesity,  renal  disease,  and  great  size  of  the 
hernia  are  also  contraindications.  In  the  last  case  a  course  of  preliminary 
treatment,  consisting  of  rest  in  bed,  attention  to  diet  and  bowels,  and  keep- 
ing the  hernia  reduced  by  a  truss  or  bandage,  is  essential.  In  these  large 
hernife  the  abdomen  contracts  when  the  hernia  has  been  unreduced  for  a 
long  time,  and  if  operation  is  undertaken  at  once  there  may  actually  not 
be  room  in  the  cavity  for  the  extruded  organs.  Even  if  the  hernia  cannot 
be  entirely  reduced  before  the  operation,  owing  to  the  ijresence  of  hyper- 
trophied  omentum,  a  partial  reduction  may  accustom  the  abdomen  to  retain 
the  bowel  which  has  been  contained  in  the  hernia,  and  the  bowel  can  usually 
be  returned,  while  the  return  of  the  omentum  is  of  less  consequence,  as  the 
latter  can  be  removed  at  the  time  of  operation. 

After-Treatment. — During  the  after-treatment  it  is  all-important  to 
secure  early  and  regular  evacuation  of  the  bowels,  especially  if  there  is  a 
rise  of  temijerature  or  any  tymisauites,  as  these  are  more  likely  to  be  trouble- 
some than  after  ordinary  laparotomies.  If  the  wound  is  infected,  as  shown 
by  fever,  tenderness,  and  swelling,  the  superficial  sutures  are  to  be  removed. 
The  deeper  ones  may  be  allowed  to  remain  if  the  wound  is  kept  open  by 
packing,  so  that  they  are  in  sight  and  can  be  watched,  but  they  must  also 
be  taken  out  if  the  symptoms  continue  or  if  pus  is  i^roduced.  The  patient 
should  be  kept  lying  down  for  at  least  three  weeks,  and  in  cases  of  umbilical 
and  ventral  hernia  should  wear  an  abdominal  bandage  for  a  year.  All 
violent  effort  must  be  forbidden  for  several  mouths,  but  gentle  muscular 
exercise  will  strengthen  the  jjarts  and  should  be  encouraged. 

With  the  exception  of  the  use  of  an  abdominal  bandage  iu  cases  of 
umbilical  and  ventral  hernia,  a  truss  should  not  be  worn  after  these  oper- 
ations, as  the  ijressure  of  the  pad  is  apt  to  cause  ati'ophy  of  the  parts.  A 
truss  should  be  applied,  however,  at  the  first  sign  of  a  recurrence.  Even  if 
a  i^ermanent  cure  is  not  obtained,  such  an  operation  as  Bassini's  often 
enables  a  light  truss  to  hold  herni;e  wliich  were  formerly  uncontrollable. 

Strangulation  and  Other  Complications.— If  the  protruded 
bowel  becomes  clogged  with  fecal  matter  the  passage  of  the  latter  may  be 
completely  arrested,  and  the  hernia  is  said  to  be  obstructed  or  incarcerated. 
If  the  rupture  has  been  previously  reducible  its  contents  can  no  longer  be 
returned,  and  the  tumor  becomes  distended,  doughy,  and  the  impulse  on 
coughing  is  lost.  Absolute  constipation  exists  after  the  intestine  below  the 
hernia  has  been  emptied,  and  vomiting  begins,  assuming  a  fecal  character 
later.  Tympanites  develops  in  the  tumor  and  in  the  abdomen.  The  first 
symptoms  are  those  of  subacute  intestinal  obstruction,  and  if  not  relieved 
they  are  soon  succeeded  by  those  of  strangulation.  The  tumor  is  usually 
painless,  and  i>ressure  over  the  neck  of  the  sac  does  not  give  pain.  But 
later  it  may  be  painful  and  show  signs  of  inflammation.  Treatment. — 
While  it  is  sometimes  possible  to  empty  the  obstructed  bowel  by  massage 


990  STRANGULATED   HERNIA. 

and  the  use  of  strong  euemata,  there  is  little  hope  of  success  in  well- 
developed  cases,  for  strangulation  usually  follows.  Operation  is  generally 
necessary. 

Acute  inflammation  of  the  sac  may  be  caused  by  perforation  of  the 
bowel.  Acute  inflammation  is  sometimes  seen  without  strangulation,  as  the 
result  of  perforation  of  the  bowel  due  to  injury,  or  ulceration,  or  inHamma- 
tion  of  the  vermiform  appendix  contained  in  the  hernia.  "When  inflamma- 
tion occurs  the  hernial  tumor  is  greatly  swollen,  the  tissues  become  infiltrated, 
the  skin  red,  and  an  abscess  may  develop  in  the  connective  tissue.  In  very 
rare  cases  recovery  has  taken  place  after  spontaneous  dischai'ge  of  the 
abscess  and  the  formation  of  a  fecal  fistula  at  the  opening.  The  inflamma- 
tion may  extend  backward  into  the  peritoneal  cavity,  setting  up  a  general 
peritonitis.  Treatmen  t. — Slight  pain  and  swelling  of  an  irreducible  hernia 
may  be  treated  by  cold  applications  and  thorough  evacuation  of  the  bowels 
by  enemata.  But  if  the  symptoms  are  very  severe  or  persistent  the  sac  should 
be  opened  at  once.  If  an  abscess  forms  it  must  be  incised.  The  sac  should 
be  allowed  to  drain  until  all  signs  of  infection  disappear,  before  the  question 
of  operation  for  a  radical  cure  can  be  considered.  A  fecal  fistula  can  be 
repaired  at  the  same  time  as  the  operation  for  radical  cure. 

Strangulation. — Hernise  with  large  oj)enings  are  less  liable  to  strangu- 
lation than  those  with  narrow  rings.  Strangulation  is  less  common  in 
children  than  in  adults,  but  we  have  seen  it  at  birth.  Symptoms. — 
Wlien  strangulation  takes  jslace  there  is  severe  pain  ;  vomiting  begins  early, 
is  apt  to  be  violent,  and  soon  becomes  fecal ;  and  the  constiiiation  is  abso- 
lute, not  even  gas  being  passed  by  rectum.  There  maj'  be  rectal  tenesmus. 
The  patient  is  often  severely  prostrated,  and  the  temperatm-e  may  be 
subnormal.  The  hernial  tumor  becomes  irreducible,  tense,  and  tender, 
especially  at  the  neck  of  the  sac,  and  the  cough  impulse  is  lost.  The  tumor 
will  be  resonant  on  percussion  if  gas  is  present.  There  are  often  signs  of 
beginning  peritonitis,  such  as  tympanites  and  abdominal  tenderness.  There 
may  be  increased  peristalsis  of  the  bowel  above  the  part  in  the  hernia.  The 
urine  is  diminished  in  quantity,  and  it  is  claimed  that  it  contains  albumin 
if  bowel  is  included  in  the  hernia.  The  symptoms  are  more  acute  in 
strangulation  of  bowel  than  in  that  of  omentum,  and  a  true  epiplocele  is 
seldom  strangulated,  a  small  concealed  loop  of  bowel  being  generally  found 
in  cases  sui^jDOsed  to  contain  omentum  only.  When  gangrene  of  the 
strangulated  loop  has  taken  place,  the  pain  ceases  and  collapse  sets  in,  the 
apparent  relief  being  so  marked  that  the  patient  and  his  friends  often 
imagine  that  the  condition  has  been  relieved. 

If  strangulation  occurs  and  is  not  x>romptly  relieved,  death  is  almost 
inevitable  and  takes  place  in  from  two  to  ten  daj'S.  Death  may  be  caused, 
as  in  intestinal  obstruction,  by  shock  within  a  few  hours,  by  exhaustion 
from  vomiting,  by  peritonitis,  by  pneumonia  from  aspiration  of  vomited 
matter  into  the  lungs,  or  by  local  suppuration  and  septicaemia.  In  some 
rare  cases  the  bowel  has  sloughed,  a  fecal  abscess  has  formed  and  discharged, 
and  the  patient  has  recovered  with  a  fecal  fistula.  But  even  then  death 
may  ensue  from  inanition,  if  the  fistula  allows  the  contents  of  the  upper 
small  intestine  to  escape. 


TREATMENT  OF  STRANGULATED  HERNIA.  991 

Treatment  of  Strangulated  Hernia. — ^Taxis  is  the  manipulation 
employed  to  reduce  a  heruia.  It  consists  of  a  steady  pressure  made  upon 
the  contents  of  the  sac,  while  the  iingers  of  the  other  hand  exercise  gentle 
stroking  movements  towards  the  aperture  of  the  sac  along  the  neck.  The 
patient  must  be  so  placed  as  to  lessen  the  amount  of  traction  and  compres- 
sion of  the  ring.  Thus,  in  inguinal  and  femoral  hernia,  and  in  obturator 
hernia  also,  the  thigh  should  be  flexed  upon  the  pelvis  and  rotated  inward. 
In  umbilical  hernia  the  back  should  be  bent  forward  hj  pillows  under  the 
shoulders  and  the  hips,  in  order  to  relax  the  abdominal  muscles.  The 
recumbent  position  should  always  be  employed,  and  in  some  cases  it  is  of 
advantage  to  place  the  shoulders  lower  than  the  pelvis.  The  greatest  gen- 
tleness should  be  exercised  in  taxis,  in  order  to  avoid  injury  to  the  bowel, 
especially  when  strangulation  exists,  for  when  the  intestinal  circulation  has 
been  impaired  the  gut  is  likely  to  be  much  softened.  After  the  contents  of 
the  hernia  have  been  reduced  it  is  sometimes  possible  to  reduce  the  sac  also, 
the  attachments  of  the  latter  by  loose  cellular  tissue  being  so  elastic  as  to 
enable  one  to  invaginate  it  and  return  it  to  the  abdomen.  In  applying 
taxis  it  should  be  remembered  that  the  part  which  has  come  down  last 
should  be  the  first  to  return,  and  that  this  part  will  generally  be  found  at  the 
back  of  the  sac,  and  therefore  the  fingers  should  be  made  to  press  upward 
along  this  part.  As  the  patient  lies  upon  his  back,  the  sac  should  be 
elevated,  in  order  to  bring  the  contents  more  into  line  with  the  canal,  and  it 
is  sometimes  of  advantage  to  lift  the  hernial  tumor  vertically,  so  as  to  have 
the  aid  of  gravity  in  the  reduction.  In  femoral  hernia,  when  there  is  a 
tendency  of  the  sac  to  roll  upward  towards  Poupart's  ligament,  as  is  often 
the  case,  the  tumor  should  be  drawn  down  during  taxis.  The  surgeon  should 
place  his  fingers  underneath  the  sac  and  his  thumb  in  front  of  it,  and  the 
fingers  should  make  regular  kneading  movements  upward.  If  more  force  is 
necessary  in  large  ruptures  the  sac  is  grasped  in  both  hands,  the  fingers 
being  behind  and  the  thumbs  in  front,  while  the  wrists  steady  the  neck  of 
the  sac  and  make  lateral  pressure  to  force  the  parts  into  a  funnel  shape  with 
the  apex  directed  towards  the  ring. 

An  anaesthetic  is  of  great  assistance  in  the  reduction  of  a  strangulated 
hernia,  many  mixtures  which  have  previously  resisted  persistent  efforts 
being  reduced  with  ease  when  full  muscular  relaxation  is  obtained.  But  it 
is  undesirable  to  administer  the  anaesthetic  often,  and  therefore  the  patient's 
consent  to  immediate  operation  should  be  secured  before  it  is  given,  and  the 
necessary  preparations  must  be  made  in  order  that  the  oiieratiou  maj"  be 
undertaken  at  once  if  a  five  minutes'  trial  of  taxis  fails.  If  there  is  any 
objection  to  the  use  of  an  anaesthetic,  the  well-known  methods  of  applying 
ice-bags  or  an  ether  spray  to  the  tumor,  or  allowing  ether  to  evaporate 
from  a  cloth  laid  over  the  rupture  in  order  to  contract  and  empty  the  blood- 
vessels, will  sometimes  be  of  service.  Partial  muscular  relaxation  may  also 
be  obtained  by  placing  the  patient  in  a  hot  bath.  But  the  anaesthetic  is 
to  be  j)referred  to  all  other  adjuvants  of  the  taxis,  because  the  employment 
of  others  causes  the  loss  of  valuable  time,  and  to  be  successful  either  taxis 
or  operation  must  be  carried  out  at  the  earliest  possible  moment.  Before  the 
antesthetic  is  given  the  patient' s  stomach  should  be  washed  out  lest  vomiting 


992  TAXIS   IN  STRANGULATED   HERNIA. 

take  place  while  lie  is  unconscious,  and  pheumouia  be  set  up  by  aspiration 
of  vomited  material. 

Sometimes  the  symptoms — vomiting,  constipation,  and  abdominal  pain — 
are  not  relieved  even  when  the  hernia  has  appax-ently  been  successfully 
reduced,  a  condition  which  may  be  the  result  of  peritonitis  caused  by  per- 
foration of  the  bowel,  of  paralysis  of  the  affected  loop  of  bowel  from  long- 
continued  pressure  during  the  incarceration,  of  reduction  in  mass,  or,  finally, 
of  the  presence  of  another  hernia.  If  peritonitis  develops,  the  abdominal 
pain  will  become  more  marked,  there  will  be  a  rise  of  temi^erature,  and  tym- 
panites will  appear.  If  the  incarcerated  loop  is  paralyzed,  tj^mpanites  and 
constipation  will  be  the  chief  symptoms,  and  they  may  be  relieved  by  the 
administration  of  a  mild  laxative  or  of  high  enemata  ;  but  if  the  patient's 
strength  is  failing,  the  abdomen  should  be  oi^ened  at  once,  in  order  to 
ascertain  the  condition  and  correct  it  if  possible. 

Accidents  in  Taxis. — If  too  great  force  is  used  in  taxis  it  is  possible  to 
rupture  the  sac  just  beyond  its  neck  and  force  the  contents  into  the  space 
between  the  peritoneum  and  the  muscles  of  the  abdominal  wall,  or,  the  sac 
remaining  intact,  both  the  sac  and  its  contents  may  be  forced  through  the 
ligamentous  ring  into  this  sjjace,  the  constriction  of  the  neck  of  the  sac  con- 
tinuing as  before.  This  is  termed  reduction  in  mass  (en  bloc),  and  has  serious 
consequences,  the  real  strangulation  not  being  reduced.  If  there  is  a  sus- 
picion that  this  accident  has  occurred,  the  usual  gurgling  at  the  moment  of 
reduction  being  absent,  it  may  be  verified  by  finding  a  tumor  in  the  abdo- 
men in  the  neighborhood  of  the  ring  which  is  formed  of  the  contents  of  the 
sac,  and  by  the  continuation  of  the  symptoms  with  unabated  intensity,  the 
pain  in  particular  being  increased.  In  such  cases  the  tumor  must  be  cut 
down  upon  immediately  and  the  seat  of  the  strangulation  sought.  This  may 
be  in  the  neck  of  the  sac,  the  entire  sac  having  been  forced  into  the  abdo- 
men, together  with  its  contents.  The  strangulation  may  be  due  also  to  the 
incarceration  of  the  bowel  in  an  aperture  in  the  omentum,  or  to  the  pinch- 
ing of  the  gut  by  an  intestinal  diverticulum  or  adhesion,  and  although  these 
cases  are  rare  they  are  probably  more  common  than  a  true  reduction  in 
mass.  Multiple  hernise  are  not  unusual,  and  there  may  be  more  than  one 
irreducible  hernia  in  the  same  person,  so  that  the  wrong  hernia  may  be 
operated  upon,  the  strangulated  one  remaining  undiscovered,  especially  if 
it  be  of  the  obturator  or  sciatic  variety,  for  the  local  symptoms  of  tension 
and  tenderness  are  somewhat  uncertain.  Internal  strangulation  or  intestinal 
obstruction  may  also  coexist  with  an  irreducible  hernia,  and  would  naturally 
be  unrelieved  by  an  operation  on  the  latter. 

Contraindications  to  Taxis. — In  certain  cases  taxis  is  contraindi- 
cated,  and  herniotomy  should  be  undertaken  at  once.  If  there  is  evidence 
that  the  hernia  was  irreducible  before  the  strangulation  took  place,  taxis 
should  not  be  attempted.  If  there  is  any  reason  to  fear  that  the  vitality 
of  the  bowel  is  impaired,  because  the  strangulation  has  been  very  acute, 
as  shown  by  severe  pain,  violent  emesis,  and  great  prostration,  or  because 
the  symptoms  have  lasted  more  than  forty-eight  hours,  no  attempts  at  reduc- 
tion should  be  made,  as  they  might  easily  cause  perforation  of  the  bowel 
and  a  fatal  peritonitis.    This  is  especially  true  of  ruptures  through  a  narrow 


OPERATION   FOR  STRANGULATED   HERNIA.  993 

apei'ture,  as  iu  obturator  hei-uia.  Large  ruptures  are  better  suited  for  taxis, 
because  the  aperture  is  usually  wide  and  the  constriction  less  severe.  Imme- 
diate operation  is  also  demanded  if  there  are  local  signs  of  inflammation, 
such  as  redness,  a?dema,  or  indications  of  sloughing.  In  the  majority  of 
cases  operation  is  safer  and  preferable  to  taxis  if  the  necessary  surgical 
skill  is  available. 

Operation  for  Strangulated  Hernia. — Reduction  of  the  strangulated 
bowel  may  be  undertaken  from  the  abdominal  side  either  by  sinking  the 
hand  deeply  into  the  abdomen  by  depressing  its  wall  and  catching  the  bowel 
or  omentum  where  it  cau  be  felt  to  pass  into  the  internal  ring,  or  by  insert- 
ing the  finger  in  the  rectum.  It  has  even  been  suggested  to  perform  a 
laparotomy  and  pull  the  bowel  out  from  above,  but  this  method  has  never 
been  generally  accepted,  because  it  does  not  allow  investigation  of  the  con- 
dition of  the  bowel  before  it  returns  to  the  peritoneal  cavity,  nor  does  it 
permit  the  division  of  any  constricting  bands  or  adhesions  at  the  neck  of 
the  sac.  Obturator  hernia,  however,  may  be  treated  in  this  manner,  as  the 
external  operation  is  very  difficult  iu  that  variety  of  hernia.  The  old 
operation  for  strangulated  hernia,  or  kelotomy,  in  which  the  sac  was  left 
unopened,  is  now  little  used,  being  limited  to  extreme  cases  in  unfavorable 
surroundings  where  more  thorough  measures  are  impossible.  An  incision 
is  made  over  the  neck  of  the  sac,  exxjosiug  the  latter  and  the  ring.  It  may 
be  very  difficult  to  recognize  the  sac,  and  it  is  seldom  possible  to  distinguish 
the  usual  auatomical  "coverings,"  as  the  tissues  are  apt  to  be  matted 
together  and  inflamed.  The  sac  is  recognized  by  its  dull  white  or  trans- 
lucent color  and  the  arrangement  of  its  fibres  and  vessels  in  longitudinal 
lines,  which  is  quite  different  from  the  circular  course  of  the  vessels  of  the 
bowel.  When  these  parts  are  exposed  a  blunt-jjointed  bistoury  is  inserted 
under  the  edge  of  the  ring,  and  the  latter  enlarged  by  very  small  incisions, 
and  then  the  contents  of  the  hernia  are  to  be  reduced.  If  this  cannot  be 
done,  the  sac  must  be  opened,  and  the  contents  drawn  down  and  examined, 
and  if  no  other  point  of  obstruction  can  be  found  the  neck  of  the  sac  must 
be  still  further  enlarged.  In  the  case  of  inguinal  or  femoral  hernia  the  con- 
stricting ring  may  be  divided  directly  forward  or  upward,  the  blade  of  the 
knife  being  held  parallel  with  the  median  line.  This  incision  must  be  made 
as  shallow  as  possible,  to  avoid  wounding  blood-vessels  which  may  cross  the 
neck,  esjiecially  iu  the  case  of  femoral  hernia  ;  therefore  the  knife  should  be 
very  dull,  and  it  is  better  to  make  several  shallow  incisions  than  a  single 
deep  cut.  If  the  protruding  loop  of  bowel  is  small,  it  should  be  held  down 
while  the  stricture  is  being  divided,  lest  it  slip  up  before  a  thorough  exami- 
nation of  its  condition  can  be  made. 

Modern  Operation. — Surgeons  now  open  the  sac  at  once  and  exam- 
ine the  contents,  especially  if  violent  efforts  of  taxis  have  been  made  or  if 
the  strangulation  is  sevei'e  or  has  lasted  over  twenty-four  hours.  The  con- 
striction is  then  relieved  in  inguinal  hernia  by  open  incision  of  the  canal, 
but  in  femoral  by  nicking  the  ligament  as  just  described.  If  the  patient's 
condition  is  good  and  the  vitality  of  the  gut  is  not  impaired,  the  hernia  cau 
be  reduced,  and  the  operation  is  concluded  by  suturiug  the  opening,  as  iu 
one  of  the  methods  of  radical  cure. 


994  OPERATION   FOR  STRANGULATED   HERNIA. 

Treatment  of  the  Contents  of  the  Sac. — The  treatment  of  the  con- 
tents of  the  sac  will  depend  nx)on  their  condition.  If  they  are  perfectly 
natural,  they  are  returned  to  the  abdomen.  If  they  are  doubtful,  a  delay  of 
a  few  minutes  will  often  decide  the  question,  for  when  relieved  of  the  con- 
striction they  rapidly  regain  their  color.  There  is  usually  considerable 
serum  in  the  sac,  often  with  a  fecal  odor,  but  unless  cloudy  it  does  not 
forbid  the  return  of  the  strangulated  bowel.  A  free  escape  of  serum  upon 
opening  the  sac  may  be  looked  upon  as  a  good  sign  as  to  the  vitality  of  the 
gut,  for  it  protects  the  liowel  from  injury  during  attempts  at  taxis,  and  by 
its  pressure  probably  decreases  venous  congestion,  thus  diminishing  the  risk 
of  gangrene.  If  omentum  is  found  in  the  sac,  it  should  be  resected,  a  liga- 
ture being  placed  around  its  narrow  neck  ;  but  it  should  be  carefully  exam- 
ined in  order  to  avoid  injury  to  any  small  loop  of  bowel  which  may  be 
enclosed  in  it.  If  the  intestine  is  dark  purjile  or  of  a  whitish-gray  color,  it 
must  be  considered  suspicious,  and  especial  care  must  be  taken  in  examining 
the  narrow  part  of  the  bowel  lying  directly  under  the  constriction.  There 
is  no  certain  sign  of  viability,  for  dark-colored  gut  has  recovered,  and  gut 
which  bled  freely  has  sloughed  after  reduction.  Free  separation  of  the 
peritoneal  coat  indicates  sloughing.  In  doubtful  cases  the  intestine  may  be 
left  lying  in  the  wound  lightly  covered  with  gauze  for  from  six  to  twenty- 
four  hours,  until  the  surgeon  is  certain  of  its  viability.  If  it  is  evident 
that  the  intestine  cannot  live,  it  is  generally  best  to  make  an  artificial  anus 
by  attaching  the  intestine  loosely  to  the  edges  of  the  ring  with  peritoneal 
stitches,  so  as  to  shut  off  the  peritoneal  cavity,  and  incising  the  most  depend- 
ent part  of  the  loop,  which  should  be  left  in  place  until  adhesions  have 
formed,  when  it  can  be  cut  away.  If  the  patient's  condition  is  good,  how- 
ever, and  the  surgeon  is  trained  in  intestinal  surgery,  the  affected  loop  of 
bowel  may  be  resected  and  the  ends  united  at  once  by  sutures  or  by  Muri^hy's 
button,  the  latter  being  the  more  rapid  method.  But  even  with  the  greatest 
skill  there  is  danger  of  infection  of  the  peritoneum  by  the  sloughing  bowel. 
(For  the  details  of  the  resection  we  refer  to  the  chapter  on  intestinal  surgery.) 


CHAPTEE    XXXIX. 

SURGERY  OF  THE  URINARY  ORGANS. 
By  B.  Paequhae  Cuetis,  M.D. 

THE  TJEETHRA. 

Injuries. — The  m-etlira  is  seldom  wounded  by  objects  penetrating  from 
without,  although  gunshot  wounds  may  open  it,  and  pointed  objects  may 
perforate  it  in  the  perineum.  It  is  sometimes  lacerated  in  the  female  during 
parturition,  or  contused  so  that  its  walls  slough,  and  urethro-vagiual  fis- 
tulse  are  produced,  which  often  involve  the  entire  length  of  the  canal,  and 
almost  invariably  the  vesical  end.  Plastic  operations  are  sometimes  under- 
taken for  the  repair  of  the  fistulse,  but  if  the  vesical  sphincter  is  involved 
they  are  of  little  practical  utility.  The  urethra  itself  can  be  easily  restored 
by  methods  similar  to  those  described  below  for  the  relief  of  hypospadias. 
Similar  sloughing  may  take  place  in  the  male  from  severe  contusions,  but  is 
most  frequently  seen  as  the  result  of  urinary  extravasation.  The  most  com- 
mon injur  J-  of  the  male  urethra  is  its  subcutaneous  laceration,  or  so-called 
rupture,  which  is  generally  the  result  of  severe  blows  or  falls  upon  the  peri- 
neum, of  fracture  of  the  ijelvis,  or  of  the  so-called  "  fracture  of  the  penis." 
The  laceration  is  usually  situated  upon  the  floor  of  the  urethra.  The 
symptoms  of  this  injury  are  the  escape  of  a  few  drops  of  blood  from  the 
meatus,  difficult  micturition  or  retention  of  urine,  and  the  sudden  appear- 
ance of  a  tumor  formed  by  the  extravasated  urine  near  the  seat  of  the  injury 
when  the  patient  attempts  to  urinate.  If  the  case  is  neglected,  the  usual 
picture  of  urinary  extravasation  is  seen,  with  the  formation  of  a  local 
abscess  when  a  small  amount  escapes,  or  of  an  extensive  swelling  of  the 
penis,  scrotum,  and  front  of  the  abdomen  in  worse  cases,  resulting  in  the 
sloughing  of  the  cellular  tissue  in  these  regions.  This  condition  will  be  more 
completely  described  in  connection  with  stricture. 

Treatment. — The  patient  should  not  be  allowed  to  pass  urine  if  it  is 
probable  that  the  urethra  has  been  lacerated.  A  large  soft  rubber  catheter 
is  to  be  passed  with  great  care,  and  it  will  usually  meet  with  resistance  at 
the  seat  of  the  injury.  If  it  can  be  passed  to  the  bladder  and  the  injury  is 
slight,  some  surgeons  merely  retain  the  catheter  for  drainage.  It  should  not 
be  removed  because  it  may  be  impossible  to  pass  it  again.  We  believe, 
however,  that  urethrotomy  should  be  performed  in  every  case,  because 
urine  will  leak  along  the  retained  catheter  and  lead  to  infection.  The 
perineal  urethra  is  to  be  opened,  if  possible,  behind  the  injury,  and  the 
bladder  drained  by  a  catheter  retained  in  this  wound.  The  injury  may  lie 
so  deep  that  it  is  impossible  to  open  the  urethra  behind  it,  and  the  incision 
should  then  be  made  through  the  injured  tissues  and  the  vesical  end  of  the 
urethra  sought.  If  it  cannot  be  found  the  bladder  is  to  be  opened  above 
the  pubes  and  a  sound  passed  forward  into  the  urethra  from  the  bladder. 


996  CONGENITAL   DEFORMITIES   OF  THE  URETHRA. 

and  made  to  project  in  the  perineum,  by  whicli  the  torn  end  of  the  canal 
can  be  located,  and  drainage  of  the  bladder  established.  The  divided  ends 
of  the  urethra  have  been  exposed  and  united  by  suture  successfully,  and  if 
the  injury  is  severe,  this  should  certainly  be  attempted.  In  this  operation 
the  urethra  is  exposed  at  the  jjoint  of  injury,  the  divided  ends  found,  all 
contused  and  lacerated  tissue  cut  away,  and  the  freshened  ends  united  by 
sutures  of  fine  silk,  leaving  the  floor  of  the  urethra  open,  for  a  complete 
circular  suture  will  seldom  be  entirely  successful,  and  drainage  is  important 
if  any  leakage  takes  place.  In  any  case,  after  five  or  six  days  have  elajised, 
the  weekly  use  of  steel  urethral  sounds  should  be  begun,  in  order  to  avoid 
stricture  from  cicatricial  contraction.  In  neglected  cases  free  incisions  will  be 
necessary  to  combat  the  urinary  extravasation,  as  will  be  described  farther  on. 

Foreign  Bodies. — Various  objects  may  be  introduced  into  the  urethra  in 
unnatural  erotic  excitement  or  in  play  by  children,  or  instruments  may  break 
in  the  canal.  Loose  foreign  bodies  may  be  removed  by  forceps,  but  if  they 
become  impacted  it  may  be  necessary  to  remove  them  through  an  incision. 
Hair-pins  lying  with  the  points  towards  the  meatus  can  be  removed  by  intro- 
ducing a  stiff  tube  and  catching  both  ends  of  the  pin  in  it,  or  by  cutting  the 
■  loop  with  a  small  lithotrite  and  removing  the  pieces  sej^arately.  Long  pins 
with  large  heads,  which  have  been  introduced  head  first,  can  be  reversed  by 
making  the  point  penetrate  the  floor  of  the  urethra  and  drawing  out  all  but 
the  head,  which  is  then  turned  over  and  thrust  towards  the  meatus,  and  the 
pin  withdrawn  head  first. 

Calculi. — Stones  rarely  form  in  the  urethra,  but  vesical  or  renal  calculi 
may  be  caught  behind  a  urethral  stricture.  The  presence  of  a  calculus 
causes  i)ain,  obstructed  micturition,  and  a  bloody  or  purulent  discharge.  If 
the  stone  is  in  the  prostate,  the  symptoms  resemble  those  of  vesical  calculus. 
Calculi  can  be  felt  through  the  substance  of  the  penis  or  touched  by  a  sound 
in  the  urethra.  They  may  cause  perforation  of  the  urethra  and  extrava- 
sation of  urine.  They  can  be  removed  by  forceps,  or  crushed,  or  taken  out 
through  a  median  incision. 

Congenital  Deformities. — Narrow  Meatus. — The  meatus  may  be 
congenitally  small,  and  is  sometimes  imperforate.  (See  Atresia  of  the 
Urethra,  below.)  Close  contraction  may  also  result  from  the  cicatrix  fol- 
lowing ulceration  or  injury  at  this  point.  A  narrow  meatus  may  cause  such 
obstruction  to  the  escape  of  the  urine  as  to  result  in  hypertrophy  of  the 
bladder,  dilatation  of  the  ureters,  and  hydronephrosis.  Even  when  the 
orifice  is  not  small  enough  to  interfere  sei'iously  with  micturition,  various 
nervous  disturbances,  such  as  irritability  of  the  bladder,  convulsions,  sexual 
hypersesthesia,  and  many  others,  may  be  caused  by  it. 

Treatment. — The  meatus  should  be  enlarged  by  an  incision  upon  the 
floor  of  tlie  urethra,  cutting  towards  the  frenum,  but  the  incision  should  be 
limited  to  the  urethra,  for  the  skin  just  outside  is  usually  distensible,  and 
can  be  stretched  if  the  inner  layer  be  cut.  The  shape  and  elasticity  of  the 
orifice  are  thus  preserved,  and  the  iinpleasant  dribbling  after  urination 
caused  by  imj)roper  enlargement  is  avoided.  A  sound  should  be  passed 
every  day,  to  maintain  the  size  of  the  canal,  until  the  wound  is  healed. 
While  the  operation  is  a  trifling  one,  death  from  hemorrhage  has  been  known 


HYPOSPADIAS.  997 

to  follow  it,  and  there  is  also  danger  of  infection.  The  ordinary  antiseptic 
precautions  should  be  taken,  therefore,  and  the  patient  should  have  some 
one  near  him  at  night  in  order  to  act  promptly  in  case  severe  hemorrhage 
occurs  during  an  erection  while  asleep.  In  contraction  of  the  meatus  from 
ulceration  an  incision  sufflcieutly  free  to  enlarge  the  opening  to  the  necessary 
size  must  be  made  without  attempting  to  preserve  the  shape  of  the  orifice. 

Atresia  of  the  Urethra.— Atresia  of  the  canal  most  commonly  occurs 
at  the  meatus,  but  may  involve  the  glandular  portion  or  even  the  entire 
canal,  an  abnormal  opening  between  the  rectum  and  the  bladder  usually 
existing  in  the  last  variety.  The  urethra  will  often  be  found  distended  with 
urine  behind  the  closed  portion,  and  can  be  readily  incised.  An  imperforate 
meatus  can  be  punctured  with  an  aspirating  needle  in  hopes  that  the  atresia 
may  not  exteud  far  backward,  but  if  urine  cannot  be  obtained  at  the  depth 
of  an  inch  the  attempt  should  be  given  up.  The  urethra  should  then  be 
opened  in  the  perineum  if  it  can  be  felt  by  a  rectal  examination,  but  if  it 
cannot  be  recognized,  a  suprapubic  fistula  must  be  made,  through  which  it 
may  be  possible  to  insert  an  instrument  into  the  urethra  from  above  and 
find  its  position  and  extent.  The  urethra  can  be  constructed  by  a  plastic 
operation  later. 

Hypospadias  and  Epispadias.— The  most  common  deformity  of  the 
urethra  is  hypospadias,  which  occurs  in  some  degree  in  one  out  of  every 
three  hundred  males  born.  Hypospadias  is  a  more  or  less  complete  absence 
of  the  floor  of  the  urethra.  Epispadias  is  the  absence  of  the  roof  of  that 
canal.  Both  are  the  results  of  faults  iu  develoi^ment,  the  parts  which  should 
spring  from  each  side  to  unite  in  the  middle  line  and  form  the  genitals  fail- 
ing to  accomijlish  their  union.  The  cause  is  probably  the  same  as  that  of 
other  congenital  defects,  and  is  most  frequently  the  pressure  of  amniotic 
bands  or  the  formation  of  amniotic  adhesions,  as  desciibed  in  the  section  on 
harelip,  or  perhaps  the  pressure  of  the  umbilical  cord  drawn  across  the 
perineum.  In  epispadias  premature  development  of  the  perineum  may 
hasten  union  of  the  floor  of  the  urethi-a  and  intei'fere  with  the  proper  forma- 
tion of  its  roof.  A  less  probable  theory  ascribes  both  deformities  to  a  dis- 
turbance in  the  formation  of  the  urethra  owing  to  a  failure  of  the  glandular 
and  penile  portions  to  unite.  As  the  anus  forms  separately  from  the  rec- 
tum, so  the  glandular  portion  of  the  urethra  and  the  meatus  form  seijarately 
from  the  rest  and  are  united  with  the  main  urettira  at  a  later  period  in  fcBtal 
life.  The  theory  supposes  that  this  junction  fails  to  take  place,  or  is  imper- 
fectly made,  and  the  obstruction  in  the  uretln'a  by  the  septum  between  the 
two  portions  results  in  the  retention  of  urine  at  a  very  early  period  in  fcetal 
life,  with  distention  of  the  urethra  and  sloughing  of  its  floor  or  of  its  roof, 
similar  to  the  extravasation  of  urine  from  urethral  stricture,  and  thus  the 
deformity  is  produced.  There  are  three  grades  of  hypospadias,  according 
to  the  position  of  the  urethral  opening.  First,  the  glundalar  form,  which  is 
the  lightest  grade,  and  consists  iu  a  defect  limited  to  the  glandular  urethra 
only,  the  meatus  being  situated  just  behind  the  giaus.  Secondly,  the 
penoscrotal  form,  in  which  the  defect  extends  to  the  penile  portion,  which  is 
usually  completely  absent  if  wanting  at  all,  and  the  urethra  then  ends  at 
the  iieno-scrotal  junction..    (Fig.  791.)    Thirdly,  xhe.  perineal  form  (Fig.  792), 

64 


998 


HYPOSPADIAS. 


Penile  hypospadias. 


in  which  the  scrotum  is  split  and  the  floor  of  that  portion  of  the  urethra  is 
absent,  the  canal  then  opening  in  the  perineum  just  in  front  of  the  mem- 
branous urethra,  which  is  never 
involved  in  the  deformitj'.  In 
very  rai-e  cases  the  urethra  is 
properly  formed  anteriorly,  and 
only  the  middle  portion  of  the 
canal  is  deficient,  but,  as  a  rule, 
the  urethral  floor  is  wanting  from 
the  unnatural  meatus  to  the  end 
of  the  penis.  The  glandular  va- 
rietjr  is  very  common,  but  the 
severer  forms  are  rare.  Hypo- 
spadias is  rare  in  the  female,  but 
when  it  occurs  the  urethra  may 
be  represented  by  a  groove,  or 
there  may  be  no  trace  of  it,  the 
urine  ptassing  directly  into  the 
vagina  from  the  neck  of  ,  the 
bladder,  which  is  usually  defi- 
cient in  sphincter  action. 

Epispadias. — In  epispadias 
the  roof  of  the  urethra  is  absent 
and  the  deformity  is  often  associated  with  exstrophy  of  the  bladder.  The 
corpora  cavernosa  are  not  in  contact  in  this  deformity,  and  lie  side  by  side, 
separated  by  the  groove  which 
represents  the  urethra.  Epispa- 
dias is  also  present  in  three  ^ 
grades, — the  glandular,  the  jje- 
7iile,  and  the  complete,  the  sphinc- 
ter of  the  bladder  being  divided 
in  the  last.  Epispadias  is,  how- 
ever, almost  always  complete, 
only  three  cases  of  the  glandular 
form  being  on  record,  contrary 
to  the  rule  in  hypospadias, 
which  is  usually  seen  in  the 
glans.  Epispadias  is  a  rare  con- 
dition, but  in  the  female  it  is 
about  as  common  as  hypospa- 
dias, and  in  that  sex  is  always 
associated  with  exstrophy  of  the 
bladder. 

The  extreme  grades  of  these 
deformities,    and    especially    of 
epispadias,   are  associated  with 
marked  lack  of  development  of  the  penis,   and  often  with   undescended 
testes,  so  that  the  sex  of  the  individual  is  often  uncertain.     Many  cases 


Perineal  iij'pospadias. 


TREATMENT  OF  HYPOSPADIAS.  999 

of  so-called  heruiapLroclitisiu  are  instances  of  extreme  hypospadias  in  the 
male.  lu  both  hypospadias  and  epispadias  the  foreskin  shares  the  deformity 
and  hangs  like  au  apron,  in  the  one  case  above  the  glans,  in  the  other 
ease  below  it.  The  milder  forms  of  hypospadias  are  of  little  clinical  con- 
sequence, except  so  far  as  they  affect  the  individual  mentally,  because  tlie 
opening  is  sufficiently  far  forward  to  allow  of  comfortable  urination  and  a 
satisfactory  deposit  of  the  semen  in  coition.  But  in  some  cases  the  orifice 
may  be  very  narrow  and  may  require  to  be  enlarged  by  incision.  In  the 
higher  grades  of  the  deformity  the  semen  would  not  be  deposited  in  the 
vagina,  and  the  individual  would  be  sterile.  In  jDerineal  hypospadias  the 
individual  must  sit  like  the  female  iu  making  water.  These  males  are  often 
deficient  in  sexual  power  or  are  sexual  perverts,  preferring  to  play  the 
female  in  coition,  although  some  are  capable  of  performing  both  parts. 

Treatment. — Both  these  conditions  are  remedied  by  plastic  operations, 
the  general  plan  of  which  is  similar.  The  operations  are  quite  difficult,  and 
union  often  fails,  so  that  repeated  attempts  may  be  necessary  for  success. 
The  penis  is  usually  very  small  in  these  cases  and  may  be  sharply  flexed, 
and  it  is  necessary  first  to  restore  it  to  the  ]3roper  position.  This  is  accom- 
plished by  cutting  transversely  across  the  skin  which  binds  it  down  and 
then  uniting  the  edges  of  the  transverse  wound  in  a  longitudinal  direction, 
dissecting  up  the  tissue  in  the  neighborhood  so  that  it  may  slide  more  easily, 
or  utilizing  the  loose  skin  of  the  prepuce  to  fill  the  gap.  This  preliminary 
operation  should  be  done  at  a  very  eai'ly  period,  even  at  two  or  three  years 
of  age,  but  the  rest  of  the  work  should  be  left  until  the  patient  is  nine  or 
ten  years  old  and  the  parts  have  reached  sufficient  size  to  enable  fiaps  to  be 
cut  and  readily  handled.  A  longer  delay  is  not  to  be  recommended,  because 
the  erections  of  the  organ  are  apt  to  be  troublesome  in  the  adult. 

■  Iu  operating  for  glandular  hyjDospadias  an  incision  may  be  made  through 
the  skin  over  the  penile  urethra  and  that  canal  dissected  free.  A  narrow 
bistoury  or  a  trocar  is  then  made  to  enter  at  the  depression  where  the  normal 
meatus  should  be  in  the  glans  and  thrust  backward  towards  the  anterior  end 
of  the  first  wound.  A  forcejDS  j^assed  through  the  channel  thus  formed  is 
made  to  seize  the  end  of  the  dissected  urethra  and  the  latter  is  drawn  for- 
ward through  the  channel  in  the  glans,  its  natural  elasticitj'  allowing  this, 
and  the  end  is  secured  by  a  few  silk  sutures  to  the  new  meatus.  The  incision 
below  is  closed  with  sutures.  Another  method,  especially  useful  when  the 
penile  m-ethra  is  also  deficient,  is  as  follows  :  A  deep  incision  is  made  into 
the  substance  of  the  glaus  on  each  side  of  the  urethral  furrow,  and  a  stiff 
catheter  about  15  French  in  size  is  laid  between  these  cuts,  so  as  to  com- 
jiress  the  tissues  and  deepen  the  urethral  groove,  while  the  outer  edges  of 
the  wounds  on  each  side  are  raised  and  united  across  the  instrument  by 
sutures  or  harelip  pins.  The  penile  portion  of  the  urethra  is  formed  by 
cutting  two  rectangular  flaps  (Fig.  793,  A),  the  base  of  one  being  parallel 
to  the  urethral  groove  and  three-eighths  or  half  an  inch  distant  from  it,  and 
the  base  of  the  other  being  at  the  urethral  groove.  Both  flaps  are  dissected 
up,  and  the  one  with  its  base  at  the  urethral  farrow  is  turned  over  the  latter, 
and  its  free  edge  united  to  the  raw  edge  at  the  other  side  of  the  groove, 
where  the  free  side  of  the  second  flap  has  been  formed.     (Fig.  793,  B. )    In 


1000 


TREATMENT  OF  HYPOSPADIAS. 


this  manner  a  canal  is  obtained  whicli  is  lined  throughout  with  ej)ithelium, 
partly  skin  and  partly  mucous  membrane.  The  flap  with  its  base  away 
from  the  furrow  is  then  drawn  over  the  first  one,  so  as  to  cover  its  raw  sur- 
face partially  or  wholly,  and  secured  in  place  by  sutures.     (Fig.  793,  C.) 

The  first  flap  may  be  secured  by  two 
or  three  mattress-sutures  through 
the  base  of  the  second  flap ;  or  it 
may  be  sutured  with  stitches  which 
do  not  penetrate  the  epithelial  coat- 
ing of  the  caual,  in  order  that  they 
shall  not  be  exposed  to  infection. 
Fine  catgut  or  very  fine  silk  may 
be  employed.  The  scrotal  and  peri- 
neal portions  of  the  urethra  may  be 
formed  in  a  similar  manner,  but  in 
the  complete  cases  the  work  at  the 
anterior  end  of  the  organ  should 
be  finished  first,  so  as  to  allow  the 
urine  to  escape  by  the  posterior 
opening  without  coming  in  contact 
with  the  wound  during  its  healing. 
When  the  glandular  and  penile 
Ijortions  have  been  formed,  the 
opening  which  exists  between  them 
should  be  sutured,  and  finally  the 
perineal  opening  may  be  closed  and 
the  urine  diverted  into  the  new 
channel.  These  small  openings  may 
be  closed  by  freshening  their  edges 
obliquely,  cutting  away  the  sur- 
face, so  that  the  opening  into  the 
canal  is  left  smaller  than  that  on 
the  skin,  and  then  passing  sutures 
of  fine  silk,  which  should  not  enter 
the  canal.  When  the  opening  is 
of  considerable  size,  two  flaps  may 
be  cut  on  the  same  principles  as  already  described,  one  being  turned  over 
the  opening  with  its  epithelial  surface  towards  the  canal,  and  the  second 
being  sutured  across  the  raw  surface  of  the  first  to  reinforce  it. 

The  after-treatment  of  these  cases  may  be  conducted  in  three  different 
ways.  (1)  The  escape  of  the  urine  may  be  maintained  by  the  perineal 
opening  in  the  complete  cases  or  by  establishing  perineal  or  suprapubic 
drainage  beforehand.  (2)  A  catheter  may  be  passed  through  the  m-ethra 
and  left  in  the  bladder  to  drain  the  urine ;  but  this  method  is  not  so  reli- 
able, because  a  certain  amount  of  urine  leaks  by  the  side  of  the  catheter  and 
reaches  the  surfaces  of  the  wound.  (3)  Finally,  the  urine  may  be  drawn 
regularly  by  the  catheter  passed  by  the  urethra,  the  latter  being  kept  clear 
of  urine  by  the  following  method.     The  urethra  is  thoroughly  irrigated,  the 


OpeTation  for  hypospadias :  d,  urethral  defect ;  V ,1" , 
flaps  ;  «;,  raw  surface  left  by  turning  up  the  flap  I' .  A 
shows  the  flaps  cut;  B,  V,  sutured  in  position;  C,  the 
operation  completed,  I"  covering  V.    (Lauenstein.) 


URETHRITIS.  1001 

catheter  introduced,  and  the  urine  drawn  off;  a  small  amount  of  salt  solu- 
tion is  then  thrown  into  the  bladder  and  allowed  to  remain,  so  that  when  the 
catheter  is  withdrawn  the  few  drops  which  follow  its  point  are  the  harmless 
salt  solution  instead  of  urine.  The  patients  can  sometimes  be  induced  to 
retain  the  urine  for  from  eight  to  twelve  hours  at  a  time,  so  as  to  leduce  the 
number  of  catheterizations  as  much  as  possible.  In  operating  ujjon  the 
glandular  cases,  or  to  close  a  communication  between  the  new  urethra  and 
the  old  in  the  penile  portion,  it  is  often  sufficient  to  cause  the  patient  to 
immerse  the  penis  in  a  vessel  of  water  during  urination,  the  fluid  being  thus 
diluted  at  once,  and  to  irrigate  the  urethra  immediately  afterwards.  The 
main  difficulty  of  these  operations  is  not  in  making  the  canal,  but  in  closing 
the  connection  between  the  different  portions  after  they  are  constructed, 
small  sinuses  often  persisting,  which  are  exceedingly  difficult  to  close,  in 
spite  of  the  most  careful  attempts.  If  the  sinuses  aie  very  small,  it  is  better 
to  cauterize  their  edges  with  nitric  acid  and  so  excite  cicatricial  contraction. 
The  lacuna  magna  and  other  follicles  of  the  urethra  are  occasionally 
abnormally  large,  and  may  be  the  seat  of  chronic  inflammation  or  even  small 
calculi,  in  which  case  they  require  free  incision.  True  diverticula  of  the 
urethra  are  rare,  but  are  found  in  the  floor  of  the  penile  portion  and  may 
form  sacs  of  immense  size.     These  are  also  seen  in  the  female  (Fig.  794),  and 

Fig.  794. 


Normal  urethra.  Dilatation.  Dislocation.  Diverticulum. 

Some  deformities  of  the  female  urethra :  .1,  bladder ;  £,  symphysis.     (Eouth.) 

may  require  excision  followed  by  plastic  operations.  Prolapse  of  the 
urethral  mucous  membrane  takes  place  in  women,  usually  as  the  result  • 
of  stretching  in  parturition,  combined  with  cystitis  and  straining  in  the  act 
of  urination.  The  prolapsed  membrane  may  be  intensely  painful  and  tender 
and  bleed  when  touched,  forming  the  most  common  variety  of  the  so-called 
urethral  caruncle.  It  is  best  treated  by  excision  and  circular  suture  of 
the  edges  around  the  meatus. 

Inflamraations.— Urethritis. — The  inflammations  to  which  the  ure- 
thra is  subject  are  principally  gonorrha^al,  chancroidal,  and  tuberculous,  but 
some  pyogenic  infection  usually  takes  place  at  the  same  time.  The  female 
urethra  is  liable  to  the  same  infections  as  the  male,  but  they  are  less  intense 
and  less  apt  to  have  serious  complications,  owing  to  the  shorter  and  more 
direct  course  of  the  canal,  which  allows  of  better  drainage.  The  venereal 
diseases  are  treated  of  in  separate  chapters. 


1002  STRICTURE   OF  THE  URETHRA. 

Tuberculosis. — Tuberciilosis  of  the  urethra  may  be  primary,  and  some- 
times begins  with  the  symptoms  of  an  acute  gonorrhoea  or  is  inoculated 
simultaneously  with  a  gonorrhoea.  In  other  cases  the  first  symptom  is  a 
scanty  watery  discharge  mixed  with  a  little  blood.  Extensive  ulceration 
takes  place,  and  if  recovery  should  occur,  which  is  improbable,  stricture 
would  follow.  Tuberculosis  of  the  urethra  is  almost  invariably  associated 
with  the  same  inflammation  in  the  jDrostate,  to  which  the  principal  symptoms 
are  due  ;  hence  it  will  be  considered  with  the  diseases  of  the  prostate. 

Periurethritis. — Pyogenic  or  gonococcus  infection  often  reaches  the 
tissues  around  the  urethra  through  the  follicles  in  the  mucous  membrane. 
These  follicles  may  continue  to  be  inflamed  when  the  rest  of  the  canal  has 
recovered  from  the  attack,  and,  the  mouth  of  the  follicle  being  closed  by  the 
swelling,  a  minute  abscess  may  form,  penetrate  into  the  tissue  outside  of  the 
urethra,  and  result  in  extensive  suppuration.  As  a  rule,  these  follicular 
abscesses  are  situated  in  the  pendulous  portion  of  the  urethra,  and  form 
hard,  not  very  painful  swellings  on  the  under  surface  of  the  penis.  If  left 
to  themselves,  they  slowly  point  and  discharge  through  the  skin.  In  some 
cases  the  inflammation  may  be  due  to  a  drop  of  urine  which  remains  stag- 
nant in  one  of  the  mucous  glands,  but  when  the  abscess  has  once  formed  the 
connection  with  the  urethra  can  seldom  be  found.  When  freely  opened 
these  abscesses  generally  heal  at  once.  A  very  different  type  of  periure- 
thritis is  seen  as  the  result  of  urinary  extravasation  from  injury  of  the 
urethra,  which  causes  sloughing  rather  than  suppuration,  and  may  destroy 
the  submucous  cellular  tissue  from  the  triangular  ligament  forward  even  to 
the  glans.  The  mucous  membrane  in  such  cases  is  entirely  dissected  from 
its  surroundings,  and  the  cellular  tissue  around  it  comes  away  through  the 
incisions  made  to  relieve  the  inflammation  of  the  parts,  so  that  the  finger 
may  be  passed  forward  and  backward  entirely  around  the  urethra,  the  vital- 
ity of  the  latter  being  sustained  by  its  longitudinal  vessels.  Cicatricial 
narrowing  may  follow,  involving  the  whole  length  of  the  canal,  unless  it  be 
prevented  by  systematic  dilatation  by  the  passage  of  sounds. 

Stricture. — Pathological  Anatomy. — Stricture  of  the  urethra  is  the 
consequence  of  destruction  of  the  mucous  membrane  by  injury  or  gonor- 
rhoea! or  chancroidal  ulceration,  or  of  cicatricial  contraction  following 
inflammation  in  the  cellular  tissue  around  it.  The  lesion  of  stricture  con- 
sists in  the  deposit  of  cicatricial  tissue  either  in  the  mucous  membrane  itself 
or  around  it,  but  most  frequently  in  the  latter  situation.  (Fig.  795.)  This 
cicatricial  tissue  in  its  early  stages  is  soft,  and  microscopic  examination 
shows  fibrous  tissue  with  an  abundant  round-cell  infiltration.  The  number 
of  round  cells  diminishes  later  and  the  fibrous  tissue  grows  very  dense  and 
hard.  The  cicatricial  tissue  may  project  into  the  urethra,  but  the  reduction 
in  the  caliber  of  the  canal  is  principally  caused  by  the  contraction  of  this 
tissue.  In  estimating  the  degree  of  contraction  it  should  be  borne  in  mind 
that  the  urethral  canal  is  not  of  the  same  diameter  from  one  end  to  the 
other,  and  that  at  the  meatus  it  is  naturally  much  smaller.  (Fig.  796.)  The 
narrowing  at  the  meatus  and  the  widening  at  the  bulb  are  universal,  but  the 
other  variations  in  caliber  differ  with  the  individual.  The  caliber  of  the 
urethra  may  be  diminished  simply  by  a  thickening  of  the  mucous  mem- 


STRICTUKE  OF  THE  URETHRA. 


1003 


Fig.  79.5. 


braiie,  cansiug  it  to  project  into  the  centre  of  the  canal  or  to  lose  its  distcn- 
sibility.  A  tumor  may  grow  upon  the  surface  of  the  mucous  membrane  and 
■project  into  tlie  urethra,  or  a  tumor  or  a  col- 
lection of  pus  or  blood  in  the  submucous  tissue 
may  lift  the  mucous  membrane  and  thus  reduce 
the  caliber  of  the  canal.  These  obstructions 
are  not  called  stricture,  that  name  being 
limited  to  cicatricial  contractions,  and  spas- 
modic stricture  should  also  be  excluded,  for  it 
is  a  spasm  of  the  muscle  surrounding  the 
urethra.  A  narrowing  of  the  canal  by  stric- 
ture may  involve  its  entire  length  or  may  be 
limited  to  a  very  small  part  of  the  canal,  and 
in  some  cases  there  may  be  a  narrow  band 
winding  spirally  or  obliquely  around  the  wall 
of  the  urethra. 

The  changes  are  usually  naost  marked  on 
the  iioor  of  the  urethra,  and  the  orifice  of  the 
obstructed  portion  is  therefore  near  the  upper 
wall.  Complete  closure  of  the  urethra  by  a 
stricture  is  rare,  and  is  found  onlj^  when  fistu- 
lous tracts  behind  it  allow  of  the  escaiie  of  the 
urine.     The  prostatic  urethra  is  exempt  from        ggetion  through  stricture  of  theure- 

Cicatricial  stricture,  although  severe  spasm  of    thra,  showing  mass  of  connectwe  tissue 
,,  1-^  (.J111TT  •         Tj_-j_      in  the  corpus  spongiosum  and  dilatation 

the  sphincter  of  the  bladder  may  simulate  it.    of  the  i>osterior  urethra.   (Agnew.) 
Strictures  are  most  "frecxuent  at  the  bulbo- 

membranous  junction,  and  next  in  order  stands  the  anterior  portion  within 
two  inches  of  the  meatus.    TSTiile,  as  a  rule,  there  is  more  or  less  infiltration 


and  narrowing  of  the  entire  urethra  with  tighter  strictures  located  at  various 
points,  in  some  cases  the  intermediate  portions  are  healthy.    Strictures  admit- 


1004  SYMPTOMS   OF  STRICTURE  OF  THE  URETPIRA. 

ting  a  sound  over  20  Frencli  in  size  liave  been  arbitrarily  called  strictures 
of  large  caliber.  Some  have  even  claimed  that  a  perfect  urethra  is  one  of 
equal  size  from  end  to  end,  and  designate  any  reduction  of  its  largest  diameter 
a  stricture  of  large  caliber.  It  is  true  that  in  chronic  inflammation  of  the 
canal,  where  it  is  desirable  to  treat  the  mucous  membrane  by  stretching  it 
by  the  passage  of  large  sounds,  a  very  slight  narrowing  may  interfere  with 
the  treatment  and  assist  in  keeping  up  the  inflammation,  and  may  therefore 
require  surgical  attention  ;  but  it  is  scarcely  proper  to  designate  these  nar- 
rower points  as  strictures  on  this  account.  The  caliber  of  the  urethra  bears 
some  proportion  to  the  size  of  penis  :  according  to  Otis,  a  penis  three  inches 
in  circumference  should  have  a  urethra  of  30  French  ;  one  of  three  and  a 
quarter  inches,  of  32  French ;  one  of  two  and  three-quarter  inches,  of  28 
French.  Some  sui'geons  think  these  figures  too  large,  but  in  treating  stricture 
we  have  usually  aimed  at  obtaining  a  caliber  of  30  or  32  French,  and  have 
had  no  accidents  attributable  to  this  cause,  and  but  few  recurrences  of  the 
stricture.  The  mucous  membrane  behind  a  stricture  is  usually  in  a  condition 
of  chronic  inflammation,  because  the  narrowing  of  the  canal  retains  the  urine 
and  purulent  discharge,  and  ulceration  frequently  exists  at  this  point.  The 
urethra  behind  the  obstruction  is  apt  to  be  dilated,  owing  to  the  increased 
pressure  necessary  to  expel  the  urine,  and  the  pressure  may  extend  backward 
and  dilate  the  bladder,  the  ureters,  and  even  the  pelvis  of  the  kidneys.  The 
incomplete  evacuation  of  the  urine  also  leads  to  infection  and  disease  of  the 
bladder  and  kidney,  and  sometimes  a  stone  is  formed  in  the  bladder  or 
urethra.  Stricture  of  the  urethra  is  rare  in  the  female,  probably  because 
gonorrhceal  urethritis  is  less  severe  in  that  sex.  Obstruction  of  the  urethra 
usually  begins  in  from  four  to  eight  months  after  an  injury,  and  in  from  two 
to  ten  years — on  the  average  four  years — after  an  attack  of  gonorrhoea. 

Symptoms. — The  symptoms  of  stricture  often  begin  long  before  any 
obstruction  is  noticed,  for  a  slight  discharge  of  purulent  or  watery  material 
is  caused  by  the  chronic  inflammation  of  the  mucous  membrane  behind  the 
stricture,  and  a  dribbling  of  urine  occurs  at  the  end  of  micturition  because 
the  urethra  has  lost  its  natural  elasticity  and  fails  to  expel  the  last  drop 
promptly.  The  discharge  may  be  so  slight  as  to  be  noticeable  only  in  the 
morning,  when  no  urine  has  been  passed  for  several  hours.  The  difficulty 
in  making  water  develops  gradually,  and  if  the  bladder  be  healthy  and 
hypertrophy  early  a  considerable  amount  of  obstruction  may  exist  without 
the  patient's  knowledge.  The  first  marked  symptom  may  be  an  attack  of 
retention,  owing  to  errors  of  diet,  exposure  to  cold,  alcoholism,  a  fresh 
urethritis,  or  some  such  condition,  causing  the  mucous  membrane  to  become 
swollen  about  the  stricture  and  block  the  canal  completely. 

In  such  cases  a  jjatient  who  has  been  making  water  without  much  diffi- 
culty suddenly  becomes  unable  to  pass  auy  urine.  The  bladder  is  distended, 
and  intense  pain  is  caused  by  the  spasmodic  efl'orts  to  evacuate  it.  A  slight 
rise  of  temperature  may  be  observed,  and  if  cystitis  or  pyelitis  be  present 
this  rise  will  be  marked,  and  there  will  be  a  chill.  Urtemic  symptoms  may 
also  develop  under  these  circumstances.  If  the  bladder  and  kidneys  are 
healthy,  the  general  symptoms  are  limited  to  discomfort  and  x^ain.  If  not 
soon  relieved,  the  pressure  behind  the  stricture  may  force  the  urine  through 


EXTRAVASATION  OF  URINE.  1005 

some  weak  point  iu  the  mucous  membrane  into  the  submucous  tissue  and 
cause  urinary  infiltration. 

Extravasation  of  Urine. — The  urine  may  escape  at  any  point  from  tlie 
triangular  ligament  to  the  glans  penis,  but  it  does  so  most  frequently  in  the 
deeper  portions  of  the  canal.  The  urine  spreads  through  the  submucous 
tissue  and  as  far  outward  as  the  superficial  perineal  fascia,  which  prevents 
its  extension  backward,  or  to  the  thighs,  aud  forces  it  to  a^scend  on  the 
abdomen.  The  penis  and  the  scrotum  become  intensely  swollen,  and  the 
swelling  sometimes  reaches  as  high  as  the  umbilicus.  The  skin  is  cedema- 
tous  and  red,  and  there  is  a  hard,  brawny  infiltration  which  pits  on  deep 
pressure.  If  left  unrelieved,  the  redness  becomes  dusky,  the  circulation  is 
impaired,  points  of  softening  and  fluctuation  appear,  and  if  an  incision  is 
made  at  th«se  points  it  will  be  found  that  the  subcutaneous  tissue  is  gan- 
grenous throughout  the  infiltrated  part.  A  foul,  serous  fluid,  with  an  odor 
of  aramoniacal  urine,  surrounds  the  sloughs. 

If  incisions  are  made  early,  the  spread  of  the  urinary  infiltration  may 
be  prevented,  the  fluid  escaping  from  the  wounds  and  the  sloughing  subcu- 
taneous tissue  slowly  separating  and  leaving  granulating  surfaces  behind 
it  in  favorable  cases.  The  large  subcutaneous  spaces  left  by  the  sloughing 
of  the  cellular  tissue  then  heal,  but  if  the  leakage  from  the  urethra  still 
continues  because  the  obstruction  persists,  the  urine  makes  channels  for 
itself  through  the  tissues,  and  sinuses  are  formed,  which  spread  in  a  tor- 
tuous manner  in  all  directions,  so  that  when  the  patient  attempts  to  make 
water  the  urine  escapes  from  a  dozen  or  more  openings  in  various  parts  of 
the  scrotum,  the  penis,  and  even  the  abdomen.  In  unusually  strong  and 
healthy  men  a  spontaneous  cure  of  the  extravasation  by  the  formation  of 
these  fistulffi  is  not  uncommon,  but  a  fatal  issue  is  to  be  expected  in  those 
who  are  less  robust,  and  especially  if  the  bladder  and  kidneys  are  already 
diseased.  The  constitutional  symjitoms  of  urinary  extravasation  are  usually 
very  severe,  for  in  addition  to  the  ordinary  synijitoms  of  cellulitis,  such  as 
pain,  fever,  rigors,  and  prostration,  the  constituents  of  the  urine  are  absorbed 
by  the  tissues,  and  a  condition  of  uremia  is  produced,  with  eonti-acted 
pupils,  a  urinary  odor  to  the  breath,  a  hard,  quick  pulse,  dyspnoea,  coma  or 
delirium,  and,  finally,  convulsions.  Some  of  these  urtemic  symptoms  are 
undoubtedly  caused  by  interference  with  the  action  of  the  kidneys  by  the 
damming  back  of  the  urine,  but  the  majority  are  the  result  of  absorption 
of  the  extravasated  fluid.  In  other  cases  the  urinary  extravasation  takes 
place  much  more  slowly,  only  a  few  drops  escaping  at  a  time,  and  localized 
abscesses  are  produced,  which,  on  being  opened,  result  i  a  the  formation  of 
urinary  fistulte  iu  the  perineum  and  scrotum.  As  a  rule,  urinary  infiltration 
does  not  affect  the  skin  itself,  aud  it  is  only  iu  extreme  cases  that  any  con- 
siderable amount  of  skin  becomes  gangrenous,  although  in  such  cases  the 
entire  covering  of  the  penis  and  scrotum  may  be  lost. 

While  acute  retention  may  h^ve  these  immediate  consequences,  the  more 
chronic  form  results  in  over-distention  of  the  bladder  aud  au  increased 
backward  pressure  on  the  kidneys,  with  a  greater  liability  to  infection  aud 
inflammation  of  both.  In  such  cases  the  patient  is  unable  to  evacuate  the 
bladder  completely,   aud  gradually  that  organ  becomes  distended  to  its 


1006  URETHRAL  FEVER. 

utmost  and  loses  its  contractile  power,  when  a  condition  of  overflow  is  estab- 
lished in  which  the  urine  constantly  dribbles  away.  In  such  cases  the  com- 
plication of  kidney  disease  will  usually  be  found,  and  its  symptoms  are 
added  to  those  of  the  urethral  condition.  Such  patients  are  anaemic  and 
worn  out  by  suffering  and  loss  of  sleep,  the  establishment  of  leakage  by 
overflow  being  preceded  by  a  long  period  of  frequent  and  painful  micturi- 
tion. The  micturition  is  not  increased  in  frequency  at  night,  thus  differing 
from  the  symptoms  of  prostatic  hypertrophy.  Patients  with  tight  stricture 
usually  suffer  an  impairment  of  sexual  power,  and  may  become  impotent. 

Prognosis. — The  prognosis  of  a  stricture  depends  upon  its  extent  rather 
than  its  caliber,  for  a  stricture  involving  a  large  part  of  the  urethra  will 
cause  more  obstruction  to  the  passage  of  the  urine  and  be  more  liable  to  the 
accidents  of  retention  and  urinary  extravasation  than  a  narrow  band  of  the 
same  caliber.  If  the  bladder  is  healthy,  and  tolerance  is  established  so  that 
the  urine  is  regularly  evacuated,  even  if  the  intervals  be  frequent  and  the 
amount  be  small,  the  patient  may  enjoy  tolerably  good  health.  If  his 
habits  are  irregular,  however,  acute  retention  may  set  in  at  any  moment, 
and  in  any  case  the  symjDtoms  will  constantly  grow  worse.  The  danger  to 
life  depends  upon  the  condition  of  the  bladder  and  kidneys.  The  presence 
of  cystitis  or  pyelitis  renders  the  prognosis  very  bad,  and  also  increases  the 
danger  of  treatment. 

The  Use  of  Bougies  and  Catheters. — Urethral  Fever. — In  any 
examination  or  treatment  of  the  urethra  the  most  thorough  antiseptic  pre- 
cautions are  necessary.  The  instruments,  the  hands,  and  the  penis  must 
be  most  carefully  cleansed  and  sterilized.  If  antiseptic  precautions  are 
not  observed,  urethral  fever  may  occur,  either  at  once  or  the  next  time 
that  the  patient  passes  water.  The  fever  begins  with  a  severe  chill,  and 
the  temperature  may  reach  105°  or  106°  F.  (40.5°  or  11°  C),  but  usually 
promptly  subsides.  This  chill  and  rise  of  temi^erature  follows  every  pas- 
sage of  urine  over  the  wounded  canal  or  the  introduction  of  any  instrument. 
The  attack  may  be  prevented  or  controlled  by  the  administration  of  quinine, 
ten  or  fifteen  grains  being  given  at  a  dose  an  hour  before  the  instrumen- 
tation or  micturition  is  expected  ;  and  also  by  the  administration  of  urotro- 
pin  or  salol,  which  are  excreted  by  the  kidneys  and  partially  sterilize  the 
urine.  These  symptoms  are  known  as  urethral  fever,  and  were  formerly  very 
frequent  in  all  urethral  surgery,  and  supposed  to  be  of  nervous  origin. 
They  are  probably  due  to  the  absorj^tion  of  toxines  produced  by  bacterial 
growth  within  the  canal.  If  the  condition  lasts  for  any  length  of  time  a 
true  septic  fever  is  established,  with  irregular  exacerbations,  purulent 
urethritis  or  cystitis,  secondary  pyelitis,  and  general  septicaemia  or  j)yaemia. 

Sterilization  of  Instruments  and  of  the  Urethra. — Metal  and  rubber 
instruments  may  be  sterilized  by  boiling,  although  the  rubber  is  injured 
by  prolonged  or  repeated  boiling.  Gum  instruments  should  be  carefully 
washed  with  soft  soap,  and  then  laid  for  fifteen  or  twenty  minutes  in  a  1  to 
1000  solution  of  bichloride  of  mercury,  and  again  carefully  rinsed  in  steril- 
ized water  before  they  are  introduced.  In  cleansing  catheters  a  strong  stream 
of  water  should  be  driven  through  the  instrument,  and  the  catheters  should 
be  filled  with  the  bichloride  solution  and  left  to  soak  in  it  for  half  an  hour 


EXAMINATION   OF  THE   ITRETHRA.  1007 

or  an  hour.  The  vapor  of  formalin  is  very  useful  in  the  sterilization  of 
catheters  (See  page  120),  but  it  requires  several  hours'  exposure  ;  and  it  is  so 
irritating  that  the  catheter  must  be  washed  in  sterile  water  before  introduc- 
tion. The  urethra  should  be  ii-rigated  with  some  mild  antiseptic  solution, 
such  as  the  boro-salicylic  solution.  The  patient  should  be  directed  to  pass 
water  before  the  examination,  if  possible,  in  order  to  wash  out  the  urethra 
behind  the  stricture.     Complete  sterilization  of  the  urethra  is  impossible. 

For  lubrication,  any  sterilized  medium,  such  as  vaseline,  glycerin,  boro- 
glyceride,  or  lubrichondrin,  may  be  employed,  but  sweet  oil  is  the  best  in 
cases  of  narrow  stricture.  These  substances  are  sterilized  by  heat.  The 
lubricant  is  rubbed  upon  the  instrument  with  sterilized  gauze,  or  the  sweet 
oil  may  be  injected  into  the  urethra  with  a  glass  syringe,  the  latter  procedure 
being  useful  in  tight  strictures.  If  applications  are  to  be  made  to  the  canal, 
glycerin  should  be  employed,  as  the  oil  would  protect  the  mucous  mem- 
brane.    The  metal  sounds  should  be  warmed  before  introduction. 

Instruments  for  Examination. — The  instruments  used  in  the  exam- 
ination of  the  urethra  may  be  flexible  or  stiff,  the  former  being  less  likely  to 
do  injury,  and  the  latter,  when  made  of  metal,  being  easier  to  render  aseptic. 
For  sizes  under  12  French,  flexible  instruments  should  be  employed,  but 
over  that  size  the  metal  sounds  are  more  convenient.  Solid  instruments, 
called  bougies  or  sounds,  are  used  for  dilatation,  and  hollow  bougies,  or 
catheters,  for  drawing  off  the  urine.  These  instruments  are  made  in  various 
sizes,  which  are  known  by  certain  numbers,  but  three  different  scales  are  in 
use  to  designate  them,  the  American,  English,  and  French,  or  Charriere. 
The  numbers  of  the  American  scale  give  the  diameter  of  the  sound  in  half 
millimetres,  while  the  English  scale  is  purely  arbitrary.  The  French  or 
Charriere  scale  is  most  frequently  used,  and  its  numbers  give  the  diameter 
of  the  instruments  in  one-third  of  a  millimetre,  and  therefore  nearly  corre- 
spond with  the  circumference  in  millimetres,  j^o.  3  is  thus  one  millimetre 
in  diameter  and  3.1416  millimetres  in  circumference,  and  ISTo.  30  is  ten  milli- 
metres in  diameter  and  31.416  millimetres  in  circumference. 

For  very  tight  strictures  filiform  bougies  of  whalebone  are  employed  of  a 
diameter  of  one  millimetre  or  less,  straight,  or  bent  at  an  angle  or  made 
spiral  at  the  end.  Flexible  bougies  and  catheters  may  be  made  of  soft  rub- 
ber, but  the  smaller  instruments  need  to  be  stiffer,  and  are  made  of  linen  or 
silk  thread  covered  with  shellac,  often  called  "gum"  bougies.  Sometimes 
a  soft  wire  stylet  is  inserted  to  stiffen  them  and  gi^'e  them  certain  shapes. 
A  very  useful  flexible  instrument  is  the  "  whip  bougie,"  which  tapers  from 
a  filiform  point  to  15  French  and  is  very  long.  The  stiff  bougies  are 
generally  made  of  metal  and  are  called  sounds,  those  of  polished  steel 
being  most  common  and  most  useful.  The  sounds  have  a  straight  shaft, 
and  the  end  bent  to  the  curve  of  a  circle  three  and  one-quarter  inches  in 
diameter,  which  is  the  subpubic  curve  of  the  normal  urethra,  aud  the  beak 
should  never  include  more  than  ninety  degrees  of  the  circle.  The  sounds 
should  taper  towards  the  point,  which  should  be  two  sizes  smaller  than  at 
the  curve. 

Introduction  of  Instruments. — The  patient  lies  upon  his  back,  and 
the  surgeon,  standing  by  his  side,  takes  the  penis  in  one  hand,  while  with 


1008  INTRODUCTION   OF  URETHRAL  INSTRUMENTS. 

the  otlier  he  gently  passes  the  instrument  into  the  canal.  If  a  flexible 
instrument  is  used,  the  penis  is  held  vertical  and  placed  somewhat  on  the 
stretch,  so  that  the  canal  shall  be  rendered  rigid.  In  the  introduction  of  a 
stiff  instrument  its  point  should  be  gently  inserted  into  the  meatus,  and  the 
sound  then  held  steady,  with  its  shaft  ijarallel  to  Poupart's  ligament,  while 
the  hand  holding  the  penis  gently  draws  the  organ  up  over  the  sound. 
Very  slowly  and  gently  the  advance  is  made,  with  slight  rotatory  movements, 
until  the  sound  has  passed  the  peuo-scrotal  junction,  when  the  beak  of  the 
instrument  should  be  turned  backward  (towards  the  bladder),  and  the  shaft 
brought  into  the  median  line  of  the  body.  The  hold  upon  the  penis  is  then 
relaxed,  the  handle  of  the  sound  is  slowly  raised,  and  the  instrument  is 
allowed  to  slip  downward  of  its  own  weight,  following  the  natural  curve  of 
the  urethra.  The  shaft  thus  gradually  becomes  vertical,  showing  that  the 
point  of  the  sound  is  in  the  neighborhood  of  the  triangular  ligament.  If  it 
is  necessary  to  pass  the  sound  into  the  bladder,  the  handle  is  turned  still 
farther  downward  in  the  same  curve  towards  the  patient's  thighs  with  great 
gentleness,  the  sound  being  allowed  to  enter  simply  by  its  weight  and  with- 
out pressure.  This  manceuvre  can  be  assisted  by  laying  the  other  hand  flat 
upon  the  surface  of  the  abdomen,  just  above  the  pubes,  and  drawing  the 
skin  downward,  which  relaxes  the  tension  of  the  parts  at  the  root  of  the 
penis. 

With  a  very  relaxed  iirethra  there  may  be  obstruction  to  the  sound  at 
the  penoscrotal  junction  and  at  the  triangular  ligament,  the  point  of  the 
sound  pushing  the  abnormally  soft  urethral  wall  before  it  like  a  pouch. 
The  former  is  overcome  by  j)ulling  the  penis  strongly  uj)  on  the  sound 
towards  the  umbilicus,  and  the  latter  by  lifting  the  sound  a  trifle  when  its 
end  impinges  on  the  surface  of  the  ligament.  The  point  of  the  sound  should 
be  kept  against  the  roof  of  the  urethra,  as  it  provides  a  much  firmer  guide  to 
the  instrument  than  the  more  distensible  floor  of  the  canal,  and  obstructions 
are  also  more  likely  to  be  found  on  the  latter.  The  entrance  of  the  sound 
into  the  bladder  is  proved  by  the  fact  that  its  beak  can  be  turued  freely 
from  side  to  side,  and  the  patient  has  a  sensation  as  if  he  were  making  water. 
The  point  of  a  filiform  is  so  fine  that  it  may  be  caught  in  one  of  the  small 
lacuuiie-  or  the  ducts  of  glands  in  the  mucous  membrane,  and  it  should  be 
slightly  withdrawn  if  it  meets  with  any  obstruction,  and  an  attempt  made 
by  bending  the  penis  or  the  instrument  to  cause  the  latter  to  slip  along 
another  portion  of  the  urethral  wall  before  it  is  concluded  that  the  obstruc- 
tion in  question  is  a  stricture.  If  there  is  a  stricture  and  the  filiform  cannot 
be  made  to  pass,  it  should  be  inserted  as  far  as  possible  and  then  another 
filiform  passed  alongside  of  it.  If  three  or  four  instruments  are  together  in 
the  urethra,  one  after  another  being  tried,  it  is  often  possible  to  introduce 
one  of  them  into  the  stricture  when  a  single  bougie  would  not  enter.  A  tem- 
porary bend  is  easily  given  to  the  tip  of  the  whalebone  filiform  by  pinching 
it  between  the  finger-nails.  The  angular  filiforms  often  enter  where  the 
straight  would  not,  and  the  same  is  true  of  the  spiral  shapes.  When  a  fili- 
form has  been  passed  into  the  stricture  in  a  difficult  case  and  an  oj)eration 
is  proposed,  it  is  wise  to  keep  the  bougie  in  place  until  the  operation.  To 
secure  a  bougie  or  catheter  in  the  urethra,  a  "clove-hitch"  knot  should  be 


DIAGNOSIS  OF  STRICTURE.  1009 

made  around  the  instrument  with  a  silk  thread,  and  the  ends  of  the  latter 
secured  to  the  penis  by  rubber  plaster  or  tied  to  the  hair  of  the  pubes. 

Accidents. — There  may  be  pain  in  urination  and  a  slight  mucous  dis- 
charge from  the  urethra  after  the  introduction  of  instruments.  This  can  be 
lessened  by  alkalinization  of  the  urine.  Epididymitis  may  also  follow  from 
infection  of  the  seminal  ducts  by  urethral  discharge  or  by  an  unclean  instru- 
ment. False  passages  may  be  made  by  penetration  of  the  urethral  mucous 
membrane  by  a  stiff  instrument  used  with  too  great  force,  an  accident  which 
usually  causes  pain  and  hemorrhage  and  sometimes  an  abscess. 

Catheterization  in  the  Female. — The  introduction  of  the  female 
catheter  is  usually  very  easy,  unless  the  parts  are  abnormal,  either  congeni- 
tally  or  as  a  result  of  parturition  and  its  accidents.  The  same  care  as  to 
asepsis  is  necessary  as  in  the  male,  lest  a  cystitis  develop,  and  this  compels 
the  rejection  of  the  older  methods  of  introducing  the  instrument  by  the 
touch  alone.  The  genitals  should  always  be  washed  and  sterilized,  the  labia 
held  apart,  and  the  cathether  introduced  by  the  aid  of  sight  so  that  it  shall 
touch  nothing  but  the  meatus. 

Anaesthesia. — A  general  anaesthetic  is  seldom  necessary  for  the  intro- 
duction of  these  instruments,  but  cocaine  may  be  employed  locally.  In  the 
use  of  urethral  injections  of  cocaine  there  apjiears  to  be  unusual  liability  to 
poisoning  by  absorption,  so  the  solutions  used  should  be  only  two,  or  at 
most  four,  per  cent. ;  not  over  fifteen  minims  should  be  employed,  and  the 
urethra  should  be  irrigated  with  warm  sterilized  water  in  order  to  remove 
the  cocaine  as  soon  as  the  ansesthetic  effect  has  been  obtained. 

Diagnosis  of  Stricture. — The  diagnosis  of  stricture  is  made  by  the 
local  examination,  for  which  the  bulbous  bougie  (Fig.  797)  is  the  proper 

Fig.  797. 


Bulbous  bougies. 

instrument.  When  introduced  into  a  stricture  through  which  it  just  passes, 
the  broad  shoulder  of  the  bulb  is  grasped  by  the  stricture  on  withdrawal,  so 
that  the  exact  depth  of  the  narrowest  point  may  be  ascertained  by  placing 
the  finger  on  the  stem  of  the  instrument  at  the  meatus,  withdrawing  it,  and 
measuring  the  distance  marked.  The  peculiar  jump  which  a  bulb  gives 
when  withdrawn  through  a  stricture  is  an  important  diagnostic  sign,  as  the 
sensation  is  much  less  distinct  when  the  obstruction  is  the  result  of  the 
pressure  of  an  abscess  or  of  a  tumor  upon  the  canal.  The  bulbous  bougie 
is  of  little  value  in  the  deep  urethra,  as  it  may  catch  upon  the  edges  of  the 
opening  in  the  triangular  ligament  and  simulate  the  existence  of  a  stricture. 
It  is  also  difficult  to  dislodge  the  instrument  in  that  case,  and  the  necessary 
force  may  break  it  and  leave  the  bulbous  end  in  the  bladder ;  consequently 
it  should  not  be  introduced  over  six  inches  from  the  meatus.  Before  exam- 
ining a  urethra  for  stricture  a  narrow  meatus  must  be  divided.     The  largest 


1010  URETHROTOMY. 

possible  instrument  should  be  introduced  first,  for  it  more  readily  overcomes 
muscular  spasm  and  is  less  apt  to  catch  in  the  lacunse  and  false  passages. 
Successively  smaller  bulbs  are  employed,  down  to  10  French,  until  one  is 
found  which  passes  the  stricture,  but  under  that  size  flexible  bougies  ai'e  to 
be  used.  The  urethrameter  is  an  instrument  which  can  be  expanded  after 
introduction  into  the  urethra,  and  which  will  show  on  a  dial  the  exact  limit 
of  distensibility  at  any  point  of  the  canal.  The  best  known  is  that  of  Otis. 
It  is  intended  to  measure  the  urethra  in  order  to  demonstrate  the  existence 
of  strictures  of  large  caliber,  but  is  useful  also  in  locating  strictures  which 
exist  behind  a  meatus  narrower  than  the  strictures  when  it  is  not  desirable 
to  enlarge  that  orifice. 

Treatment. — Only  two  methods  of  treating  strictures  need  be  consid- 
ered,— namely,  dilatation  and  urethrotomy.  Electrolysis  has  no  advantage 
over  the  cutting  operation  if  the  currents  are  strong  enough  to  destroy  the 
mucous  membrane,  and  none  over  dilatation  if  very  feeble  currents  are 
employed. 

Dilatation. — A  stricture  can  be  dilated  by  the  introduction  of  instru- 
ments of  constantly  increasing  diameter,  passed  at  regular  intervals,  the 
length  of  the  interval  depending  ujaon  the  tightness  of  the  stricture  and  its 
tendency  to  recontraction.  The  method  of  rapid  dilatation,  by  which  the 
stricture  is  also  lacerated,  is  too  uncertain  and  dangerous,  and  has  fallen 
into  disuse.  If  the  stricture  is  very  tight,  it  may  be  necessary  to  begin  with 
a  filiform  bougie,  and  if  retention  is  present  when  treatment  is  begun,  the 
filiform  should  be  left  in  the  bladder,  for  enough  urine  will  escape  by  its  side 
to  relieve  the  worst  symptoms  of  the  retention.  A  filiform  which  is  tightly 
grasped  by  the  stricture  at  the  time  of  introduction  becomes  loose  in  a  few 
hours  owing  to  its  pressure  upon  the  tissues  about  it.  Thicker  filiforms  are 
introduced,  or  several  of  the  same  size,  dilating  the  stricture  until  a  fine 
flexible  instrument  may  be  passed  through  it.  The  patient  is  kept  in  bed 
during  this  continuous  dilatation.  He  is  then  allowed  up,  and  larger  instru- 
ments are  i^assed  daily  until  the  stricture  has  reached  the  size  of  15  or  20 
French,  and  then  the  intervals  may  be  lengthened  to  from  three  to  seven 
days,  for  after  this  point  the  improvement  will  not  be  so  rapid.  The  intro- 
duction of  instruments  through  the  stricture  not  only  stretches  the  narrowed 
part  but  brings  about  a  change  in  the  tissues,  for  their  circulation  is 
improved,  the  round-cell  infiltration  melts  away,  new  vessels  form  in  the 
fibrous  tissue,  and  absorption  is  gradually  ijroduced.  If  false  passages  are 
made  by  the  instruments  used  in  dilatation,  no  instrument  should  be  passed 
for  at  least  a  week,  in  order  to  give  them  an  opportunity  to  heal.  Some- 
times they  can  be  avoided  at  the  next  introduction  of  the  sound  by  keeping 
its  i)oint  directed  against  the  roof  of  the  urethra,  as  they  are  apt  to  be  situ- 
ated upon  the  floor. 

Urethrotomy. — Urethrotomy  may  be  internal  or  external. 

Internal  Urethrotomy. — Internal  urethrotomy  is  now  usually  pei'- 
formed  with  an  instrument  which  stretches  the  canal  and  holds  the  mucous 
membrane  steady  while  a  concealed  knife  is  drawn  through  it,  dividing  it  to 
any  extent.  The  incision  made  by  the  knife  is  very  shallow,  except  where 
the  tension  of  the  parts  across  the  instrument  is  very  great.     Otis' s  dilating 


INTERNAL  URETHROTOMY.  lOH 

urethrotome  is  the  instrument  generally  preferred.  (Fig.  798.)  When  the 
stricture  has  been  located  with  the  bulbous  bougie,  the  instrument  is  passed 
through  it  and  screwed  up  until  the  desired  degree  of  dilatation  is  obtained, 
as  shown  on  the  dial,  or  as  near  that  as  the  tension  of  the  parts  will  allow, 

Fig.  798. 


The  Otis  urethrotome. 

and  the  knife  drawn  once  through  the  stricture  and  then  jjuslied  back  again. 
If  the  required  size  of  the  urethra  has  not  been  obtained  at  the  first  attempt, 
a  second  cut  is  made  in  the  same  manner.  The  instrument  is  then  partially 
closed,  rotated  on  its  long  axis  half-way  in  order  to  free  the  branches  from 
the  edges  of  the  divided  mucous  membrane,  and  withdrawn.  Smart  hem- 
orrhage may  follow  this  procedure,  but  it  is  usually  soon  arrested  by  pre.ss- 
ure.  If  it  be  troublesome,  a  stout  rubber  catheter  should  be  inserted  and  a 
bandage  applied  to  the  penis.  A  sound  of  the  full  size  should  be  ijassed 
twenty-four  or  forty-eight  hours  after  the  operation,  and  in  ordinary  cases 
it  will  be  unnecessary  to  pass  it  again  for  five  or  six  days.  Our  own  prac- 
tice is  to  pass  the  sound  once  a  week  after  an  oj)eration  of  this  nature  unless 
there  is  a  tendency  to  rapid  contraction,  and  then  it  may  be  passed  twice  a 
Aveek.  A  tendency  to  contraction  usually  indicates  that  the  cicatricial  tissue 
has  not  been  entirely  divided,  and  in  some  cases  comj)lete  division  is  impos- 
sible on  account  of  the  great  extent  of  the  lesion.  After  weekly  use  of  the 
sound  for  three  months  it  should  be  passed  once  a  month  for  a  year. 

Before  introducing  the  urethrotome,  the  meatus  should  be  enlarged  to 
the  necessary  size  with  a  bistoury.  The  Otis  urethrotome  can  only  j^ass 
through  a  stricture  of  about  15  French,  and  for  smaller  strictiu'es  it  is  neces- 
sary to  use  the  Maisonneuve  instrument,  which  consists  of  a  grooved  staff, 
along  which  a  stylet  carrying  a  triangular  knife  with  a  blunt  apex  is  pushed 
from  before  backward.  The  instrument  has  a  very  fine  flexible  bougie, 
which  can  be  introduced  and  then  screwed  to  the  end  of  the  urethrotome,  so 
that  it  guides  the  latter  through  a  very  tight  stricture.  When  the  urethra 
has  been  somewhat  enlarged  the  Otis  instrument  can  be  used.  Internal 
urethrotomy  can  be  performed  in  any  part  of  the  canal,  but  is  now  seldom 
used  for  attacking  strictures  in  the  membranous  urethra,  or  deeper,  on 
account  of  the  danger  of  uncontrollable  hemorrhage.  The  only  other  danger 
of  the  operation  is  septic  infection,  and  this  can  be  avoided  by  full  antiseptic 
precautions,  unless  the  stricture  is  so  tight  that  the  urethra  behind  it  cannot 
be  thoroughly  irrigated.  If  there  are  signs  of  considerable  inflammation 
behind  a  tight  stricture  (local  tenderness,  foul  discharge,  fever),  the  urethra 
should  be  opened  in  the  perineum  in  order  to  afford  drainage,  otherwise 
urethral  fever  or  sepsis  will  follow.  Slight  strictures  can  be  divided  pain- 
lessly by  the  use  of  cocaine  with  the  i^recautions  already  noted,  but  very 
extensive  or  tight  strictures  should  be  treated  under  general  anaesthesia. 


1012 


EXTERNAL  URETHROTOMY. 


Fig.  799. 


External  Urethrotomy. — External  urethrotomy  is  now  generally 
emj)loyed  for  deep  strictures  or  for  the  purpose  of  drainage  with  internal 
urethrotomy  as  just  mentioned.  The  operation  is  performed  by  introducing 
into  the  urethra  as  large  a  guide  as  circumstances  will  permit.  In  some 
cases  only  a  filiform  can  be  passed  through  the  stricture,  and  in  others  no 
instrument  will  enter  it,  and  then  the  operation  must  be  performed  without 
a  guide. 

External  Urethrotomy  with  a  G-uide. — If  i^ossible,  a  metal  guide  should  be 
used.  For  this  purpose  there  is  no  instrument  more  useful  thau  the  tun- 
nelled sound  or  catheter  recommended  by  Gouley.  (Fig.  799.)  This  instru- 
ment has  a  perforation  at  the  point,  through  which  the 
filiform,  which  has  been  passed  through  the  stricture,  may 
be  threaded,  and  the  instrument  is  then  pushed  down 
along  the  filiform,  which  guides  it  through  the  stricture. 
It  is  unsafe  to  use  much  force,  for  the  edge  of  the  opening 
in  which  the  filiform  plays  may  cut  the  bougie,  and  when 
the  guide  is  thus  lost  a  false  passage  may  be  made.  The 
filiform,  moreover,  may  enter  a  false  passage,  and,  curling 
up  in  it,  may  appear  to  be  in  the  bladder,  and  if  the  sur- 
geon introduces  the  tunnelled  sound  with  force,  that  in- 
strument necessarily  follows  the  guide  and  may  add  to  the 
injury.  In  order  to  overcome  these  objections  the  tun- 
nelled catheter  has  a  hollow  shaft  instead  of  a  solid  one, 
through  which  the  urine  can  flow,  and  it  can  thus  be  proved 
that  the  instrument  has  entered  the  bladder. 

The  guide  having  been  introduced  into  the  bladder,  an 
incision  is  made  in  the  median  line  of  the  perineum  from 
the  posterior  limits  of  the  scrotum  to  the  anterior  edge  of 
the  sphincter  ani.  This  incision  Is  deepened  until  the  bul- 
bous urethra  is  reached.  If  the  bulb  is  very  well  marked,  it 
can  sometimes  be  drawn  forward  by  a  retractor  and  the 
troublesome  hemorrhage  from  this  source  avoided,  but 
in  the  majority  of  cases  the  bulb  does  not  bleed  very  profusely.  The  inci- 
sion is  deepened  in  the  median  line  until  the  urethra  is  reached,  when  the 
guide  can  generally  be  felt  with  the  tip  of  the  finger  and  the  canal  oj^ened. 
A  director  is  inserted,  the  staff  removed,  and  then  a  small  silver  female 
catheter  can  be  slipped  backward  along  the  director  into  the  bladder.  When 
the  anterior  strictures  have  been  dealt  with  by  internal  urethrotomy,  a  large 
sound  is  carried  down  from  the  meatus  to  the  wound  and  then  passed  onward 
into  the  bladder.  If  any  obstruction  is  met  with  in  this  region,  it  is  removed 
by  passing  a  director  into  the  canal  and  nicking  the  obstructing  band  with  a 
blunt-pointed  knife.  Occasionally  there  is  troublesome  oozing  of  blood,  or 
even  active  hemorrhage  from  the  deeper  parts,  which  persists  after  the  opera- 
tion. In  such  cases  a  canule  ct  chemise  is  constructed  by  inserting  the  end  of 
a  catheter  through  a  hole  in  a  square  piece  of  gauze,  and  tying  the  latter 
firmly  around  the  catheter  by  a  string  embracing  the  edges  of  the  hole  in  the 
gauze.  The  catheter  is  inserted  in  the  bladder  and  the  gauze  spread  over  the 
edge's  of  the  wound  so  that  it  has  the  shape  of  a  funnel,  the  apex  being  in  the 


Tunnelled  catheter. 


EXTERNAL  URETHROTOMY.  1013 

bladder.  Strips  of  gauze  are  packed  in  the  funnel  thus  formed  until  suffi- 
cient ijressure  is  obtained  to  control  the  heaiorrhage. 

External  Urethrotomy  xoUhout  a  Guide. — If  no  guide  can  be  passed,  the 
operation  becomes  one  of  the  most  difficult  in  surgery,  and  even  experienced 
men  occasionally  fail  to  find  the  urethra.  The  patient  should  be  placed  in 
the  lithotomy  position  squarely  on  his  back,  in  front  of  a  good  light,  and 
the  incision  ^'ery  cautiously  made  exactly  in  the  median  line,  and  deepened 
layer  by  layer  in  order  to  recognize  the  different  parts  as  they  are  divided. 
Eetractors  should  be  placed  in  the  wound,  silk  sutures  passed  through  its 
edges  being  best  for  this  puri^ose,  and  the  assistants  should  be  careful  to 
maintain  equal  traction  on  both  sides  so  as  not  to  mislead  the  operator. 
The  umbilicus  of  the  patient  should  be  in  full  view,  so  that  the  operator 
may  be  perfectly  certain  of  the  direction  of  the  median  plane  of  the  body. 
When  the  deepest  parts  are  reached,  a  finger  in  the  rectum  may  assist  in 
giving  the  exact  relations  of  the  urethra,  and  the  apex  of  the  subpubic  arch 
can  also  be  used  as  a  guide.  If  there  has  been  but  little  infiltration  of  urine, 
the  urethra  may  be  recognized  when  it  is  reached,  but  when  there  are  fistulfe 
and  cicatricial  tissue,  or  where  there  is  actual  extra\'asation  of  urine  at  the 
time  of  operation,  all  landmarks  may  be  lost.  The  surgeon  should  then  carry 
the  knife  gradually  deeper  in  the  median  line,  watching  for  anything  which 
looks  like  mucous  membrane  to  indicate  that  the  urethra  has  been  opened. 
He  may  be  misled  by  the  endothelial  lining  of  the  vessels  in  the  cavernous 
tissue,  which  often  resembles  the  diseased  mucous  membrane  of  the  urethra. 
Any  opening  which  appears  to  present  mucous  membrane  should  be  cau- 
tiously explored  with  the  probe  and  director,  using  the  greatest  gentleness. 
When  the  urethra  has  been  opened,  a  probe  or  director  will  pass  readily 
backward  to  the  bladder  or  forward  towards  the  meatus,  and  if  there  is  the 
least  obstacle  to  its  passage  the  operator  may  feel  certain  that  he  Is  merely 
pushing  the  instrument  parallel  with  the  urethra  in  the  cellular  tissue. 

If  the  urethra  cannot  be  found  and  the  symptoms  are  acute  with  much 
extravasation  of  urine,  lateral  incisions  may  be  made  on  each  side  at  right 
angles  to  the  median  one,  and  the  patient  allowed  to  recover  from  the  anes- 
thetic. In  the  majority  of  cases  it  will  be  found  that  the  urine  passes  by 
the  wounds,  and  the  opening  into  the  urethra  can  be  discovered  then,  or 
after  the  sloughs  have  separated.  If  urinary  extravasation  exists,  the  sur- 
geon should  not  be  content  with  merely  opening  the  urethra,  but  should 
make  incisions  through  the  skin  and  cellular  tissue  of  all  the  inflamed  region 
in  order  to  allow  free  escape  to  the  urine.  The  scrotum,  the  penis,  the  tissues 
of  the  perineum,  and  the  anterior  surface  of  the  abdomen  must  all  be  treated 
in  this  way,  and  all  loose  sloughs  removed.  An  anaesthetic  is  not  necessary 
for  these  incisions,  as  the  parts  are  generally  insensitive  and  the  patient  is 
often  so  weak  that  ansesthesia  would  be  dangerous.  In  extreme  cases  it  is 
best  not  to  attempt  an  external  urethrotomy  if  no  guide  can  be  passed,  but 
to  be  satisfied  with  these  free  incisions,  one  of  which  should  be  made  deeply 
in  the  median  line  of  the  perineum  in  the  dii-ection  of  the  urethra  without 
eudea-s'oring  to  find  that  canal,  as  the  urine  will  probably  make  its  own  way 
out.  In  some  cases  it  may  be  necessary  to  relieve  the  bladder  at  once,  when 
a  suprapubic  cystotomy  may  be  done  and  an  instrument  passed  forward 

65 


1014  CHOICE  OF  TREATMENT   OF   STRICTURE. 

into  the  uretlira  from  the  bladder, — retrograde  catheterization.  Suprapubic 
aspiration  of  the  bladder  may  be  performed  for  temporary  relief.  The  after- 
treatment  of  external  urethrotomy  consists  in  the  maintenance  of  a  drainage- 
tube  or  catheter  in  the  bladder  for  two  or  three  days,  after  which  the  wound 
can  be  packed  if  the  bladder  is  healthy.  If  cystitis  exists,  drainage  should 
be  maintained  longer.  The  sounds  must  be  introduced  at  regular  intervals, 
slowly  increased,  as  after  internal  urethrotomy.    • 

In  Syme's  method  of  external  urethrotomy  the  incision  is  made  at  the 
seat  of  the  stricture  upon  a  grooved  guide  with  a  shoulder  which  rests 
against  the  anterior  face  of  the  stricture.  In  Wheelhouse's  method  a  sound 
with  a  bulbous  end  of  peculiar  shape  is  passed  down  to  the  stricture  and  the 
urethra  opened  anteriorly  to  the  latter.  The  bulbous  end  of  the  sound  is 
brought  out  of  the  wound  and  answers  as  a  retractor,  exposing  the  anterior 
end  of  the  stricture,  so  that  the  entrance  to  it  may  be  sought  with  a  probe 
under  the  guidance  of  the  eye.     These  methods  are  now  seldom  employed. 

In  cases  of  stricture  with  very  dense  masses  of  cicatricial  tissue  some 
surgeons  cut  away  all  the  scar-tissue  after  performing  external  urethrotomy, 
but  this  is  seldom  necessary,  as  it  melts  away  si^ontaneously  after  free 
incision.  Resection  of  the  stricture  followed  by  suture  of  the  urethra 
appeal's  to  be  growing  in  pojoularity  and  is  well  suited  for  deep  strictures 
limited  to  a  small  extent  of  the  urethra,  especially  those  of  traumatic 
origin.  The  best  method  is  that  of  Guyon,  who  resects  the  floor  and  sides 
of  the  canal,  leaving  the  roof,  which  is  usually  not  much  altered,  untouched, 
and  sutures  the  wound  as  described  in  rupture  of  the  urethra.  Experiments 
on  dogs  (Ingianni)  show  that  large  portions  of  the  urethra  may  be  resected 
and  a  normal  new  urethra  will  be  regenerated  in  the  gap  if  a  catheter  is 
fastened  in  the  bladder  and  the  soft  parts  united  over  it.  This  explains  the 
good  results  obtained  bj^  urethrotomy  in  extensive  narrow  strictures. 

Aspiration  of  the  Bladder. — In  cases  of  acute  retention  of  urine  when 
no  instrument  can  be  passed  and  external  urethrotomy  for  some  reason  is 
inadvisable,  and  when  the  hot  bath  and  full  doses  of  opium  have  no  effect, 
the  patient's  sufferings  may  be  relieved  by  aspiration  of  the  contents  of  the 
bladder  through  a  hollow  needle  introduced  above  the  pubes.  When  the 
bladder  is  fully  distended  its  anterior  wall  is  uncovered  by  peritoneum  for 
an  inch  above  the  pubic  bone  in  the  median  line,  and  in  some  cases  this 
interval  is  even  wider.  (See  under  Suprapubic  Cystotomy.)  The  needle 
should  be  inserted  exactly  in  the  median  line  and  close  to  the  pubic  bone, 
and  should  be  as  fine  as  consistent  with  easy  withdrawal  of  the  urine,  a 
caliber  of  about  one-twenty-fifth  of  an  inch  being  proper.  The  needle  and 
the  skin  should  be  carefully  sterilized.  Strong  aspiration  should  be  kept  up 
as  the  needle  is  withdrawn  after  the  fluid  has  been  evacuated,  as  in  this  way 
the  risk  of  escape  of  urine  into  the  cellular  tissue  in  front  of  the  bladder  is 
reduced  to  a  minimum.  The  bladder  has  in  some  cases  been  evacuated  by 
aspiration  every  twelve  hours  for  days  at  a  time,  but  it  is  not  advisable 
to  repeat  the  operation  too  frequently,  as  there  is  some  risk  of  infection. 

Choice  of  Treatment. — The  choice  of  treatment  in  stricture  will 
depend  upon  the  variety  of  lesion  and  uj)on  the  accompanying  infection. 
In  strictures  situated  in  the  anterior  four  inches  of  the  canal  an  internal  ure- 


URETIiRAL   FISTUL^O.  ]015 

throtomy  is  safe  and  yields  better  results  than  continuous  dilatation,  wLich 
is  very  slow  and  exposes  the  iiatient  to  greater  danger  of  infection  on 
account  of  the  more  frequent  instrumentation  which  is  necessary.  Dilata- 
tion, however,  may  be  employed  for  soft  strictures  in  this  part  of  the  urethra, 
recognized  soon  after  the  gonorrhceal  infection  which  has  occasioned  them, 
and  limited  to  a  small  part  of  the  canal.  On  the  other  hand,  if  infection 
of  the  urethra  or  cystitis  is  present,  it  is  wise  to  combine  the  external  and 
internal  operations,  and  to  maintain  drainage  of  the  bladder  for  some  days 
afterwards,  in  order  to  lessen  the  danger  of  infection  of  the  wound  and  to 
relieve  the  bladder  at  the  same  time. 

Deep  strictures  may  be  successfully  treated  by  dilatation  unless  they  are 
traumatic  in  origin  or  there  is  much  cicatricial  tissue.  In  the  latter  cases  a 
cutting  oijeration  is  almost  imj)erative  if  a  permanent  result  is  to  be  obtained. 
In  strictures  deeper  than  four  and  a  half  inches  the  external  operation  is 
advisable  on  account  of  the  danger  of  hemorrhage  and  the  greater  liability 
to  infection  because  of  the  difficulty  of  maintaining  strict  asepsis  of  the  deep 
urethra.  It  is  true  that  after  internal  or  external  urethrotomy  regular  treat- 
ment with  the  sound  is  necessary,  but  the  patient  is  at  once  restored  to  the 
full  use  of  the  canal,  and  it  is  not  necessary  to  pass  the  sound  so  frequently 
as  in  the  first  few  months  of  treatment  by  dilatation. 

Rapid  dilatation  of  the  urethra  or  divulsion  has  fallen  into  disfavor 
because  of  the  severe  traumatism  inflicted,  by  which  the  mucous  membrane 
is  badly  torn  and  contused  and  rendered  more  liable  to  infection,  while  the 
results  are  no  better  than  those  of  an  internal  urethrotomy. 

After-Treatment. — After  the  urethra  has  been  brought  to  its  proper 
dimensions  by  any  of  these  measures  the  patient  should  have  a  sound  passed 
once  a  month  for  at  least  a  year,  and  after  that  at  intervals  of  three  months 
until  it  is  evident  that  no  recontraction  will  take  place.  In  any  urethra 
which  has  been  the  seat  of  stricture  the  surgeon  should  aim  at  obtaining  a 
caliber  of  at  least  30  French,  and  in  a  large  penis  of  32  or  34  French,  if  the 
caliber  is  to  be  maintained,  for  very  full  dilatation  of  the  canal  is  necessary 
in  order  to  secure  complete  absorption  of  the  cicatricial  tissue  about  it. 
Even  larger  instruments  than  these  must  be  passed  in  individuals  who  are 
suffering  from  gleet,  iu  order  fully  to  stretch  the  widest  ijortions  of  the  canal. 

Urethral  Fistulae. — Extravasation  of  urine  may  result  in  the  pro- 
duction of  fistula,  but  they  usually  heal  after  thorough  division  of  the 
stricture.  They  should,  however,  be  sufficiently  laid  open  for  drainage  or 
curetting.  Large  fistulte  on  the  lower  surface  of  the  ijcnis  may  make  very 
extensive  gaps  in  the  flooi-  of  the  urethra  and  the  perineal  incision  in  exter- 
nal urethrotomy  sometimes  fails  to  close.  They  may  be  repaired  by  opera- 
tions similar  to  those  for  hypospadias. 

Spasm  of  tlie  Urethra. — Spasmodic  contraction  of  the  circular  mus- 
cular fibres  surrounding  the  deep  urethra  may  cause  symptoms  of  stricture. 
It  is  even  claimed  by  some  that  in  the  majority  of  cases  obstruction  of  the 
deep  urethra  is  spasmodic,  but  there  can  be  no  question  that  cicatricial  stric- 
tures frequently  occur  iu  this  region.  Si)asni  of  the  urethra  may  be  a  reflex 
result  of  irritation  of  the  mucous  membrane  of  the  canal  or  of  the  bladder, 
and  most  frequently  the  irritation  is  due  to  a  moderate  stricture  anteriorly 


1016  EXSTROPHY   OF  THE   BLADDER. 

or  to  a  slight  prostatitis.  The  spasm  may  be  so  intense  as  to  prevent  even  the 
passage  of  a  bougie.  In  some  cases  It  is  constant  and  persists  for  years, 
the  ijatient  never  being  able  to  make  water  without  an  effort,  while  in  other 
cases  it  is  intermittent  and  there  are  longer  or  shorter  periods  of  freedom. 
Spasm  of  the  urethra  is  to  be  treated  by  removing  the  cause  when  it  can 
be  ascertained,  and  by  the  passage  of  very  large  sounds  to  the  bladder.  In 
this  condition  a  large  blunt-pointed  sound  will  often  enter  the  bladder  by 
steady,  gentle  pressure  maintained  for  some  minutes  even  when  the  intro- 
duction of  smaller  instruments  is  impossible,  the  sharp  points  of  the  latter. 
j)robably  irritating  the  muscle  to  closer  contraction. 

Tumors  of  the  Urethra. — ISTeoplasms  of  the  urethra  are  not  com- 
mon, tlie  least  rare  being  small  mucous  polypi.  The  canal  is  sometimes 
invaded  by  malignant  disease  of  neighboring  parts,  but  jDrimary  cancer  is 
too  rare  to  require  description.  The  poly j)i  are  recognized  by  endoscopic 
examination,  and  in  some  cases  they  may  protrude  fi'om  the  meatus.  The 
only  symjjtoms  they  excite  are  slight  obstruction  to  urination  and  a  scanty 
mucous  discharge.     They  are  readily  removed  by  avulsion. 

INJURIES  AND  SURGICAL  DISEASES  OF  THE  BLADDER. 
Malformations. — The  bladder  is  in  very  rare  cases  entirely  absent,  the 
ureters  opening  into  the  urethra,  vagina,  or  rectum.  In  the  fcetus  the  lower 
end  of  the  bowel  is  at  first  in  connection  with  a  canal  leading  to  the  allan- 
tois,  and  the  ureters  discharge  into  the  same  passage,  the  first  sign  of  the 
bladder  being  a  sac-like  dilatation  of  the  allantois  canal  in  front  of  the  rec- 
tum. As  development  proceeds,  the  bladder  and  rectum  become  separated, 
the  anus  forms,  and  the  urethra  appears  anteriorly,  being  formed  as  already 
described.  Defects  of  develoi^ment  are  found  on  both  the  anterior  and  pos- 
terior walls  of  the  organ.  On  the  posterior  wall,  owing  to  the  lack  of  forma- 
tion of  the  septum  between  the  bladder  and  the  rectum,  both  may  open  into 
a  common  cloaca,  or,  the  anus  being  imperforate,  tlie  faeces  may  be  dis- 
charged through  the  iirethra  by  way  of  the  bladder.  Extensive  defects  of 
this  variety  are  incomj)atible  with  life,  but  the  minor  forms  are  sometimes 
seen  in  the  adult,  and  may  even  be  rectified  by  oj^eration.  They  are  fortu- 
nately very  rare. 

Exstrophy. — More  common  is  a  failure  of  development  of  the  anterior 
wall  of  the  bladder,  usually  seen  in  connection  with  epispadias,  which  is 
termed  exstrophy  of  the  bladder.  The  etiology  is  similar  to  that  of  epi- 
spadias. It  is  nine  times  as  frequent  in  males  as  in  females.  When  the 
exstrophy  is  complete  the  pubic  bones  have  usually  failed  to  unite,  and  the 
bladder  is  spread  out  on  the  anterior  wall  of  the  abdomen,  forming  a  shal- 
low pouch  of  mucous  membrane  communicating  below  with  the  urethra,  or 
directly  continuous  with  the  groove  which  represents  it  in  the  case  of  epi- 
spadias, the  ureters  opening  in  the  usual  position  in  the  trigone.  In  the 
female  the  clitoris  is  also  divided.  (Fig.  800.)  Inguinal  hernise  are  usu- 
ally present  as  well.  In  crying  or  straining  the  abdominal  pressure  forces 
the  viscera  through  the  defect  in  the  abdominal  wall,  pushing  before  them 
the  everted  bladder  as  the  covering  of  the  hernia.  Occasionally  the  lower 
,  bowel  also  terminates  in  this  opening,  the  anus  being  imperforate.     Exstro- 


TEEATMENT  OF  EXSTROPHY   OF  THE  BLADDER. 


1017 


phy  of  the  bladder  may,  however,  be  of  lighter  grade,  the  anterior  wall 
beiug  deficient  only  at  the  neck  in  connection  with  epispadias,  or  partially 
wanting  above,  the  urethra  being  per- 
fect. The  condition  of  a  patient  with 
exstrophy  is  pitiable,  the  urine  leak- 
ing constantly,  and  the  j)rotruded 
vesical  mucous  membrane  beiug  lia- 
ble to  inflammation  and  ulceration. 
When  the  child  cries  the  urine  can  be 
seen  to  issue  from  the  ureters  in  jets. 
The  upper  margin  of  the  defect  is 
marked  by  a  cicatricial  line,  and  ex- 
tending upward  from  this  towards  the 
umbilicus  is  often  seen  a  broad  cica- 
tricial area  in  which  the  recti  muscles 
are  deficient  or  separated. 

Treatment. — Many  operations 
have  been  suggested  for  this  condition. 
They  can  be  classified  as  follows  :  («) 
immediate  union  of  the  edges  of  the 
defect ;  (b)  flap  operations  ;  (c)  trans- 
j)lantation  of  the  ureters  ;  and  (d)  for- 
mation of  a  bladder  from  intestine, 
(a)  Czerny  succeeded  in  dissecting  up 
the  edges  of  the  bladder  and  uniting 
them  to  each  other  so  as  to  make  a  very 

small  bladder,  covering  its  external  surface  with  flaps  of  skin.     (&)  Of  the 
flap  operations,  one  of  the  best  is  WoocVs  method,  in  which  a  flap  abundantly 

large  to  cover  the  entire  surface  is  cut 
from  above,  with  its  base  at  the  upper 
border  of  the  defect.  A  lateral  flap  is 
then  formed  on  each  side  of  the  everted 
bladder,  each  flap  one-half  the  size  of 
the  first,  their  bases  being  below  at  the 
pubes.  The  first  flaj)  is  turned  downward 
so  that  its  cutaneous  surface  is  directed 
towards  the  bladder,  and  sirtured  to  the 
lower  edge  of  the  defect,  and  the  lateral 
flaps  are  then  slid  over  and  united  with 
their  raw  surfaces  against  the  exposed 
raw  surface  of  the  upper  flap.  (Fig.  801. ) 
But  this  method  brings  skin  into  the 
interior  of  the  bladder,  which  is  a  serious 
defect,  for  it  favors  deposition  of  urinary 
salts.  Thiersch's  method  consists  in  cut- 
ting a  bridge-like  lateral  flap  on  each 
side,  each  flap  being  nearly  large  enough  to  cover  the  defect  entirely.  These 
flaps  are  detached  from  the  subcutaueous  tissues,  and,  tin-foil,  hard  rubber  or 


Bxstroph: 


Fig.  801. 


Result  of  operation  for  exstrophy  of  the  bladder. 


1018  DIVERTICULA  OF  THE  BLADDER. 

thick  glass  having  been  slipped  underneath,  they  are  left  for  a  week  and  the 
under  surface  allowed  to  granulate,  during  which  the  flaps  shrink  somewhat 
in  size.  The  upper  end  of  one  bridge-flap  is  cut  away,  and  the  lower  end  of 
the  other.  The  first  flap  is  used  to  cover  the  lower  part  of  the  defect,  while 
the  other  covers  the  upper  part,  the  two  being  united  transversely  where  their 
edges  meet,  and  their  granulating  surfaces  being  turned  towards  the  bladder. 
These  seem  less  likely  to  be  incrusted  with  salts,  but  are  not  entirely  free 
from  them.  When  there  is  wide  separation  of  the  pubic  bones,  Trendelen- 
burg approximates  them  by  dividing  the  sacro-iliac  synchondrosis,  and 
Passavant  crowds  the  separated  ends  together  without  division  by  a  broad 
pelvic  band  to  which  heavy  weights  are  attached,  before  any  attempt  is 
made  to  cover  in  the  defect.  The  subsequent  plastic  work  is  thus  rendered 
simpler,  as  the  bladder  is  more  easily  inverted.  These  operations  must 
often  be  followed  by  plastic  work  for  epispadias,  (c)  Transplantation  of 
the  ureters  has  therefore  been  preferred  by  some  surgeons.  Sonnenburg 
extirpated  the  rudimentary  bladder  and  secured  the  ureters  to  the  urethral 
mucous  membrane  so  that  the  patient  was  relieved  of  the  irritation  of  the 
exposed  bladder  and  a  useful  urinal  could  be  applied.  Others  transplanted 
the  ureters  into  the  rectum,  and  although  in  some  cases  a  secondary  pyelitis 
followed,  it  seems  possible  to  avoid  this  by  proper  technique  (Fowler).-  The 
rectum  ajipears  to  become  accustomed  to  the  urine  and  to  retain  it  for  sev- 
eral hours  at  a  time,  (d)  Mikulicz  succeeded  in  isolating  a  loop  of  small 
intestine  and  (at  a  second  operation)  forming  a  fundus  for  the  bladder  out 
of  this  loop,  the  ectopic  organ  acting  as  the  base.  In  no  case  has  any  of 
these  operations  xjroduced  a  bladder  with  voluntary  control,  and  there  is 
always  a  tendency  to  cj^stitis  and  vesical  calculus.  If  operation  is  impossi- 
ble the  treatment  is  limited  to  the  protection  of  the  parts  with  a  hard  rubber 
CU13,  which  furnishes  at  the  same  time  a  receptacle  for  the  urine,  and  is  held 
in  place  by  an  abdominal  belt  or  truss.  This  apparatus  is,  however,  very 
unsatisfactory,  as  it  is  impossible  to  make  it  fit  water-tight. 

Hernia. — The  bladder  is  not  infrequently  found  in  hernia  through  the 
inguinal,  femoral,  and  obturator  openings,  and  has  been  wounded  during 
operations  for  the  radical  cure  of  hernia.  (See  chapter  on  Hernia.)  The 
bladder  may  prolapse  through  the  dilated  urethra  in  the  female  and  resem- 
ble a  polypoid  tumor  in  rare  cases. 

Diverticula. — Congenital  diA^erticula  of  the  bladder  are  occasionally 
met  with,  and  the  most  common  of  these  is  formed  by  the  urachus,  the 
cavity  of  which  extends  to  the  umbilicus  in  the  foetus,  but  should  be  entirely 
obliterated  during  development,  so  that  no  trace  of  it  remains.  In  infancy 
an  indication  of  the  situation  of  the  urachus  is  very  common  in  the  rather 
pointed  shape  of  the  fundus  of  the  bladder,  but  in  the  adult  the  latter  is 
usually  broad  and  flat.  The  urachus  may  remain  patent  throughout,  so 
that  urine  is  discharged  at  the  umbilicus  (some  congenital  obstruction  of 
the  urethra  generally  being  present),  or  it  may  be  partially  patent,  being 
obliterated  at  either  end.  Occasionally  it  closes  at  both  ends  and  the  inter- 
mediate part  forms  a  cyst,  but  this  is  a  great  rarity.  More  commonlj-  the 
vesical  end  closes,  while  the  umbilical  remains  open,  and  a  congenital  sinus 
lined  with  epithelial  tissue  is  formed,  which  is  of  little  moment,  although 


RUPTURE  OF  THE  BLADDER.  1019 

some  anuoying  mucous  discharge  may  take  place.  The  true  congenital 
diverticula  are  irsually  found  near  the  base  of  the  bladder  as  small  pouches, 
very  narrow  iu  proportion  to  their  depth,  and  they  seldom  attain  a  large 
size.  These  pouches  must  not  be  confounded  with  the  pockets  which  are 
found  in  the  bladder  as  a  consequence  of  over-distention  and  are  formed  by 
a  hernial  protrusion  of  the  mucous  membrane  between  the  trabecuhe  of  the 
muscular  coat.  As  they  are  produced  by  the  stretching  of  weak  places  in 
the  bladder  wall,  they  have  a  muscular  layer  as  well  as  one  of  mucous 
membrane.  The  acquired  pouches  are  much  more  common  than  the  con- 
geultal  diverticula.  The  opening  of  these  pouches  into  the  bladder  may  be 
imperfect,  and  urine  collecting  in  them  may  decomijose  and  excite  inflam- 
mation or  even  abscess,  and  calculi  may  also  form  in  them. 

Treatment. — Before  attempting  to  close  a  patent  urachus,  the  urethra 
must  be  made  fully  sufficient  for  the  escape  of  the  urine.  The  sinus  may 
then  be  treated  by  curetting,  cauterization,  or  a  plastic  operation.  It  can 
also  be  extirpated  by  a  median  laparotomy,  the  vesical  end  being  closed  by 
sutures.  Diverticula  have  been  successfully  removed  by  an  extraperitoneal 
laparotomy  or  by  an  operation  similar  to  Kraske's  for  resection  of  the  rectum. 

Rupture  of  the  Bladder. — The  most  common  injury  of  the  bladder  is 
rupture  by  a  severe  blow  wheu  it  is  in  the  distended  condition.  This  injury 
is  most  frequently  the  result  of  a  kick  of  a  horse  or  of  a  man,  or  of  a  fall 
across  a  ijost  or  some  article  of  furniture.  It  may  also  occur  as  a  complica- 
tion of  fractures  of  the  pelvic  bones.  It  is  most  likely  to  occur  in  intoxi- 
cation, because  of  neglect  to  empty  the  bladder  and  the  relaxation  of  the 
abdominal  muscles.  An  ulcerated  or  thinned  bladder  may  rupture  from 
internal  pressure  from  retention,  without  external  force.  The  distended 
bladder  bursts  from  the  pressure  of  the  contained  fluid  under  the  force  of 
the  blow,  and  the  rupture  is  usually  situated  near  the  fundus,  although  it 
may  take  place  on  the  anterior  wall,  or  on  the  sides.  The  intraperitoneal 
ruptures  outnumber  the  extraj)eritoueal  in  the  proijortion  of  three  to  one. 

Symptoms. — When  rujjture  has  taken  place,  the  urine  escapes  into  the 
pelvic  connective  tissue  or  into  the  peritoneal  cavity.  There  is  usually 
severe  shock,  which  may  be  fatal.  The  bladder  is  empty,  although  no  urine 
is  passed,  but  when  the  rupture  is  small  some  urine  may  collect  from  time 
to  time  in  the  bladder  and  be  evacirated.  If  any  urine  is  passed  it  will  con- 
tain blood,  and  blood  may  be  evacuated  even  when  no  urine  can  be  passed. 
There  is  pain,  usually  referred  to  the  end  of  the  penis,  and  there  may  be 
some  vesical  tenesmus.  When  a  catheter  is  introduced  it  may  withdraw 
urine  from  the  cavity  of  the  bladder,  and  after  the  flow  has  ceased  a  deeper 
introduction  may  i^roduce  a  new  supply  of  urine,  the  point  of  the  instru- 
ment having  penetrated  the  vesical  wound  and  entered  the  collection  of  the 
fluid  outside.  The  extravasated  urine  forms  a  more  or  less  distinct  tumor 
when  the  rupture  is  extraperitoneal,  the  effusion  being  limited  bj'  the 
stretched  peritoneum  and  extending  well  u]3  to  Poupart's  ligament  on  both 
sides  and  above  the  pubes  to  the  umbilicus.  After  some  time  the  inflamma- 
tion excited  by  the  urine  may  cause  oedema  and  redness  of  the  surface. 
When  the  urine  escapes  into  the  peritoneal  cavity  the  symptoms  of  a  begin- 
ning peritonitis  are  present,  but  a  perfectly  healthy  urine  may  be  slow  in 


1020  PERFORATING  WOUNDS  OF  THE  BLADDER. 

exciting  peritonitis,  or  the  inflammation  may  be  of  a  very  low  grade 
without  definite  synaptoms  for  some  days.  Signs  of  urinary  absorption, 
however,  are  present  in  nearly  all  cases,  as  shown  by  a  quick  hard  pulse, 
a  flushed  face,  and  in  advanced  cases  a  coated  tongue  and  a  typhoid 
condition  of  the  mind.  The  symptoms  may,  however,  be  very  obscure 
and  even  absent,  for  in  exceptional  cases  the  patient  is  able  to  evacuate 
the  bladder  at  regular  intervals,  and  no  susi^icion  is  entertained  of  a 
wound  of  that  organ.  The  difficulty  is  increased  by  the  fact  that  many 
of  these  j>atients  are  drunk  at  the  time  and  are  not  aware  of  the  injury. 

Diagnosis. — The  diagnosis  must  be  made  by  the  bladder  symptoms 
when  any  are  present,  and  some  assistance  can  be  gained  by  passing  a 
catheter  into  the  organ  and  injecting  a  sterilized  fluid  under  very  low 
pressure.  If  the  same  amount  of  fluid  returns  as  is  injected,  it  is  proof 
that  the  bladder  is  not  injured.  This  test  should  not  be  made  until  the 
patient  is  ready  for  operation,  because  the  injected  fluid  may  spread  the 
infection,  and  the  incision  must  be  made  directly  if  rupture  is  proved. 
The  prognosis  of  these  injuries  is  grave  in  the  extreme,  and  spontaneous 
cure  is  scarcely  to  be  hoped  for,  even  in  the  extraperitoneal  rents.  Sup- 
puration takes  place  as  far  as  the  urine  has  extended,  and  even  if  the 
peritoneum  be  not  involved  it  results  in  the  death  of  the  patient. 

Treatment. — Free  opening  of  the  abdominal  wall  and  exposure  of  the 
bladder  is  the  best  method  of  treatment.  The  incision  should  be  made  in 
the  median  line  as  if  for  a  suprapubic  lithotomj^,  and  the  peritoneum  not 
incised,  but  separated  fi-om  the  pubes.  Careful  examination  should  then  be 
made  of  the  anterior  wall  and  the  sides  of  the  bladder  with  a  finger  in  the 
wound  and  a  sound  in  the  organ.  If  any  signs  of  urinary  extravasation  are 
found,  they  should  be  followed  down  to  the  point  of  escape.  When  the  rent 
■  is  discovered  a  drainage-tube  should  be  inserted  through  it  into  the  bladder 
and  the  external  wound  packed  with  gauze.  The  cellular  tissue  should  be 
broken  down  with  the  fingers  as  far  as  the  urinary  extravasation  has 
extended,  and  secondary  incisions  for  drainage  should  be  made  if  necessary. 
In  recent  cases,  when  the  rupture  of  the  bladder  is  high  up  and  the  tissues 
are  sound,  a  suture  may  be  applied  to  the  wound  in  the  organ,  but  the 
external  wound  should  be  packed  and  kept  open.  If  signs  of  peritonitis 
are  present,  or  if  no  extraperitoneal  rupture  can  be  found,  the  peritoneal 
cavity  should  be  opened  at  once  and  the  wound  sought  uj)on  that  surface  of 
the  organ.  If  it  is  found,  it  may  be  sutured  after  Lembert's  method  and 
the  peritoneal  cavity  then  drained,  after  thorough  irrigation,  as  described 
in  speaking  of  sux^porative  peritonitis. 

Perforating  Wounds. — Stab-wounds  and  gunshot-wounds  may  per- 
forate the  bladder,  or  fi-agments  of  bone  may  lacerate  it  in  fractures  of  the 
pelvis.  When  these  injuries  occur  high  up  the  symptoms  and  treatment 
resemble  those  of  rupture  of  the  organ.  Perforating  wounds  of  the  bladder 
from  below  require  free  incision  and  drainage  of  the  organ  through  the 
wound  or  by  a  deep  urethral  incision.  The  wounds  should  be  packed  with 
gauze,  and  usually  heal  bj^  granulation  without  a  permanent  sinus.  In  some 
cases  it  may  be  possible  to  suture  the  injured  bladder.  The  rectum  may  be- 
wounded  at  the  same  time,  and  if  this  complication  is  present  the  recto- 


INFLAMMATION   OF  THE   BLADDER.  1021 

vesical  interval  should  be  exposed  by  a  perineal  horseshoe-shaped  incision 
as  for  prostatectomy,  and  the  rectum  and  the  bladder  separated  by  blunt  dis- 
section to  a  point  above  both  perforations.  The  bladder  should  be  drained 
by  the  perineal  wound  or  by  a  catheter  in  the  urethra  and  tlie  wound  jjacked 
-with  gauze.  If  the  perforations  do  not  heal  by  granulation  tlie  opening  into 
the  bowel  should  be  sutured  later. 

Fistulas. — Injuries  or  sloughing  of  the  bladder  may  result  in  the  forma- 
tiou  of  urinary  fistulae  which  may  open  externally,  upon  the  abdomen  or  in 
the  perineum  ;  or  internally,  forming  a  communication  with  the  vagina, 
rectum,  or  the  bowel  higher  up.  A  j)atent  urachus  may  also  form  a  urinary 
fistula.  The  course  of  the  external  fistula  may  be  very  tortuous.  The 
urine  escajpes  mixed  usually  with  pus.  The  urine  may  collect  in  the  rectum 
and  cause  proctitis.  Gas  or  fteces  may  enter  the  bladder  and  set  up  cystitis. 
When  the  opening  is  small  it  may  be  located  by  injecting  a  solution  of 
methyl  blue  into  the  bladder  or  by  administering  that  drug  by  the  mouth  so 
as  to  color  the  urine  as  it  is  eliminated.  Treatment. — If  an  obstruction  to 
the  normal  passage  of  the  urine  exists  it  will  tend  to  keep  the  fistula  open, 
and  the  cause  of  the  obstruction  must  be  removed  in  order  to  obtain  a  cure. 
The  fistula  will  then  often  close  spontaneously.  Abdominal  sinuses  should 
be  freely  incised,  the  bladder  exposed  by  laparotomy,  and  the  opening  in  that 
organ  sutured  after  freshening  the  edges.  Perineal  openings  should  be 
treated  by  free  excision  of  the  cicatricial  tissue  around  the  fistula,  drainage 
of  the  bladder,  and  packing  the  wound  with  gauze,  as  in  fresh  ijenetrating 
wounds.  Plastic  operations  are  needed  to  close  fistulte  of  the  vagina  and 
rectum,  as  described  in  the  chapter  on  the  Vagina.  Intestinal  fistulte 
require  laparotomy  and  suture  of  both  bladder  and  bowel. 

Foreign  Bodies. — A  great  variety  of  foreign  bodies  have  been  found 
in  the  bladder,  the  majority  having  been  introduced  intentionally  in  erotic 
excitement  or  accidentally  in  using  instruments.  The  most  common  are 
broken  catheters,  knitting-needles,  hair-pins,  f)ipe-stems,  and  such  objects. 
Old  rubber  catheters  often  become  brittle,  and  are  then  easily  broken  off. 
When  left  for  some  time  in  the  bladder  they  become  encrusted  with  urinary 
salts  and  may  form  the  nucleus  of  a  calculus.  Elongated  objects  usually 
assume  a  transverse  position  near  the  base.  The  recognition  of  the  presence 
of  foreign  bodies  is  difficult.  They  maj^  be  demonstrated  by  the  cystoscope, 
by  seizing  them  with  a  lithotrite,  or  by  exploratory  cystotomy.  Flexible 
bodies  can  sometimes  be  removed  by  a  lithotrite,  by  seizing  them  in  the  cen- 
tre so  that  they  will  double  up  when  withdrawn.  In  the  female  they  can 
often  be  removed  by  dilatation  of  the  m-ethra,  and  if  this  fails  a  vaginal 
cystotomy  should  be  done,  as  for  stone.  If  the  foreign  body  is  rigid,  a 
suprapubic  cj^stotomy  should  be  i^erfoi-med  in  the  male. 

Inflammation.— Cystitis.— Pathology. — Cystitis,  or  inflammation 
of  the  bladder,  is  always  the  i-esult  of  infection  with  germs,  and  may  be  pyo- 
genic, gouorrhceal,  or  tubercular.  The  pyogenic  form  may  be  either  catar- 
rhal or  sui)purative.  It  is  caused  by  any  of  the  pyogenic  bacteria,  most 
commonly  the  B.  coli  communis.  The  infection  is  usually  carried  from 
without  by  the  introduction  of  instruments,  and  only  exceptionally  through 
oi^en  wounds  of  the  bladder  or  by  direct  extension  from  the  kidney  above  or 


1022  SYMPTOMS  OF  CYSTITIS. 

the  urethra  below.  The  instrument  itself  may  be  infected,  or  a  sterile  instru- 
ment may  carry  in  with  it  some  infectious  material  from  the  urethra.  The 
instruments  are  readily  sterilized  by  the  ordinary  means,  but  it  is  less  easy 
to  disinfect  the  urethra  thoroughly.  Germs  introduced  into  the  healthy 
bladder  have  very  little  effect  upon  it,  but  if  it  is  altered  by  traumatism  or 
contains  a  foreign  body,  a  stone,  or  blood,  or  even  if  there  is  retention  and 
the  urine  is  stagnant,  infection  readily  takes  place.  These  conditions  are  the 
predisposing  causes  of  cystitis,  and,  unfortunately,  they  are  almost  always 
present  in  those  cases  which  demand  the  introduction  of  instruments  into 
the  bladder.  The  inflammation  may  be  limited  to  the  neck  of  the  bladder 
or  may  extend  over  its  entire  internal  surface.  In  the  catarrhal  forms  the 
usual  changes  are  seen  in  the  mucous  membrane, — namely,  hypertemia, 
increased  mucous  secretion,  and  desquamation  of  cells.  When  suppuration 
occurs  the  congestion  increases,  and  ulceration  may  take  place,  either  suf)er- 
ficially  or  extending  through  the  mucous  membrane.  Sometimes  false  mem- 
branes are  formed,  or,  still  more  rarely,  the  lining  membrane  of  the  bladder 
may  become  detached  in  sheets. 

Symptoms. — The  cases  vary  much  in  their  onset,  the  changes  in  the 
urine  sometimes  being  the  first  indication  of  the  inflammation,  esj)ecially 
when  the  infection  is  slight  and  of  a  chronic  type.  The  changes  produced 
in  the  urine  are  the  appearance  in  it  of  mucus,  epithelial  cells,  pus,  blood, 
or  ti:iple  phosphates,  and  an  increased  liability  to  decomposition.  The  urine 
is  generally  alkaline,  but  may  remain  acid,  and  the  latter  reaction  is  not  a 
proof  that  pyelitis  is  present.  When  the  inflammation  is  more  intense,  fre- 
quent or  painful  micturition  may  be  the  first  symptom  observed.  Inflamma- 
tion at  the  neck  of  the  bladder  renders  the  discharge  of  urine  difficult,  by 
the  swelling  of  the  parts  and  by  spasmodic  contraction  of  the  spincter.  The 
urine  is  voided  frequently  and  with  effort,  and  occasionally,  even  when  the 
bladder  is  empty,  there  are  violent  contractions,  known  as  vesical  tenesmus. 
Pain  is  present,  either  a  dull,  aching  isain  felt  above  the  pubes,  or,  more 
commonly,  a  sharp  pain  referred  to  the  end  of  the  penis.  In  acute  cystitis 
affecting  the  neck  of  the  bladder  the  pain  occurs  at  the  end  of  micturition, 
when  the  contraction  of  the  bladder  exerts  the  greatest  pressure  on  the  tender 
and  inflamed  neck.  The  sufferings  of  a  patient  with  acute  cystitis  are. 
extreme,  the  constant  pain  in  the  bladder,  the  frequent  desire  to  urinate, 
and  the  tenesmus  depriving  him  of  rest  day  and  night.  He  may  be  com- 
pelled to  evacuate  the  bladder  every  ten  or  fifteen  minutes,  and  the  act  may 
be  painful.  In  chronic  cystitis,  even  when  the  urine  is  voided  very  fre- 
quently, the  disturbance  is  not  so  great,  because  the  pain  is  less.  The  com- 
plications of  cystitis  are  pyelitis  excited  by  the  ascent  of  the  infection  along 
the  ureters,  and  pyaemia  following  ulceration  of  the  bladder,  but  ulceration 
is  rare  in  ordinary  cystitis.  The  sequelae  of  cystitis  are  suppurating  diver- 
ticula, atony  amounting  to  paralysis,  stone,  and  iDermanent  contraction  of 
the  bladder. 

Treatment. — The  most  effective  treatment  of  cystitis  lies  in  its  prophy- 
laxis. Every  instrument  which  is  introduced  into  the  bladder  must  be 
scrupulously  sterilized  by  boiling  or  by  antisei^tic  solutions ;  the  hands  of 
the  surgeon  and  the  penis  of  the  patient  should  also  be  sterilized.      The 


TREATMENT  OF  CYSTITIS.  1023 

urethra  should  be  carefully  cleansed  by  irrigation  with  a  salt  solution,  and  a 
considerable  quantity  of  water  should  be  used  for  this  purpose, — not  merely 
a  few  small  sj'ringefuls.  The  urethi'a  should  be  gently  stroked  with  the 
fingers  during  the  irrigation,  so  as  to  dislodge  any  particles  of  pus  which 
may  be  contained  in  the  follicles.  It  is  only  by  extreme  precautions  that 
cystitis  can  be  avoided,  and  not  always  even  by  these.  In  woin'en  the  entire 
vulva  should  be  thoroughly  cleansed  before  using  the  catheter,  and  the 
instrument  should  be  introduced  under  the  guidance  of  the  eye,  the  fingers 
holding  the  labia  so  widely  apart  that  they  shall  not  come  in  contact  with 
the  catheter. 

When  the  symjitoms  of  cystitis  ai-e  very  acute,  the  patient  should  be  kept 
in  bed,  with  the  pelvis  elevated  on  a  pillow  ;  a  milk  diet  with  abundance 
of  alkaline  drinks  should  be  ordered  (acetate  of  potassium,  gr.  xv,  in  a  large 
amount  of  water,  every  three  hours),  and  opium  given  bj^  suppositories. 
Occasionally  injections  of  cocaine  may  be  necessary  to  relieve  the  tenesmus, 
ten  drops  of  a  two  per  cent,  solution  being  thrown  into  the  neck  of  the 
bladder  by  an  Ultzmaun  syringe.  Hot  applications  to  the  perineum  and 
hypogastric  region  may  assist. 

Local  Applications. — Local  treatment  should,  if  possible,  be  postponed 
until  the  acute  pain  is  relieved.  It  is  then  to  be  begun  by  irrigation  of  the 
bladder  with  warm  mild  solutions,  such  as  Thiersch's  solution  one-half 
strength,  or  normal  salt  solution.  Only  two  or  three  ounces  of  fluid  shoiald 
be  allowed  to  enter  at  a  time,  under  low  pressure,  but  a  considerable  amount 
of  fluid  in  all  should  be  employed.  The  cause  of  the  cystitis  should  be 
sought  for  and  removed,  especiallj'  if  it  be  urethral  stricture,  prostatic 
hypertrophy,  or  vesical  calculus.  Very  frequently  these  measures  will  effect 
a  cure.  In  subacute  or  chronic  cases  more  stimulating  irrigations  may  be 
used,  such  as  a  solution  of  nitrate  of  silver,  one-half  to  three  grains  to  the 
j)int ;  protargol,  one  to  five  per  cent.  ;  kreolin,  one  to  five  per  cent.  ;  potas- 
sium permanganate,  one  part  to  two  thousand.  The  urine  should  be  ren- 
dered neutral  by  the  administration  of  alkalies  if  it  is  acid,  or  of  benzoic 
acid  if  it  is  strongly  alkaline.  Salol  and  urotropin  are  excreted  with  the 
urine,  and  their  administration  by  the  mouth  is  an  excellent  method  of 
obtaining  a  partial  sterilization  of  that  fluid.  Copaiba,  santal,  buchu,  and 
pareira  may  be  useful.  In  cystitis  limited  to  the  neck  of  the  bladder,  such 
as  is  common  after  gonorrhceal  infection,  it  is  well  to  inject  from  one  to  five 
drops  of  a  strong  nitrate  of  silver  solution  (from  five  to  ten  grains  to  the 
ounce)  by  the  prostatic  catheter  of  Ultzmann.  The  bladder  should  contain 
some  urine  or  irrigating  fluid,  in  order  that  the  effect  of  the  strong  solution 
shall  be  limited  strictly  to  the  region  at  the  tip  of  the  catheter. 

Drainage. — When  irrigation  fails  to  produce  a  cure,  the  bladder  should 
be  drained  through  an  incision  in  the  perineum,  above  the  pubes,  or  in  the 
vagina  in  the  female.  Some  surgeons  prefer  a  catheter  retained  in  the 
urethra,  to  making  incisions,  but  the  drainage  is  not  so  jDerfect.  The  peri- 
neal incision  is  made  as  in  external  urethrotomy,  and  the  suprapiibic  as  in 
suprapubic  cystotomy.  The  vaginal  incision  is  made  by  placing  the  patient 
in  the  lithotomy  i^osition,  with  a  duck-bill  speculum  retracting  the  peri- 
neum.    A  sound  is  introduced  into  the  bladder  and  turned  over,  so  that  its 


1024  TUBERCULOSIS   OF  THE   BLADDER. 

point  is  prominent  in  the  vagina.  Tlie  vaginal  mucous  membrane  is  incised 
upon  the  point  of  the  sound  in  the  median  line  just  above  the  neck  of  the 
bladder.  A  long,  -well-curved  tenaculum  is  then  made  to  penetrate  the  vesi- 
cal mucous  membrane  at  the  bottom  of  the  wound,  and  while  it  is  thus 
steadied  it  is  incised.  The  edges  of  the  vesical  and  vaginal  mucous  mem- 
brane should  be  united  by  a  few  sutures  around  the  wound,  as  the  opening- 
tends  to  contract.  A  large  soft  rubber  catheter  is  inserted  through  the 
wound  and  connected  with  a  long  rubber  tube  passing  down  to  a  large 
bottle  partially  filled  with  bichloride  or  carbolic  acid  solution,  so  that  the 
urine  shall  be  delivered  under  the  surface  of  the  fluid,  descending  by  the 
action  of  siphonage.  The  tip  of  the  catheter  should  project  into  the  bladder 
only  just  enough  to  pei-mit  the  escajje  of  the  urine  by  the  eye,  to  avoid 
undue  irritation.  Drainage  of  the  bladder  at  once  gives  perfect  rest,  equal- 
izes the  circulation  in  the  parts,  and  allows  irrigation  of  the  bladder  to  be  car- 
ried out  more  efficiently.  Drainage  should  be  maintained  until  the  urine 
becomes  clear,  and  then  the  tube  may  be  removed  and  the  opening  allowed 
to  close.  When  suprapubic  drainage  is  emjjloyed,  the  end  of  the  catheter 
may  be  put  into  a  urinal  or  a  small  bottle  worn  under  the  clothing,  and  the 
patient  allowed  out  of  bed. 

Gonorrhoeal  Cystitis.— This  is  usually  confined  to  the  neck  of  the 
bladder,  and  will  be  described  in  the  chapter  on  Venereal  Diseases. 

Tuberculosis. — Tuberculosis  of  the  bladder  often  first  shows  itself 
under  the  guise  of  an  acute  cystitis,  and  suspicion  is  aroused  only  by  its 
obstinacy  or  by  frequent  relapses.  The  lesions  are  usually  in  the  form  of 
ulcers,  and  when  they  are  secondary  to  renal  tuberculosis  they  first  appear 
around  the  orifices  of  the  ureters.  The  symptoms  of  tuberculosis  may  be 
hsematuria,  appearing  without  known  cause,  or  simply  frequent  micturi- 
tion, the  urine  itself  being  clear  and  with  no  evidence  of  cystitis.  There 
may  be  pyuria,  but  even  then  the  uriue  remains  acid  and  free  from  triple 
phosphates.  Eectal  palpation  may  reveal  thickening  of  the  base  of  the 
bladder  or  tuberculosis  of  the  prostate.  The  diagnosis  may  be  made  by 
finding  tubercle  bacilli  in  the  urine,  or  by  inspection  with  the  cystoscope  or 
through  an  exploratory  incision  which  reveals  tuberculous  ulcers.  An 
exploratory  suprapubic  incision  enables  the  surgeon  to  inspect  the  interior 
of  the  bladder  and  to  ai)ply  direct  treatment  to  the  tuberculous  lesions  if 
present. 

Treatment. — The  radical  treatment  of  tuberculosis  consists  in  freely 
opening  the  bladder  and  thoroughly  removing  the  diseased  mucous  mem- 
brane by  the  curette  or  scissors.  The  entire  mucous  liuing  of  the  organ 
has  been  excised  successfully  in  these  cases,  although  recurrence  has  been 
the  rule  after  a  longer  or  shorter  period  of  freedom,  for  tuberculosis  of  the 
bladder  is  usually  secondary  to  similar  disease  of  the  i3rostate  or  of  the 
kidney.  The  injection  of  iodoform  in  a  ten  per  cent,  emulsion  with  ster- 
ilized olive  oil  has  been  practised,  and  certainly  ameliorates  the  symijtoms, 
although  it  is  doubtful  if  a  cure  can  be  thus  obtained.  Drainage  of  the 
bladder  gives  tem]3orary  good  results,  and  we  have  seen  the  bladder  symp- 
toms relieved  by  it  in  one  case,  although  the  tuberculosis  extended  to  other 
organs  and  resulted  in  the  death  of  the  patient  a  couple  of  years  later. 


EXLARGEMEXT  OF  THE  PROSTATE. 


1025 


Enlargement  of  the  Prostate.— The  prostate  properly  belongs  to 
the  genital  system,  but  its  enlargement  Is  almost  without  sexual  symptoms, 
and,  owing  to  its  situation  at  the  neck  of  the  bladder,  is  of  significance 
chiefly  to  the  latter  organ,  and  it  will  therefore  be  discussed  in  this  chapter. 
The  prostate  may  be  enlarged  by  the  growth  of  various  tumors,  but  thej-  are 
all  rare  except  the  fibromyo-adenomatous  growth  which  is  generally  known 
as  hypertrophy  or  enlargement  of  the  prostate. 

Pathology. — The  exact  pathology  of  enlargement  of  the  prostate  is  still 
a  matter  of  dispute,  some  authorities  claiming  that  the  disease  is  simply  a 
sequence  of  a  general  arteriosclerosis,  while  others  more  logicallj'  compare 
it  to  fibromyoma  of  the  uterus,  an  organ  which  is,  from  a  biological  point  of 
view,  the  analogue  of  the  prostate.  The  structure  of  these  enlargements 
resembles  that  of  the  normal  gland,  the  fibromyomatous  stroma  generally 
predominating,  but  in  some  cases  the  glandular  portions  form  the  bulk  of 
the  mass.  The  enlargement  may  be  diffuse,  the  gland  preserving  its  natural 
shape  and  all  parts  being  equally  hyi^ertrophied  (Fig.  802),  or  it  may 
involve  either  one  of  the  lateral  lobes  or  only  the  middle  lobe.  (Fig.  803.) 
Sometimes  pedunculated  tumors  project  from  the  internal  or  the  external 
surface  of  the  gland,  but  this  form  is  rarely  seen  except  in  the  middle  lobe. 
The  thickened  prostate  comj)resses  the  urethra  passing  through  the  organ 
and.  interferes  with  the  evacuation  of  the  bladder.  This  obstruction  is 
greatest  when  the  enlargement  is  limited  to  the  middle  lobe,  as  tumors  in 
this  situation  are  apt  to  project  into  the  bladder  directly  over  the  internal 
meatus,  and  even  when  small  they  may  close  the  urethra  on  the  principle  of 
a  ball-and-socket  valve.  The  enlargement  of 
the  prostate  lengthens  the  prostatic  urethra, 
and  if  it  is  not  symmetrical  it  causes  deviation 
of  the  canal,  sometimes  making  it  quite  tortuous. 
The  urethral  orifice  is  displaced  forward  and 
upward.  The  superior  wall  of  the  urethra 
remains  nearly  normal.  The  urinary  obstruc- 
tion is  of  very  slow  development,  and  is  hardly 
noticed  by  the  patient  at  first,  the  bladder 
slowly  distending  and  its  walls  becoming  hyper- 
trophied.  (Fig.  804.)  At  the  same  time  the 
muscular  fasciculi  are  apt  to  be  separated  by 
the  great  distention,  and  the  mucous  membrane 
protrudes  between  them,  so  that  the  interior 
view  of  the  organ  resembles  a  honeycomb,  con- 
taining deep  ijockets  between  projecting  bands. 
There  is  usually  a  thick  bar  between  the  ureteral 
orifices.  (Fig.  803.)  In  rai'e  cases  the  distention  is  uniform  without  the 
development  of  bands  and  without  much  hypertrophy,  the  wall  of  the 
bladder  remaining  thin.  The  internal  pressure  extends  backward  along  the 
ureters,  dilating  them,  and  reaches  the  kidney,  distending  its  pelvis. 

Symptoms. — In  the  early  stages  the  bladder  is  rather  irritable,  and 
constant  attempts  at  micturition  are  made,  but  only  a  small  quantity  of 
urine  can  be  passed  at  a  time,  and  that  with  very  little  force  and  with  drib- 


Hypertrophy  of  the  bladder  in  en- 
larged prostate,  showing  section  of 
wall  and  internal  surface. 


1026  SYMPTOIMS   OF  ENLARGEMENT  OF  THE  PROSTATE. 

bling  at  the  close.  The  frequency  of  urination  is  greatest  at  night  or  early 
in  the  morning,  and  disturbs  the  patient's  rest.  The  bladder  is  never  com- 
pletely emptied,  from  two  to  four  ounces  of  urine  being  retained,  and  this 
residual  iirine,  as  it  is  called,  constantly  tends  to  increase  in  amount.  In 
some  cases  the  organ  may  be  immensely  distended,  reaching  the  umbilicus, 
and  yet  the  patient  may  be  unaware  of  its  condition  because  he  is  constantly 
passing  small  quantities  of  water.  When  thus  distended  the  bladder- walls 
are  paralyzed  and  lose  very  much  of  their  contractile  force,  and  the  sphinc- 
ter is  also  weakened,  the  result  being  a  continuous  flow  of  urine  resembling 
the  dribbling  of  incontinence.  The  condition  is  really  one  of  leakage  by 
overflow  from  the  over-distention  of  the  bladder.  Occasionallj^  there  are 
subjective  symptoms  of  weight  in  the  perineum  and  violent  and  painful 
contractions  of  the  bladder  at  the  end  of  micturition.  As  a  rule,  however, 
the  patient  is  unaware  of  anything  serious.  If  infection  takes  place  in  such 
a  case  and  a  cystitis  be  set  up,  it  is  unusually  virulent,  because  of  the 
urinary  retention  and  the  impaired  circulation  of  the  bladder  wall-  The 
retained  urine  readily  decomposes,  and  this  decomposition  affects  not 
merely  the  bladder  but  the  kidney,  and  the  sym^Dtoms  of  ui-ethral  fever 
are  observed  in  tyj)ical  form,  beginuing  with  or  without  a  chill,  and 
resembling  in  its  course  the  pytemic  curve,  rising  very  suddenly  and  fall- 
ing as  rapidly.  The  jjatient  may  have  headache  and  usually  nausea,  the 
appetite  is  lost,  the  skin  feels  hot  and  dry,  the  tongue  is  apt  to  be  coated 
and  brown,  and  acute  uraemia  may  set  in  with  a  speedily  fatal  result.  All 
of  these  consequences  may  take  j)lace  with  very  little  alteration  of  the  urine, 
the  latter  being  slightly  cloudy,  but  without  j)us  or  albumin.  In  other  cases 
the  general  symptoms  are  less  severe  but  the  local  signs  are  more  acute,  the 
urine  then  containing  pus  in  large  amounts,  the  micturition  being  frequent 
and  becoming  painful,  especially  at  the  end  of  the  act.  As  a  consequence 
of  the  cystitis  and  very  early  decomposition  of  the  urine,  triple  phosphates 
are  thrown  down  and  phosphatic  calculi  are  formed  in  the  bladder,  espe- 
cially in  the  pouch  behind  the  prostate,  where  the  sediment  collects.  The 
sufferings  of  such  patients  are  extreme,  and,  owing  to  their  advanced  age, 
the  disease  is  apt  to  terminate  fatally  in  a  short  time. 

Local  examination  should  be  made  by  the  finger  in  the  rectum,  which 
allows  of  accurate  determination  of  the  size,  shape,  and  consistency  of  the 
prostate.  Simultaneous  pressure  with  the  other  hand  above  the  pubes 
greatly  assists  in  ascertaining  the  limits  of  the  organ,  and  the  introduction 
of  a  sound  into  the  bladder  at  the  same  time  may  give  additional  informa- 
tion. The  presence  of  a  stone  should  always  be  suspected,  and  very  careful 
search  made  for  it  with  the  sound.  The  quantity  of  residual  urine  should 
always  be  studied,  especially  as  a  tumor  of  the  median  lobe  may  cause 
obstruction  even  when  too  small  to  be  recognized  by  palpation.  It  is  meas- 
ured by  directing  the  patient  to  emjity  the  bladder  and  then  introducing  a 
catheter  and  withdrawing  the  remainder.  Over-distention  of  the  bladder  is 
easily  recognized ,  as  the  tumor  can  be  felt  and  percussed  above  the  pubes, 
even  if  there  is  no  "  overflow."  By  means  of  a  cystoscopic  examination  the 
shape  of  the  prostate  and  the  presence  of  such  complications  as  stone  can 
generally  be  recognized. 


TPxEATMENT   OF  ENLARGEMENT  OF  THE  PROSTATE. 


1027 


Fig.  sob. 


Iff 


Treatment. — Slight  cases  of  prostatic  hyijertropliy  in  wliicii  there  is 
no  cystitis,  the  urine  is  clear,  and  the  residual  amount  is  only  an  ounce  or 
two,  and  especially  when  the  patient  is  disturbed  only  once  or  twice  during 
the  night  to  evacuate  the  bladder,  may  be  treated  on  general  principles, 
without  any  local  treatment.  In  some  cases  a  large  part  of  the  pro.static 
swelling  is  due  to  congestion,  and  rest  in  bed,  with  the  use  of  cold  water 
rectal  injections,  or  of  a  double-current  hollow  instrument  passed  into  the 
rectum  so  as  to  apply  the  cold  continuously  to  the  prostate,  will  greatly 
diminish  the  size  of  the  gland.  East  in  bed,  however,  in  these  patients, 
as  with  most  old  persons,  is  a  dangerous  expedient,  for  if  they  are  deprived 
of  the  stimulus  of  moving  about  their  mental  jjower  is  apt  to  decay.  Little 
else  can  be  done  medically,  for  the  use  of  drugs,  such  as  ergot,  has  been 
found  to  be  without  effect.     Guyon  recommends  iodide  of  potash. 

Catheterization. — The  regular  evacuation  of  the  bladder  by  a  catheter 
has  long  been  a  favorite  method  of  treating  prostatic  hyi^ertrophy,  and  for 
the  majority  of  cases  is  still  the 
best.    If  a  case  can  be  seen  early,  pj,,  §05 

before  cystitis  has  been  estab- 
lished, and  the  daily  regular  use 
of  the  catheter  instituted  under 

full   antiseptic  precautions,  the     /£'  \  H  Fig.  807 

patient  may  soon  be  placed  in  a 
very  comfortable  position  and 
enabled  to  continue  his  life  for 
many  years  without  further  an- 
noyance than  the  cathetei'ization. 
The  greatest  precautions  in  re- 
gard to  cleansing  the  patient's 
penis  and  irrethra  and  sterilizing 
the  instruments  and  the  surgeon's 
hands  should  be  taken,  for  fear 
of  causing  decomposition  of  the 
urine  and  cystitis  and  secondary 
pyelitis.  The  catheter  is  to  be 
introduced  every  four,  sis,  or 
eight  hours,  according  to  the 
capacity  of  the  bladder.  Some 
surgeons  retain  the  catheter  in 
the  urethra.  If  a  metal  instru- 
ment is  emxjloyed  it  should  have 
a  large  and  long  curve, — the 
"prostatic  curve."  (Fig.  805.) 
A  flexible  catheter  is  to  be  pre- 
ferred, and   if  there   is   diihculty  Prostatic  Mercier-s  coudO 

in  Introducing  it,   a  moderately  catheter.  catheter. 

flexible  instrument,  bent  at  the 

end   (Mercier's  sonde  coude,   Fig  806),    or  one  with  a  narrow  neck  and 

bulb  point  (Fig.  807),  will  often  pass  when  the  ordinary  catheter  will  not. 


French  bougie 
catheter. 


1028  TREATMENT  OF  ENLARGEMENT  OF  THE  PROSTATE.   . 

An  ordinary  soft  catheter  provided  with  a  rather  stiff  stylet  curved  to  fit 
the  subpubic  curve  can  be  made  to  tilt  up  at  the  end,  and  so  rise  over  the 
obstruction  by  withdrawing  the  stylet  for  an  inch  or  so  after  the  instrument 
has  been  passed  to  the  obstruction.  When  over -distention  exists  it  is  dan- 
gerous to  evacuate  the  bladder  comjDletely  at  the  first  sitting,  as  fatal  syncope 
has  been  kuown  to  occur  in  such  cases,  or  acute  suppression  of  urine,  with 
uraemia.  The  latter  may  take  place  even  without  septic  infection  as  a  result 
of  the  sudden  change  in  the  conditions  of  pressure  under  which  the  renal 
epithelium  and  vessels  have  been  working.  About  one-half  of  the  urine, 
therefore,  should  be  withdrawn,  and  normal  salt  solution  amounting  to  one- 
quarter  or  one-half  of  that  quantity  should  be  injected  and  left.  This  is 
repeated  at  intervals  of  six  hours,  and  the  bladder  gradually  reduced  in  size 
without  being  subjected  to  the  disturbance  of  a  sudden  change  of  pressure. 
During  the  beginning  of  catheter  treatment  the  ijatient  should  be  confined 
to  bed,  or,  at  least,  to  his  room,  as  there  is  almost  alwaj^s  a  slight  iuflamma- 
tory  reaction  at  first.  After  the  surgeon  has  established  this  method  of  treat- 
ment, and  the  bladder  has  been  suificiently  "hardened"  to  resist  slight 
infection,  the  patient  should  be  taught  to  pass  the  catheter  himself  in  as 
aseptic  a  manner  as  possible.  He  should  be  warned  to  be  regular  in  its  use, 
because  a  single  over-distention  of  the  bladder  may  cause  a  return  of  all  the 
acute  symjatoms.  Such  patients  may  live  in  comfort  for  ten  years  or  more. 
In  some  cases,  indeed,  this  treatment  results  in  reducing  the  size  of  the  gland 
as  soon  as  the  bladder  is  regulary  evacuated,  by  diminishing  the  pressure 
which  interferes  with  its  circulation,  and  the  power  of  micturition  may  be 
almost  completely  regained.  In  cases  in  which  the  obstruction  is  not  yet 
comj)lete,  the  symptoms  of  frequent  micturition  and  some  residual  urine 
being  i^resent,  but  without  overflow,  the  use  of  the  catheter  once  or  twice  a 
day  to  free  the  bladder  of  residual  urine,  with  irrigation  if  there  is  a  mild 
cystitis,  is  sufhcient.  In  cases  of  over-distention,  however,  the  obstruction 
will  usually  be  found  to  be  complete  as  soon  as  the  increased  pressure 
has  been  removed,  and  voluntary  micturition  will  be  impossible,  at  least 
for  a  long  time.  Sometimes  considerable  improvement  can  be  obtained  by 
simply  dilating  the  urethra  thoroughly  by  the  passage  of  a  large  sound. 

Castration,  and  Ligature  of  the  Vasa  Deferentia. — Attempts  to 
reduce  the  size  of  the  prostate  by  castration  have  recently  been  made.  In 
some  cases  it  has  been  reported  that  a  patient  who  had  not  been  able  to 
pass  water  voluntarily  for  a  long  period  of  time  was  able  to  do  so  a  few 
hours  after  the  operation.  It  is  difficult  to  explain  such  cases  by  any  reason- 
able theory,  and  it  is  seldom  that  a  real  atrophy  of  the  gland  is  produced 
and  that  a  permanent  cure  is  effected.  The  operation  in  elderly  persons, 
moreover,  is  serious,  and  many  deaths  have  followed  from  hypostatic  pneu- 
monia or  senile  dementia.  It  has  been  suggested  simply  to  expose  and  divide 
both  vasa  deferentia  after  ligature  under  cocaine  autesthesia.  These  opera- 
tions are  still  on  trial,  but  they  are  less  promising  now  than  when  first 
introduced. 

Drainage. — The  iDrostatic  obstruction  has  been  relieved  by  draining  the 
bladder  behind  the  obstruction.  The  opening  has  been  made  in  the  perineum 
and  also  above  the  pubes.    The  latter  route  is  to  be  preferred,  as  it  is  easier 


PEOSTATECTOMY.  1029 

for  the  patient  to  keep  himself  dry,  and  in  some  cases  a  sort  of  sphincteric 
action  has  been  produced  iu  tliis  opening.  The  perineal  operation  is  done  in 
the  ordinary  manner,  the  urethra  being  opened  upon  a  staff  in  the  mem- 
branous portion  just  anterior  to  the  ligament.  The  urine  can  be  drained 
into  a  urinal  secured  to  the  legs,  but  the  perineal  opening  is  not  very  satis- 
factory, except  while  the  patient  is  in  bed.  The  suprapubic  operation  is 
made  in  the  usual  way  in  the  median  line  close  to  the  bone,  and  the  wound 
is  allowed  to  contract  around  a  catheter  held  in  place  by  a  rubber  plate 
which  is  secured  to  a  belt  around  the  body  and  has  a  perforation  in  the 
centre  just  large  enough  to  hold  the  catheter.  A  safety-pin  through  the 
catheter  keeps  it  at  the  right  depth.  The  catheter  can  be  closed  by  a  clamp, 
which  is  taken  off  at  regular  intervals  to  allow  evacuation  of  the  bladder, 
and  the  new  meatus  is  generally  sufficiently  tight  around  it  not  to  leak 
until  the  bladder  becomes  distended.  It  has  been  suggested  to  make  an 
opening  into  the  bladder  on  the  same  principle  as  the  valvular  method  for 
gastrostomy,  by  sewing  the  wall  of  the  organ  in  a  fold  over  the  catheter  as 
it  lies  in  place.  (G-ibson.)  The  catheter  can  then  be  entirely  withdrawn 
and  no  leakage  occurs  from  the  fistula,  but  the  opening  must  be  kept  patent 
by  the  introduction  of  a  catheter  at  least  once  in  twenty-four  hours.  Patients 
have  been  enabled  to  resume  an  active  life  after  the  establishment  of  this 
suprapubic  fistula,  and  the  method  is  undoubtedly  a  good  one. 

Prostatotomy. — Prostatotomy  can  be  performed  by  doing  a  suprapubic 
cystotomy,  and  incising  the  prostate  by  cautery-knife  or  bone-forceps,  so  as 
to  secure  drainage  into  the  lu'ethra  for  the  lowest  pocket  of  the  bladder. 
Prostatotomy  can  also  be  done  through  the  urethra  by  the  internal  aj^plica- 
tion  of  an  instrument  like  a  small  lithotrite,  containing  a  galvano-cautery 
knife  (Bottini's  operation).  The  instrument  is  introduced  under  cocaine 
ansesthesia,  the  bladder  distended  with  air,  and  three  or  four  grooves 
burnt  in  the  prostate  at  the  internal  meatus.  Primary  hemorrhage  appears 
to  be  very  rare,  and  secondary  bleeding  not  common.  Sepsis  and  kidney 
complications  also  seem  to  be  less  common  than  would  be  expected  con- 
sidering the  inflamed  condition  of  the  bladder  which  is  usual  in  these 
cases.  The  patient  is  kept  in  bed  only  'for  a  daj^  or  so.  A  large  number  of 
cases  are  on  record,  with  very  few  deaths  due  to  the  operation,  and  excellent 
results  have  been  obtained. 

Prostatectomy. — Prostatectomy  can  be  performed  by  the  suprapubic 
or  the  perineal  roiite.  In  the  first  metliod  a  large  sujirapubic  opening  is 
made,  a  rectal  balloon  having  been  in.serted  to  force  the  prostate  ujj  within 
reach  of  the  finger.  Wedge-shaped  pieces  maj'  be  excised  from  the  gland 
and  a  channel  formed  for  the  urethra,  but  it  is  better  to  relieve  that  canal 
of  pressure  by  incising  the  mucous  membrane  over  the  prostate  and  enucle- 
ating prominent  portions  of  the  growth  with  the  finger  tip  or  a  blunt  instru- 
ment, such  as  a  bone-rongeur.  Hemorrhage  is  controlled  by  the  cautery 
or  by  pressure,  and  if  necessary  the  bladder  may  be  packed  full  of  gauze  at 
the  end  of  the  operation  in  order  to  maintain  pressure  for  a  long  period. 
Drainage  must  be  employed  in  everj^  case,  and  if  the  organ  is  packed,  the 
drainage-tube  must  be  run  down  through  the  packing  so  as  to  drain  off  the 
urine  from  the  trigonum. 


1030  VESICAL  CALCULUS. 

The  perineal  method  of  attacking  the  prostate,  suggested  by  Dittel,  con- 
sists in  a  transverse  or  horseshoe-shaped  incision  in  the  perineum,  described 
in  the  chapter  on  the  prostate,  by  which  the  external  surface  of  the  prostate 
is  exposed.  Wedge-shaped  pieces  are  excised  from  the  enlarged  lobes,  and 
after  their  removal  the  gland  tends  to  fail  together,  so  that  its  inner  surface, 
which  interferes  with  the  passage  of  the  urine  by  projection  into  the  urethra, 
falls  away  from  that  canal  and  the  passage  is  made  clear.  Alexander  opens 
the  bladder  above  the  pubes  sufhciently  to  insert  a  finger  into  that  organ, 
and  also  makes  a  median  perineal  incision  into  the  urethra.  A  finger  of 
one  hand  is  inserted  into  the  perioeal  wound,  and  the  urethral  mucous 
membrane  and  capsule  of  the  prostate  are  torn  through  on  one  side  of  the 
urethra.  The  finger  of  the  other  hand  inserted  in  the  bladder  is  used  as  a 
guide  while  portions  of  the  gland  ai-e  enucleated  through  the  perineal 
wound  without  injuring  the  vesical  mucous  membrane.  If  necessary  the 
other  half  of  the  prostate  is  treated  in  the  same  manner. 

Choice  of  Treatment. — Prostatectomy  is  difficult  and  tedious,  and 
there  is  very  great  danger  of  sepsis.  The  patients,  moreover,  are  old  and 
feeble,  as  a  rule,  and  do  not  bear  even  slight  operations  well,  and  hence  the 
mortality  is  very  high.  Prostatectomy,  therefore,  is  an  operation  which 
should  be  undertaken  only  on  comparatively  young  individuals  with  a 
healthy  bladder  and  in  good  condition  otherwise.  The  treatment  of  choice 
in  old  or  feeble  subjects  is  the  use  of  the  catheter,  and  when  this  is  contra- 
indicated  by  a  tendency  to  develop  a  severe  cystitis  or  by  the  presence  of 
advanced  kidney-disease,  a  permanent  drainage  opening  must  be  made. 
Bottini's  prostatotomy  is  not  a  very  serious  oiieration,  and  is  an  ideal 
method  for  the  collar-like  intravesical  projections  so  often  seen.  Its  exact 
limitations  are  not  yet  determined.  Prostatectomy  is  especially  indicated 
for  pedunculated  tumors  which  directly  obstruct  the  vesical  exit,  and  for 
large  lateral  lobes,  in  vigorous  subjects.  A  careful  cystoscopic  examination 
is  very  useful  in  deciding  upon  the  proper  operation  for  the  special  case. 

Vesical  Calculus. — Stone  in  the  bladder  is  most  frequent  at  the  two 
extremes  of  age,  and  is  almost  limited  to  the  male  sex.  It  is  rare  in  the 
negro  race.  Its  frequency  in  children  is  due  to  the  fact  that  at  birth  the 
kidney  contains  numerous  infarctions  of  crystallized  uric  acid  in  the  urinary 
tubules,  which  are  slowly  washed  out,  and  if  there  is  any  obstruction  to 
their  iDassage  from  the  bladder  they  form  a  nucleus  around  which  a  stone 
may  grow.  In  old  age,  on  the  other  hand,  the  causes  of  calculus  are  usually 
those  which  excite  cystitis,  and  the  stones  at  this  period  of  life  are  generally 
phosphatic  on  this  account.  In  the  poor  calculus  is  most  common  in  child- 
hood, but  in  the  well-to-do  in  old  age.  Every  vesical  calculus  has  a  nucleus 
of  some  kind,  such  as  a  crystal  of  uric  acid,  a  mass  of  inspissated  mucus,  or 
a  small  foreign  body.  The  uric  acid  or  the  phosphatic  salts  are  deposited 
in  layers  around  this  nucleus  (Fig.  808),  the  mass  gradually  increasing  in 
size  until  in  some  cases  it  even  fills  the  entire  bladder.  An  albuminous 
framework  holds  the  crystals,  and  therefore  calculi  can  form  only  when  the 
urine  contains  mucus  or  blood,  besides  being  rich  in  salts.  Calculi  are  most 
commonly  formed  of  the  urates  and  uric  acid,  the  phosphatic  salts,  and 
oxalate  of  lime,  and  in  that  order,  but  rare  varieties  consist  of  such  sub- 


SYMPTOMS  OF  VESICAL  CALCULUS.  1031 

stances  as  cystine.  The  oxalate  of  lime  calculus  is  very  hard,  and  its  surface 
usually  rough  from  the  projecting  corners  of  the  crystals  which  form  the 
outer  layer,  whence  it  is  called  a  mulberry  calculus.  The  uric  acid  calculi 
are  not  so  hard,  and  are  smooth.  Those  of  the  urates  are  still  softer,  and 
the  phosphatic  calculi  are  very  friable,  the 
layers  easily  breaking  away  or  even  dissolving, 
and  their  surfaces  are  smooth.  The  uric  acid 
and  oxalate  calciili  are  usually  globular  or 
/  ^ffiV       egg-shaped,  while  the  phosphatic  form  is  often 


Fig 


ri 


section  i>l  a  \  f-Riil  Liikulus  Vesical  calculus  one  end  of  which  was  encysted  in  a  pouch. 

flattened.  The  calculi  may  lie  for  years  in  the  bladder  without  symp- 
toms, especially  if  they  have  developed  in  pouches  in  its  walls  or  at  the 
base  behind  an  enlarged  prostate.  Occasionally  they  are  elongated,  and 
one  end  extends  into  one  of  the  ureters,  into  the  urethra,  or  into  a  vesical 
pouch.  (Fig.  809.)  Not  frequently  calculi  begin  to  grow  in  the  prostatic 
sinus  and  then  extend  backward  into  the  bladder  and  forward  along  the 
urethra. 

Sometimes  more  than  one  calculus  is  found,  even  as  many  as  five  hun- 
dred. Calculi  are  of  various  sizes,  averaging  from  three  to  six  drachms  in 
weight,  and  from  half  an  inch  to  an  inch  and  a  half  in  diameter.  They 
may  weigh  only  a  few  grains  or  as  much  as  six  pounds.  Calculi  have  been 
known  to  undergo  spontaneous  fracture  in  the  bladder,  but  the  causes  of 
this  accident  are  not  understood.  Multiple  stones  in  the  bladder  are  some- 
times faceted,  or  show  other  marks  of  one  another's  presence.  The  pres- 
ence of  a  calculus  in  the  bladder  causes  congestion  and  even  sloughing  of 
the  mucous  membrane.  If  infection  takes  place  and  a  cystitis  is  produced, 
its  symjjtoms  are  rendered  much  worse  by  the  presence  of  the  stone. 

Symptoms. — The  symptoms  of  calculus  may  be  very  severe  or  slight, 
the  difference  depending  mainly  upon  the  ijresence  or  absence  of  septic  infec- 
tion. If  there  is  no  cystitis  the  symptoms  are  usually  slight,  and  in  some 
cases  the  stone  has  existed  for  years  without  being  recognized,  even  when 
of  considerable  size.  A  small  stone,  however,  may  cause  severe  symptoms 
even  without  infection,  by  its  pressure  upon  the  sensitive  neck  of  the  blad- 
der, or  in  some  cases  by  blocking  the  flow  of  the  urine,  the  patient  observing 
that  urination  is  possible  only  by  assuming  certain  positions  which  hold  the 
stone  away  from  the  internal  meatus.  The  irritation  of  its  i^resence  may 
also  excite  the  bladder  to  constant  contraction,  resulting  in  frequent  mictu- 


1032  DIAGNOSIS  OF  VESICAL  CALCULUS. 

rition,  especially  during  the  day  and  while  taking  exercise.  Blood  may  be 
passed  in  the  urine,  from  the  contraction  of  the  bladder  uj)on  the  stone  at 
the  end  of  micturition  crowding  a  rough  stone  against  the  mucous  mem- 
brane. The  frequent  micturition  and  straining  may  cause  hernia  or  pro- 
lapse of  the  rectum,  especially  in  children.  Pain  is  also  present  from  the 
same  cause,  and  is  usually  referred  to  the  end  of  the  penis,  just  below  and 
back  of  the  glans,  although  it  may  be  felt  as  a  dull,  heavy,  aching  pain  in 
the  rectum,  in  the  perineum,  or  above  the  pubes.  When  cystitis  is  present 
all  these  symptoms  are  greatly  aggravated,  and  mucus  and  pus  are  found 
in  the  urine  in  large  quantities.  The  pain  becomes  acute,  and  the  efforts  at 
micturition  are  almost  constant,  so  that  the  patient  has  no  rest  day  or  night. 
On  the  other  hand,  a  calculus  developing  as  a  sequel  to  hypertrophy  of  the 
prostate,  with  chronic  cystitis,  may  cause  no  additional  symptoms,  the 
enlarged  prostate  keeping  the  stone  away  from  the  sensitive  neck  of  the 
bladder.  Children  suffering  from  calculi  may  have  no  symptoms  except 
frequent  micturition  and  a  habit  of  pulling  at  the  foreskin,  the  elongation 
of  the  latter  having  sometimes  led  to  the  diagnosis.  The  symptoms,  there- 
fore, are  uncertain,  and  the  diagnosis  must  be  made  by  local  examination. 

Diagnosis. — A  cj'Stoscopic  examination  will  usually  show  the  calculus 
at  once,  its  character  and  its  position.  Examination  with  the  sound  will 
give  to  the  .skilful  surgeon  almost  equally  correct  information.  In  making 
an  examination  by  the  sound  or  searcher  the  i)atient  should  lie  uj)on  the 
back,  with  a  small  jjillow  under  the  hips,  so  as  to  tilt  the  lielvis  slightly  back- 
ward. This  facilitates  the  examination  by  rolling  the  stone  away  from  the 
neck  of  the  bladder,  so  that  it  can  be  more  readily  felt.  The  usual  antisep- 
tic precautions  must  be  observed.  The  bladder  should  be  distended  with 
four  or  five  ounces  of  fluid,  and  the  urine  may  be  allowed  to  collect  to  that 
amount,  or  sterilized  salt  solution  may  be  injected.  The  instrument  used  for 
this  examination  is  termed  a  searcher,  and  is  usually  a  hollow  metal  sound 
or  catheter  with  a  rather  short  end,  the  tip  of  which  is  made  solid.  The  best 
form  is  that  known  as  Thompson's,  which  has  a  straight  shaft,  the  tip  being 
very  short  and  sharjily  bent.  The  searcher  having  been  introduced,  the 
handle  is  depressed  between  the  thighs  so  that  the  curve  of  the  instrument 
shall  enter  the  bladder,  and  the  insti-ument  is  then  pushed  in  as  far  as  it. 
will  go.  It  is  then  slowly  drawn  forward,  being  given  gentle  rotatory  move- 
ments towards  one  side  at  intervals  of  a  quarter  of  a  inch,  exploring 
thoroughly  one  side  of  the  bladder.  In  these  rotatory  motions  the  beak  is 
made  to  describe  an  arc  of  about  a  quarter  of  a  circle.  The  searcher  is  then 
pushed  back  again  to  the  bottom  of  the  bladder  and  again  drawn  forward, 
the  rotatory  motions  being  made  on  the  opposite  side.  The  handle  is  still 
further  depressed  between  the  thighs,  so  that  the  instrument  may  be  turned 
completely  over  and  the  beak  directed  towards  the  base  of  the  bladder.  In 
this  position  a  stone  which  may  be  lying  in  a  pouch  at  the  base  of  the 
bladder  behind  an  enlarged  prostate  is  readily  detected.  (Fig.  810.) 
Finally,  the  beak  of  the  instrument  is  made  to  sweep  over  the  surface  of 
the  bladder  in  all  directions,  to  discover  a  stone  which  might  be  encysted  in 
a  lateral  pouch.  (Figs.  811  and  812.)  Lifting  the  base  of  the  bladder  by 
the  finger  in  the  rectum,  or  depressing  the  fundus  by  external  pressure,  is 


TREATMENT  OF  VESICAL  CALCULUS. 


1033 


sometimes  useful.  If  a  stone  is  present,  when  the  beak  of  the  instrument 
touches  it  a  sharp  metallic  click  will  be  perceptible  to  the  fingers  and  also 
to  the  ear.     When  a  stone  has  been 

found,  its  size  can  be  estimated  by  Fi°-  '^^^• 

noting  the  position  of  the  meatus  on 
the  shaft  of  the  searcher,  when  the 
latter  strikes  the  stone,  and  again 
when  it  ceases  to  strike  as  it  is  drawn 
forward,  and  measuring  the  space 
between  these  points.  The  searcher 
will  determine  if  the  surface  is  rough 
or  smooth.  In  some  cases  the  exami- 
nation is  very  simple,  but  in  others 
even  the  most  experienced  may  fail  in 
detecting  the  stone.  IS'egative  evi- 
dence is  of  no  value  unless  repeated 
examinations  have  been  made  by  an 
expert.  Sometimes  the  use  of  the 
evacuating  tube  and  aspirator,  as  in  litholapaxy,  will  detect  a  small  calculus 
which  eludes  the  sound.  A  stone  which  is  in  a  sac  or  pouch  may  be  com- 
pletely out  of  reach  of  the  searcher,  and,  on  the  other  hand,  an  incrustation 
of  the  bladder  wall  with  phosphatic  salts  may  resemble  a  calculus,  and  it  is 


Searcher  touching  a  stone  behind  the  prostate, 
assisted  by  a  finger  inserted  In  the  rectum.  (Ag- 
new. ) 


Fig.  811. 


Fig.  S12. 


stone  encysted  near  ba^ 


Stone  encysted 


in  such  obscure  cases  as  these  that  the  cystoscope  is  most  useful.  An  anaes- 
thetic may  be  given,  or  cocaine  employed  locally,  for  the  examination,  if  the 
patient  is  very  nervous  or  very  sensitive,  but  in  ordinary  cases  it  will  not  be 
necessary.  Occasionally  a  stone  develops  behind  a  urethral  stricture,  and 
the  latter  will  need  treatment  before  the  searcher  can  be  introduced  into 
the  bladder. 

Treatment. — The  medical  treatment  of  vesical  calculus  is  merely  pal- 
liative, and  no  practical  method  of  dissolving  these  stones  by  the  adminis- 
tration of  drugs  has  yet  been  discovered.  The  formation  of  uric  acid  stones 
can  be  avoided  by  careful  diet,  drinking  an  abundance  of  water,  the  admin- 
istration of  alkalies  and  salicylates,  and  attention  to  out-door  exercise. 
Oxalate  of  lime  calculi  demand  treatment  for  the  oxaluria  if  it  is  still 


1034  LITHOLAPAXY. 

present.  Pliosphatio  calculi  are  al'ways  secondary  to  some  bladder  con- 
dition, and  are  not  so  mucli  affected  by  the  general  health,  but  we  have 
seen  them  increased,  if  not  caused,  by  injudicious  use  of  alkalies  to  relieve 
the  frequent  micturition  of  an  hypertrophied  prostate.  "When  operation  is 
delayed,  the  treatment  consists  in  irrigation  of  the  bladder  to  correct  the 
cj'stitis  if  any  is  present,  rest  in  bed,  flushing  out  the  urinary  channels  with 
diuretic  drinks,  correcting  acidity  or  alkalinity  of  the  urine,  administration 
of  urotropin  or  salol  to  render  the  urine  aseptic,  and  attention  to  the  gen- 
eral health.     Anodynes  may  be  needed  for  pain  or  to  secure  sleep. 

The  operations  which  are  employed  to  remove  calculi  from  the  bladder 
are  lithotrity  or  litholapaxy  and  lithotomy. 

Lithotrity  and  Litholapaxy. — The  old-fashioned  method  of  lithotrity, 
in  which  the  stone  was  broken  into  pieces  at  several  sittings  and  allowed  to 
pass  with  the  urine,  has  been  discarded  for  the  more  thorough  operation 
introduced  by  Bigelow,  in  which  the  stone  is  crushed  at  once  into  minute 
pieces  and  evacuated  at  the  same  time  by  a  powerful  aspirating  instrument. 
A  lithotrite  is  an  instrument  devised  for  the  crushing  of  a  stone,  and  con- 
sists of  a  male  and  a  female  blade  ending  in  a  short  beak,  in  which  the  stone 
is  seized.  The  blades  are  continued  through  the  shaft  into  the  handle,  where 
a  powerful  screw  forces  them  together,  with  a  freeing  device,  by  which  the 
thread  of  the  screw  can  at  any  time  be  thrown  out  so  that  the  two  blades  can 
slide  freely  by  each  other.  The  female  blade  is  fenestrated  at  the  beak,  and 
the  male  blade,  which  is  much  smaller,  plays  in  the  fenestra,  both  being 
provided  with  teeth  on  the  sides  which  come  in  contact.     (Fig.  813.)     The 


patient  should  be  prepared  for  this  operation,  as  for  lithotomy,  by  external 
sterilization  and  by  systematic  irrigation  of  the  bladder  for  some  days  ijre- 
vious,  to  render  it  as  aseptic  as  possible.  The  condition  of  the  kidneys 
should  be  studied,  and  if  nephritis  is  present  it  should  be  corrected  as  far 
as  possible  by  medication  and  diet.  The  patient  is  placed  in  the  same 
position  as  for  the  use  of  the  searcher,  the  bladder  is  irrigated,  and  from 
four  to  sis  ounces  are  left  in  when  the  lithotrite  is  introduced.  A  general 
anaesthetic  is  usually  to  be  employed,  although  it  is  possible  to  perform  the 
operation  with  the  assistance  of  cocaine,  a  four  per  cent,  solution  being 
introduced  into  the  bladder,  allowed  to  remain  for  five  minutes,  and  washed 
out  again  before  proceeding  with  the  operation.  The  use  of  cocaine,  how- 
ever, in  this  manner  is  not  entirely  free  from  danger,  and  a  general  anaes- 
thetic is  advisable  whenever  the  patient  can  bear  it.  When  nephritis  is 
present,  chloroform  is  preferable  to  ether. 

Lithotrite,  evacuator,  and  all  other  instruments  are  to  be  thoroughly 
sterilized.  The  lithotrite  is  introduced  closed,  the  stone  having  previously 
been  located  with  the  searcher,  or  by  using  the  lithotrite  as  a  searcher.  The 
blades  are  opened,  a  rotation  of  a  quarter  of  a  circle  is  made  towards  the 


LITHOLAPAXY. 


1035 


stone,  and  the  two  jaws  are  slowly  pushed  together  with  great  gentleness,  iu 
order  to  seize  the  stone.  When  the  stone  has  beeu  seized,  firm  ^jressure  is 
made  upon  it,  and  the  lithotrite  is  returned  to  its  position  with  the  beak 
turned  upward  as  nearly  as  possible  in  the  middle  line,  carrying  the  stone 
in  its  jaws.  The  locking  device  throws  the  screw  into  action,  and  the  jaws 
are  screwed  together  and  the  stone  broken.  This  manipulation  must  be  of 
the  most  gentle  character  from  beginning  to  end,  for  the  stone  may  fly  out 
of  the  instrument  and  injure  the  bladder,  or  the  jaws  may  catch  the  walls 
and  wound  them.  It  may  be  necessary  to  invert  the  lithotrite  and  to  depress 
the  handle  like  the  searcher  in  order  to  reach  a  stone  behind  an  enlarged 
prostate  in  a  pocket  at  the  base  of  the  bladder.  The  first  action  of  the 
lithotrite  is  to  break  the  stone  into  two  or  three  pieces.  These  pieces  are 
seized  and  broken  again,  and  so  on  until  they  are  small  enough  to  pass 
through  the  evacuating-tirbe.  The  size  of  the  fragments  is  evident  from  the 
separation  of  the  jaws  of  the  instrument,  and  when  the  pieces  have  been  suf- 
ficiently reduced  the  lithotrite  is  withdrawn  and  the  evacuator  introduced. 
The  evacuator  is  a  large  metal  tube  very  slightly  curved  at  the  end  to  form  a 
beak,  which  has  a  very  large  opening,  the  edges  of  which  are  bevelled  so  as  not 
to  injui-e  the  urethra  or  bladder.  To  its  outer  extremity  is  attached  some  form 
of  aspirator,  the  best  being  Otis's  or  Chismore's  modification  of  Bigelow's 
original  instrument.      (Fig-  814.)      The  aspirator  consists  of  a  vessel  con- 


Bigelow's  aspirator  and  evacuating  tubes. 

taining  sterilized  salt  solution  and  a  large  rubber  bulb  in  connection  with  it 
and  also  containing  the  fluid,  no  air  being  allowed  in  either.  The  rubber 
bulb  being  squeezed  by  the  hand,  the  fluid  is  driven  into  the  bladder,  and 
when  the  bulb  is  released  it  is  drawn  back  again,  bringing  with  it  the  frag- 
ments of  the  calculus,  blood,  mucus,  and  urine.  These  flow  over  the  mouth 
of  the  other  vessel,  and  the  heavier  particles  tend  to  settle  to  the  bottom, 


1036 


MEDIAN  LITHOTOMY. 


where  they  are  retained.  The  bulb  forces  the  fluid  backward  and  forward, 
each  aspiration  bringing  out  fresh  particles  of  calculus,  which  are  added  to 
those  at  the  bottom  of  the  vessel  by  gravity.  After  the  small  fragments  are 
removed,  those  which  are  too  large  to  enter  the  eye  of  the  evacuator  may 
be  felt  to  click  against  it.  The  instrument  is  then  withdrawn,  the  litho- 
trite  introduced  again,  and  the  large  fragments  reduced  to  powder  as  far  as 
possible.  It  may  be  necessary  to  repeat  this  crashing  and  aspiration  several 
times  in  the  course  of  the  operation. 

A.  defective  lithotrite  may  break  during  the  crushing,  and  lithotomy 
will  then  be  necessary  to  remove  the  broken  instrument  and  the  stone. 
A  very  annoying  accident  is  the  jamming  of  the  jaws  of  the  lithotrite 
with  the  fragments  of  the  calculus,  so  that  they  cannot  be  completely  closed, 
preventing  the  withdrawal  of  the  instrument,  because  when  open  it  is  too 
large  to  pass  the  urethra,  for  the  projecting  fragments  of  calculus  would 
lacerate  the  latter.  In  such  a  case  it  is  necessary  to  do  a  lithotomy  and  free 
the  jaws  of  the  instrument.  As  a  rule,  however,  repeated  opening  and 
closing  of  the  jaws  will  clear  them  sufficiently  to  enable  them  to  be  closed. 
The  after-treatment  of  these  cases  consists  of  frequent  irrigation  of  the  blad- 
der and  watching  and  treating  the  renal  complications.  The  patient  should 
be  made  to  get  out  of  bed  at  the  earliest  possible  moment. 

Litholai^axy  has  of  late  been  strongly  advocated  for  children  and  infants, 
for  although  the  operation  is  particularly  difficult,  because  of  the  small  size 
of  the  urethra,  with  instruments  of  proper  size  (12  to  18  French)  excellent 
results  have  been  obtained.  The  Anglo-Indian  surgeons  have  operated  on 
many  hundreds  of  young  children  with  a  mortality  of  only  from  one  to 
three  per  cent. 

Lithotomy. — The  bladder  may  be  opened  through  the  perineum  or 
above  the  pubes.  Formerly  the  perineal  operations  were  preferred  :  they 
are  of  two  kinds, — the  median  and  the  lateral. 

Median  Lithotomy. — In  the  median  operation  the  patient  is  placed 
upon  the  back,  with  the  thighs  flexed  upon  the  abdomen,  and  a  sound  with 

a  groove  upon  its  lower  surface, 
called  a  staff,  is  introduced  into 
the  bladder.  The  staff  being  in 
l^lace  and  the  operator  seated 
facing  the  perineum,  with  his 
left  index  finger  in  the  rectum, 
he  incises  the  perineum  in  the 
median  line  (Fig.  815,  a),  just 
anterior  to  the  sphincter,  and 
then  inserts  the  point  of  the  knife 
into  the  groove  of  the  staff  and 
makes  an  opening  in  the  floor  of 
the  urethra.  A  long  uarrowknife 
is  then  slipped  along  the  groove 
into  the  bladder,  and  made  to  enlarge  the  incision  on  withdrawal  by  cutting 
towards  the  rectum,  which  is  held  out  of  the  way  by  the  finger.  A  director 
is  then  passed  into  the  bladder,  the  staff  withdrawn,  and  a  silver  catheter 


Fig.  815. 


Incisions  for  lithotomy  ;  a,  median  ;  b,  lateral.     ( Agnew.) 


LATERAL  LITHOTOMY.  1037 

passed  through  the  wound  into  the  bladder  to  prove  that  that  organ  has  been 
reached.  The  finger  is  then  inserted  in  the  wound,  dilating  the  opening, 
and  the  stone  felt  in  the  bladder.  A  jiair  of  forceps  slightly  curved,  with 
broad  spoon-like  ends,  is  slipped  along  the  finger,  or  inserted  after  its  with- 
drawal if  the  wound  is  too  small,  and  made  to  grasp  the  stone,  the  same 
gentleness  being  used  in  seizing  the  calculus  as  in  litholapaxy.  The  stone 
is  then  withdrawn  by  the  forceps,  which  are  given  rotatory  and  lever-like 
movements  to  facilitate  its  extraction.  When  the  stone  has  been  removed, 
a  soft  rubber  catheter  should  be  inserted,  the  bladder  thoroughly  irrigated 
until  the  fluid  returns  clear,  and  the  catheter  left  in  place  for  drainage.  The 
wound  just  admits  the  finger,  and  a  stone  larger  than  this  cannot  be  removed 
by  this  opei'atiou  unless  it  is  broken  into  fragments. 

Lateral  Lithotomy. — In  the  operation  of  lateral  lithotomy  a  staff  is 
used  which  has  its  groove  upon  the  side  towards  the  patient's  left.  The 
sui'geon  makes  an  incision  in  the  perineum  (Fig.  815,  h),  beginning  at  the 
raphe  in  the  central  point  of  the  perineum,  about  an  inch  and  a  quarter  in 
front  of  the  anus  in  the  adult,  and  directed  obliquely  backward  and  outward 
so  as  to  open  the  ischio-rectal  space.  This  incision  is  deepened  until  the 
urethra  is  reached,  which  is  exposed  somewhat  on  the  side.  The  point  of  a 
long  narrow  knife  is  made  to  j)uncture  the  wall  of  the  urethra  and  enter  the 
groove  on  the  staff,  and  is  slipped  into  the  bladder  along  the  groove  dividing 
the  urethra  on  the  left-hand  side.  As  the  knife  is  withdrawn  the  handle  is 
dropped  a  little,  so  that  the  blade  cuts  a  little  deeper  through  the  outer 
tissues.  The  operator's  finger  is  placed  in  the  rectum  before  opening  the 
urethra,  as  in  the  previous  operation,  to  avoid  injury  to  the  bowel.  The 
knife  as  it  passes  into  the  bladder  cuts  into  the  left  lobe  of  the  prostate,  and 
the  wound  can,  therefore,  be  made  much  larger  than  that  of  a  median 
lithotomy.  The  succeeding  steps  are  the  same  as  in  the  other  case,  but  a 
larger  stone  may  be  removed,  because  the  edges  of  the  incision  through  the 
prostate  can  be  allowed  to  stretch  and  tear,  the  only  limit  to  the  extent  of 
the  wound  in  this  direction  being  the  capsule  of  the  prostate,  which  must 
not  be  injured,  for  fear  of  urinary  extravasation.  Peritonitis  has  also  fol- 
lowed in  such  cases.  The  lateral  operation  involves  the  danger  of  injury  to 
the  left  seminal  vesicle  and  duct,  as  well  as  to  the  rectum,  but  permanent 
injury  to  the  sexual  organs  seems  to  be  rare.  A  recto-vesical  or  recto- 
urethral  fistula  may  be  the  result  of  injury  to  the  rectum. 

Suprapubic  Lithotomy. — The  suprapubic  method  gives  free  access  to 
the  bladder,  where  the  surgeon  can  see  what  he  is  doing  and  remove  a  stone 
of  any  size,  and  the  introduction  of  aseptic  measures  has  almost  removed 
the  dangers  of  urinary  infiltration  or  peritonitis  which  once  were  formidable. 
For  the  performance  of  this  operation  it  is  advantageous  to  place  the  patient 
in  the  Trendelenburg  position.  The  bladder  is  then  irrigated  and  moder- 
ately distended  with  fluid  or  with  air,  the  quantity  of  which  will  -s'ary 
according  to  the  condition  of  the  bladder,  and  no  great  force  should  be 
employed  in  its  introduction,  as  a  rupture  might  easily  occur.  Sometimes 
the  bladder  is  so  contracted  that  it  will  hold  only  two  or  three  ounces,  and 
in  other  cases  eight  or  ten  may  be  injected  with  impunity.  The  pressure 
should  never  be  greater  than  that  of  a  column  of  water  six  feet  high,  for ' 


1038 


SUPEAPUBIC  LITHOTOMY. 


rupture  of  tlie  bladder  has  followed  the  lujection.  The  distention  of  the 
bladder  pushes  upward  the  peritoneal  fold  in  front  of  that  organ  (Figs.  816 
and  817),  uncovering  a  space  on  its  anterior  surface  from  one-half  an  inch 
to  an  inch  above  the  pubes,  which  may  be  still  further  increased  by  inserting 


Section  of  male  pelvis,  showing  normal  relations 
of  peritoneum  and  bladder.    (Hunt. ) 


Same,  with  rectum  and  bladder  distended. 
(Hunt.) 


a  rubber  bag,  known  as  Petersen's  balloon,  in  the  rectum,  and  distending  it 
with  water  or  air.  A  maximum  of  exposure  is  obtained  by  injecting  about 
eight  ounces  of  fluid  in  the  bag  and  five  or  six  ounces  in  the  bladder  itself. 
The  rectal  balloon,  however,  has  been  known  to  cause  injury  to  that  organ 
by  over-distention  and  even  rupture,  and  the  introduction  of  Trendelen- 
burg's position  has  led  the  majority  of  surgeons  to  dispense  with  its  use, 
except  in  cases  where  it  is  advisable  to  have  the  base  of  the  bladder  lifted  uiJ 
so  as  to  be  more  accessible.  Some  surgeons  have  even  abandoned  distention 
of  the  bladder,  but  if  the  peritoneum  is  unusually  adherent  to  the  bladder 
owing  to  long-standing  inflammation  of  the  organ,  it  is  difficult  to  detach  it, 
and  the  neglect  of  distention  certainly  adds  to  the  risk  of  the  operation. 

A  median  incision  is  made  upward  from  the  pubic  bone  two  or  three 
inches  in  length.  This  incision  is  deepened  until  the  abdominal  wall  is  cut 
through.  The  index  finger  is  then  passed  into  the  prevesical  space,  keeping 
close  to  the  pubes,  and  all  loose  tissue  in  front  of  the  bladder,  including  the 
peritoneal  fold,  is  drawn  well  upward.  The  peritoneum  is,  as  a  rule,  easily 
seen  and  detached  by  the  finger  until  a  space  of  an  inch  or  more  of  the  ante- 
rior wall  of  the  bladder  lies  exposed  in  the  wound.  With  a  curved  needle 
two  loops  of  strong  silk  are  passed  through  the  bladder  walls  on  each 
side  of  the  median  line,  to  use  as  retractors.  The  bladder  is  then  incised 
between  the  loops,  avoiding  any  conspicuous  veins.  The  incision  should  be 
only  large  enough  to  admit  the  finger  at  first,  aiid  the  finger  should  be 
inserted  at  once,  before  the  contained  fluid  has  escaped.  Exploration 
then  determines  the  presence  of  the  stone  and  the  condition  of  the  blad- 
der, and  if  the  size  of  the  stone  requires  a  larger  wound  the  opening  is 
enlarged  downward  and  forward  with  the  scissors.  If  necessary,  this 
incision  may  be  carried  down  behind  the  pubes  almost  to  the  neck  of  the 
bladder.  Forceps  are  introduced  and  the  stone  is  withdrawn,  and  if  there 
is  any  difficulty  in  removing  it  the  incision  should  be  enlarged  with  the 


SUPRAPUBIC  LITHOTOMY.  1039 

scissors  rather  than  lacerated  by  the  stone  itself.  The  interior  of  the 
bladder  is  thoroughly  irrigated,  and  the  operation  finished  by  inserting  a 
drainage-tube  and  j)ackiug  the  wound,  or  by  suturing  the  wound  in  the 
bladder.  In  the  first  case  a  drainage-tube  half  an  inch  in  diameter,  having 
lateral  oijenings  near  its  lower  end,  or  a  large  rubber  catheter,  is  placed  so 
as  to  reach  to  the  base  of  the  bladder.  The  edges  of  the  bladder  wound  are 
held  together  around  the  tube  by  the  silk  threads  passed  previously,  and 
iodoform  gauze  is  packed  into  the  connective  tissue  between  the  bladder 
and  the  pubes  in  front  and  the  abdominal  M^all  on  both  sides.  A  dressing 
is  applied  around  the  tube,  which  is  connected  with  a  siphon-tube  at  the 
side  of  the  bed.  A  more  powerful  suction  apparatus  can  be  formed  by 
hanging  an  irrigator  above  the  bed  and  connecting  it  with  an  Stube  or 
simply  with  a  rubber-tube  tied  in  a  loop  so  as  to  form  a  sort  of  trap,  from 
which  the  tube  passes  to  the  T-tube,  one  end  of  which  is  connected  with  the 
catheter,  and  so  descends  to  the  vessel  beneath  the  bed.  The  constant  flow 
of  fluid  from  the  irrigator  through  the  S  and  T  tubes  makes  a  suction  .appa- 
ratus on  the  principle  of  the  air-pump,  and  constantly  draws  fluid  from  the 
bladder.  This  method  has,  however,  the  disadvantage  that  the  suction  is 
usually  so  powerful  that  it  draws  the  wall  of  the  bladder  into  the  eye  of  the 
catheter  and  causes  pain  and  interruption  to  the  flow  of  the  urine.  The 
ordinary  siphon  drainage  is  usually  sufQcient. 

Drainage  of  the  bladder  is  the  method  of  choice  when  that  organ  is 
extensively  diseased  or  when  there  is  considerable  hemorrhage  from  its 
interior.  When  the  bladder  is  comparatively  healthy  and  there  is  no 
hemorrhage,  the  wound  may  be  sutured,  and  in  any  case  a  large  wound 
should  be  partially  closed  by  sutures,  leaving  an  opening  only  large  enough 
for  the  drainage-tube.  These  sutures  must  be  of  fine  silk  or  fine  catgut, 
and  should  not  penetrate  the  interior  of  the  organ,  as  they  might  form  the 
nucleus  of  a  calculous  deposit.  The  sutures  are  therefore  passed  in  the 
Lembert  fashion,  bringing  together  the  muscular  layers  of  the  bladder,  but 
not  i^enetrating  the  mucous  membrane,  and  being  placed  about  an  eighth  of 
an  inch  apart.  A  second  tier  of  sutures  is  placed  over  these,  drawing  up 
the  wall  of  the  bladder  in  a  fold  and  covering  in  the  first  tier  completely. 
The  tightness  of  these  sutures  may  be  tested  by  injecting  water.  After  a 
thorough  washing,  a  liglit  packing  is  then  placed  in  the  external  wound, 
unless  it  is  very  large,  when  it  may  be  somewhat  reduced  by  sutures  ;  but  it 
is  unwise  to  suture  it  entirely,  because  suppuration  and  urinary  infiltration 
may  take  place  if  the  sutures  in  the  bladder  should  yield.  Some  surgeons 
leave  a  catheter  in  the  urethra  and  drain  off  the  urine  during  the  healing 
of  the  wound,  others  have  the  urine  drawn  by  catheter  at  regular  intervals, 
and  still  others  allow  the  patient  to  urinate  naturally.  We  prefer  to  retain 
the  catheter  in  the  urethra  for  a  day  or  two,  then  to  permit  natural  urina- 
tion at  frequent  intervals.  In  cases  with  cystitis  a  tube  may  be  inserted  by 
a  perineal  urethrotomy  so  that  the  bladder  may  be  thoroughly  drained. 

The  after-treatment  of  litholapaxy  and  lithotomy  consists  in  rest  in  bed, 
thorough  irrigation  of  the  bladder  two  or  three  times  daily,  light  diet,  and 
diuretics  if  there  is  any  sign  of  nephritis.  It  is  useful  to  administer  urotro- 
j)in  or  salol  to  keep  the  urine  aseptic. 


1040  STONE  IN  THE  FEMALE  BLADDER. 

Choice  of  Operation. — The  choice  of  these  differcBt  methods  of  treat- 
ment depends  upon  the  experience  of  the  surgeon,  the  character  of  the 
stone,  and  the  local  conditions.  Litholapaxy  does  not  confine  the  patient 
to  bed  for  so  long  a  period  as  lithotomy,  but  requires  special  experience  on 
the  part  of  the  surgeon,  and  the  prolonged  operation  is  a  source  of  danger 
to  an  enfeebled  patient,  for  it  often  lasts  two  or  three  hours.  Chismore 
has  sought  to  avoid  these  dangers  by  using  cocaine,  crushing  the  stone 
a  few  times,  removing  whatever  can  be  obtained  by  the  evacuator,  and 
repeating  the  operation  in  a  few  days.  He  does  not  put  his  i^atients  to 
bed.  Litholapaxy  does  not  as  surely  guard  against  a  recurrence  of  the 
stone  as  lithotomy,  for  a  fragment  may  be  left  in  the  bladder,  which  will 
form  the  nucleus  of  another  stone.  It  also  fails  to  provide  direct  drainage 
for  the  inflamed  bladder.  Litholapaxy  should  not  be  attempted  if  the  stone 
is  very  hard  or  large  or  encysted,  or  if  there  is  a  foul  cystitis  which  requires 
drainage,  or  an  enlarged  prostate  which  might  be  treated  by  operation.  A 
well-marked  nephritis  is  also  a  counterindication.  For  all  other  cases  it  is 
probably  the  best  method  if  the  surgeon  has  the  special  skill. 

Lithotomy  is  indicated  in  the  cases  not  suitable  for  litholapaxy,  although 
the  recent  improvements  in  the  suprapubic  operation  bid  fair  to  make  it  the 
rival  of  the  method  by  crushing  in  all  cases.  The  other  operations  are 
now  seldom  employed,  the  median  on  account  of  the  small  size  of  the  open- 
ing, and  the  lateral  on  account  of  the  danger  of  wounding  the  rectum  or 
the  seminal  duct.  The  bladder  can  be  efficiently  drained  by  the  suprapubic 
incision,  but  some  surgeons  prefer  to  add  a  small  perineal  incision  for 
drainage  in  bad  cases.  To  lessen  the  danger  of  urinary  iufiltratiou,  Senn 
advises  doing  the  suprapubic  section  in  two  stages,  exposing  the  bladder  at 
a  preliminary  operation,  packing  the  wound,  and  incising  the  bladder  sev- 
eral days  later,  when  the  external  wound  is  granulating. 

Stone  in  the  Female  Bladder. — In  the  female  small  stones  may  be 
removed  by  dilatation  of  the  urethra  with  the  finger,  an  enlargement  of  that 
canal  sufficient  to  admit  the  forefinger  being  possible  without  permanent 
l^aralysis.  Larger  stones  must  be  removed  bj^  litholapaxj^  or  incision.  The 
crushing  operation  is  usually  easy,  because  the  stone  can  often  be  directed 
into  the  grasp  of  the  instrument  by  the  finger  introduced  into  the  vagina, 
and  the  wide,  short  urethra  allows  very  large  and  powerful  instruments  to 
be  employed.  It  will  often  be  necessary  to  compress  the  lu-ethra  around 
the  instruments  in  order  to  retain  the  fluid  in  the  bladder.  Cystotomy  may 
be  either  vaginal  or  suprapubic.  The  vaginal  incision  is  made  in  the 
median  line  upon  a  sound  introduced  into  the  bladder,  the  beak  of  the 
sound  being  turned  downward  as  soon  as  it  passes  into  the  neck  of  the 
bladder,  and  an  incision  made  upon  it  through  the  vaginal  wall.  The 
opening  may  be  closed  at  once  by  sutures  when  the  calculus  has  been 
removed,  inserted  as  in  an  operation  for  vesicovaginal  fistula,  and  primary 
union  is  generally  obtained.  A  suprapubic  operation  will  seldom  be  neces- 
sary in  the  female,  except  for  a  very  large  stone  or  in  young  children,  and 
it  is  performed  in  the  same  manner  as  in  the  male. 

Tumors  of  the  Bladder.— Various  tumors  grow  in  the  bladder,  the 
most  common  being  the  papillomata  and  the  malignant  neoplasms,  especially 


TUMORS  OF  THE   BLADDER.  1041 

carcinoma.  The  villous  or  dendritic  form  of  papilloma  consists  of  masses 
of  slender  long  papillse,  sometimes  two  or  three  inches  in  length,  each  con- 
taining a  blood-vessel  covered  by  a  single  layer  of  epithelium  and  floating 
free  in  the  m-ine.  In  the  fibrous  form  the  papillae  have  a  solid  fibrous 
stroma,  and  are  thicker  and  shorter.  A  myxomatous  variety  has  also  been 
observed.  The  base  of  the  papilloma  is  occasionally  quite  thick  and  fibrous, 
and  a  carcinomatous  change  not  infrequently  takes  place  in  this  part.  Pri- 
mary carcinoma  of  the  bladder  may  be  epithelioma  or  glandular  carcinoma. 
It  often  develops  at  the  base  of  a  papilloma,  but  may  originate  indepen- 
dently in  the  form  of  a  superficial  ulcer  which  gradually  eats  into  the  wall, 
where  the  neoplasm  may  form  masses  of  considerable  size  beneath  the  base 
of  the  ulcer.  The  bladder  is  more  frequently  involved  by  carcinoma  of 
neighboring  organs.  Sarcoma  develops  in  the  thickness  of  the  vesical  wall, 
and  is  at  first  covered  with  normal  mucous  membrane,  but  the  latter  after- 
wards ulcerates,  and  the  tumors  are  then  difficult  to  distinguish  from  car- 
cinoma, although  they  are  not  usually  so  hard  to  the  touch. 

Symptoms. — The  symptoms  of  tumor  of  the  bladder  are  nearly  the 
same  whatever  its  nature.  They  consist  in  frequent  micturition,  bloody 
urine,  and,  if  infection  takes  place,  a  cystitis  of  a  peculiarly  intense  and 
obstinate  type.  The  micturition  in  these  cases  is  usually  free  unless  the 
growth  is  at  the  neck  of  the  bladder  and  plugs  the  orifice.  The  frequency 
is  greatest  in  the  daytime,  and  ceases  to  trouble  the  patient  at  night,  thus 
differing  from  that  due  to  prostatic  obstruction.  Bright  blood  is  passed, 
and  usually  follows  at  the  end  of  micturition,  being  squeezed  from  the  tumor 
by  the  final  contraction.  It  may,  however,  be  equally  diffused  in  the  urine, 
and  clots  are  sometimes  found.  There  may  be  long  intervals  without  hsema- 
turia.  The  patient  becomes  exhausted  by  the  disturbance  of  his  rest  and 
by  the  loss  of  blood,  and  is  usually  very  anaemic.  Pain  is  an  uncertain  and 
late  symptom.  If  infection  is  set  up  by  septic  instruments  there  is  likely 
to  be  some  elevation  of  temperature  from  the  sloughing  masses  of  the  tumor. 
Fragments  of  the  tumor  are  occasionally  passed,  especially  after  an  exami- 
nation by  the  sound.  In  rare  instances  long  papillomatous  growths  or  poly- 
poid excrescences  from  a  carcinoma  have  extended  down  the  urethra,  and 
even  appeared  at  the  meatus.  In  such  cases  there  is  considerable  obstruc- 
tion to  the  passage  of  the  urine  and  to  the  introduction  of  instruments. 

Diagnosis. — The  diagnosis  of  tumor  of  the  bladder  is  made  by  excluding 
the  presence  of  stone  by  examination  with  the  searcher,  and  the  searcher 
may  in  some  cases  detect  a  projecting  mass  upon  the  side  of  the  bladder  or 
between  the  instrument  in  the  bladder  and  the  finger  in  the  rectum.  In 
advanced  cases  of  malignant  disease  rectal  examination  will  show  infiltration 
of  the  barSe  of  the  bladder  and  siirrounding  parts  ;  in  women  digital  exami- 
nation can  be  made  through  the  dilated  urethra.  A  parasite  known  as 
Distoma  haematobium,  which  is  found  in  certain  countries,  such  as  Egypt, 
and  Southern  Africa,  becomes  lodged  in  the  renal  vessels  and  discharges  its 
eggs  into  the  kidney,  whence  they  make  their  way  downward  into  the  blad- 
der and  cause  ii-ritation  of  that  organ  and  patches  of  indurated  granulations 
resembling  sarcoma,  which  bleed  very  freely.  The  symptoms  resemble  those 
of  cystitis  or  tumor.     This  condition  is  exceedingly  diificult  to  distinguish 


1042  CYSTOSCOPY. 

from  a  tumor  of  the  bladder,  although  the  eggs  may  be  found  in  the  urine  ; 
but  the  disease  is  very  rare  in  this  country,  being  found  onlj'  in  those  -who 
have  lived  -where  it  is  endemic.  The  use  of  the  cystoscope  will,  as  a  rule, 
enable  the  surgeon  to  determine  not  only  the  presence  of  a  tumor,  but  its 
size,  and  this  examination  should  never  be  omitted,  although  it  is  unsatis- 
factory if  there  is  much  bleeding.  In  cases  of  doubt  an  exploratory  supra- 
pubic incision  should  be  made  through  the  perineum  or  above  the  pubes. 

Prognosis. — The  prognosis  of  tumors  of  the  bladder  is  bad,  as  even  the 
benign  growths  cause  death  by  the  severe  hemorrhage,  although  they  may 
have  a  very  slow  course.  The  hsematuria  and  necessary  instrumentation 
are  likely  to  result  in  cystitis  and  pyelitis.  Malignant  tumors  produce 
death  in  from  eighteen  months  to  three  years  after  the  first  symxjtoms.  The 
papillomata  can  be  cured  by  operation,  but  not  the  malignant  tumors, 
because  the  diagnosis  of  the  latter  can  seldom  be  made  sufficiently  early. 

Treatment. — Operation  is  the  only  possible  treatment  for  these  tumors, 
and  suprapubic  cystotomy  is  the  best  method  of  reaching  them.  The 
patient  should  be  prepared  for  operation  as  usual,  the  rectal  balloon 
inserted  and  the  bladder  distended  and  oi^eued  by  the  suprapubic  incision. 
The  tumor  can  then  be  thoroughly  examined  with  the  finger  and  the  eye, 
and  removed  at  once  if  removal  is  possible.  Papillomatous  growths  may 
be  removed  and  the  base  thoroughly  destroyed  with  the  curette,  thermo- 
cautery, or  curved  scissors.  Other  tumore  may  be  excised,  provided  that 
they  are  not  so  extensive  as  to  render  all  attempts  at  a  radical  cure  hopeless. 
Large  portions  of  the  wall  of  the  bladder  have  been  successfullj"  removed. 
When  the  tumor  cannot  be  removed,  the  wound  should  be  left  open  for 
drainage,  and  the  patient's  sufferings  are  greatly  relieved  by  this  treatment, 
although  it  involves  some  danger  of  infection  resulting  in  cystitis  or  pyelitis. 
Hemorrhage  fi'om  the  interior  of  the  bladder  can  be  controlled  bj'  a  gauze 
tampon,  but  the  pressure  of  the  gauze,  and  especially  its  removal,  is  apt  to 
be  painful,  and  packing  should  be  avoided  if  possible.  In  any  case  the 
bladder  should  be  drained  through  the  wound,  the  urethra,  or  a  small 
perineal  incision  made  for  the  purpose. 

Cystoscopy. — Cystoscopy  is  the  examination  of  the  bladder  with  the 
eye  by  instruments  introduced  through  the  urethra.  It  is  most  easily 
accomplished  in  the  female  by  means  of  KeUy^s  method.  This  consists  in 
dilatation  of  the  urethra  to  a  diameter  of  twelve  to  fifteen  millimetres  and 
the  introduction  of  short  cylindrical  specula,  the  patient  being  placed  in 
the  lithotomy  position  with  extreme  elevation  of  the  pelvis.  The  contents 
of  the  abdomen  then  fall  away  from  the  pelvis  and  air  enters  the  bladder 
by  the  speculum,  fully  distending  that  organ.  The  urine  is  withdrawn  by 
a  tube  with  a  suction  bulb,  and  then  the  greater  part  of  the  interior  of  the 
bladder  can  be  illuminated  by  a  forehead  mirror.  Suitable  specula  can 
also  be  obtained  with  an  incandescent  electric  light  at  the  end  which  gives 
a  perfect  illumination.  The  mouths  of  the  ureters  can  be  seen  and  bougies 
or  catheters  readily  inserted  for  exploration  or  to  collect  the  urine.  General 
anesthesia  is  advisable.  In  some  cases  it  may  be  necessary  to  put  the 
patient  in  the  knee-chest  position. 

The  Mtze-Leiter  cystoscope  can  be  used  in  either  sex,  and  consists  of  a 


NEUROSES  OF  THE  BLADDER.  1043 

hollow  tube  bent  at  an  obtuse  angle  at  the  end,  forming  a  short  beak.  At 
the  point  of  the  instrument  is  fixed  a  small  incandescent  electric  light,  the 
wires  of  which  run  through  the  shaft  of  the  instrument,  and  at  the  angle 
is  situated  a  glass  prism  which  receives  the  rays  of  light  coming  fi-om  the 
illuminated  bladder  and  reflects  them  up  the  shaft  of  the  instrument  to 
pass  through  a  system  of  lenses  which  admit  of  accurate  focussing.  The 
bladder  is  filled  with  sterilized  normal  salt  solution,  the  instrument  lubri- 
cated with  glycerin  and  introduced,  the  current  turned  on,  and  the  observer 
then  studies  the  interior  of  the  bladder  through  the  lenses.  If  there  is  much 
bleeding  from  the  interior  of  the  bladder  the  period  of  observation  will  be 
short,  as  the  instrument  must  ,be  withdrawn  and  the  bladder  washed  out. 
A  similar  instrument  has  been  invented  by  Caspar,  which  contains  a  groove 
on  one  side  of  the  shaft  through  which  a  fine  bougie  can  be  passed,  the 
end  of  which  turns  up  at  the  beak  of  the  instrument  into  the  field  of  vision. 
The  mouth  of  the  ureter  can  be  found  by  the  surgeon,  and  the  bougie  then 
projected  into  the  field  of  vision  and  guided  directly  into  the  opening.  It 
can  then  be  detached  from  the  shaft  of  the  instrument  and  passed  as  far  as 
necessary  into  the  ureter,  and  the  m-ine  from  the  kidney  of  that  side  col- 
lected for  examination.  Even  without  this  instrument  the  cystoscope  gives 
valuable  information  as  to  the  C|uantity  of  urine  passed  relatively  by  the  two 
kidneys,  and  also  whether  it  contains  pus  or  blood,  as  the  urine  can  be  seen 
flowing  from  the  ureter.  A  straight  oi)en  tube  without  lenses,  with  an 
electric  light  on  the  end,  can  also  be  used  for  catheterization  of  the  male 
ureter. 

Neuroses. — The  cases  formerly  considered  neuralgia  of  the  bladder 
ha^'e  been  gradually  distributed  under  the  different  lesions  which  cause  the 
pain  as  our  means  of  diagnosis  have  improved,  and  the  affection  is  no  longer 
recognized  as  an  independent  disease  except  in  rare  cases. 

Spasm  may  occur  either  in  the  detrusor  or  in  the  sphincter  muscles,  and 
occasionally  in  both  at  once.  Spasm  of  the  muscles  of  the  vesical  wall  is 
usually  known  as  tenesmus,  and  is  the  result  of  intense  irritation  of  the 
mucous  membrane  by  inflammation,  bj-  the  presence  of  a  calculus,  a  foreign 
body,  or  a  parasite,  or  by  certain  drugs,  such  as  cantharides.  The  patient 
is  constantly  passing  small  cxuantities  of  water,  and  the  bladder  is  kept 
empty,  unless  spasmodic  contraction  of  the  sphincter  is  also  present,  when 
there  may  be  retention.  There  is  great  i^ain  in  the  pelvis  running  down 
to  the  glans  penis.  Spasm  of  the  sphincter  alone  is  marked  by  retention  of 
urine,  and  the  contraction  may  be  so  close  as  to  prevent  the  introduction 
of  a  filiform  bougie.  Pain  is  present  only  when  efforts  are  made  to  evacuate 
the  bladder.  Treatment  consists  in  thorough  stretching  of  the  sphincter 
by  the  passage  of  large  sounds,  but  the  cause  of  the  spasm  shoiild  be  first 
sought  for  and  removed.  Opiates  are  useful  for  tenesmi;s,  especially  a  sup- 
pository of  opium  and  belladonna,  aa  gr.  ss  to  gr.  i. 

Paralysis  may  attack  either  the  detrusor  or  the  sphincter,  paralysis  of 
the  former  resulting  in  retention  and  paralysis  of  the  latter  in  incontinence 
of  urine.  Both  muscles  may  also  be  involved  at  once,  the  abdominal  press- 
ure then  causing  the  urine  to  dribble  away.  Paralytic  retention  is  found  in 
injuries  and  diseases  of  the  spinal  cord  at  any  point,  and  paralytic  incon- 


1044  FUNCTIONAL  DISTURBANCES   OF  MICTURITION. 

tinence  only  when  the  lower  lumbar  region  is  involved.  The  former  may 
also  be  the  result  of  voluntary  over-distention  from  enforced  holding  of  the 
urine  and  of  long-continued  over-distention  due  to  mechanical  obstruction. 
Muscular  power  always  returns  after  a  few  catheterizations  in  the  first  case, 
and  sometimes  in  the  second.  Sphincteric  paralysis  may  be  the  result  of  an 
examination  by  the  finger  or  by  instruments,  especially  in  the  female.  The 
sphincter  may  also  be  congenitally  deficient.  Treatment  consists  in  the 
removal  of  the  cause  of  paralysis,  and  the  use  of  the  catheter  for  retention. 
Electricity  may  be  applied  locally  and  to  the  lumbar  plexus  in  order  to 
restore  power  to  the  sphincter.  Esi^ecial  pains  must  be  taken  in  maintain- 
ing asepsis  in  all  instrumentation  during  jjaralytic  retention,  as  the  danger 
of  infection  is  much  greater  than  in  the  normal  bladder.  Paralytic  incon- 
tinence demands  the  wearing  of  a  urinal  when  the  patient  is  up,  and  careful 
nursing  to  keep  him  dry  when  in  bed. 

Functional  Disturbances  of  Micturition. — These  are  exceedingly 
common,  and  are  usually  the  result  of  disturbed  mental  states  in  nervous 
individuals.  Retention  and  irritability  of  the  bladder,  the  latter  sometimes 
amounting  to  complete  incontinence,  are  both  caused  by  hysteria,  or  by 
emotional  disturbances,  such  as  fright  or  anxiety,  and  are  also  seen  after 
certain  operations  about  the  pelvis,  especially  those  for  hemorrhoids.  The 
fact  that  many  persons  are  unable  to  pass  water  while  lying  down  or  in  the 
presence  of  others  is  well  known.  Sometimes  there  appears  to  be  a  lack  of 
co-ordination  between  the  detrusor  and  sphincter  muscles,  resulting  in  a 
feeble  or  intermittent  stream, — a  condition  well  named  "stammering  of  the 
bladder."  Treatment. — IN'ervous  retention  can  sometimes  be  overcome  by 
mental  effort,  by  distracting  the  attention,  by  placing  cold  or  wet  cloths  on 
the  wrist  or  abdomen,  or  by  making  water  run  noisily  from  a  faucet  near 
by.     The  catheter  will  often  be  necessary. 

Enuresis. — In  children  the  urine  is  often  passed  during  sleep,  and  this 
is  sometimes  observed  in  adults  who  are  epileptic,  or  during  anaesthesia,  the 
cause  being  the  suspension  of  sensation  which  should  awaken  the  voluntary 
contraction  of  the  sphincter  when  the  urine  begins  to  enter  the  urethra.  A 
careful  examination  should  be  made  of  the  genitals  and  bladder  and  of  the 
urine,  as  the  incontinence  may  be  a  symptom  of  vesical  calculus  or  other 
disease,  or  may  be  caused  by  a  long  foreskin  or  a  narrow  meatus.  Treat- 
ment.— Nocturnal  incontinence,  or  rather  enuresis,  in  children  may  be  cured 
by  circumcision.  Education  may  correct  the  habit,  but  punishment  does 
harm.  It  is  well  to  make  the  child  sleep  on  its  side,  with  light  covering, 
in  a  cool  room,  and  not  immediately  after  a  heavy  meal.  Good  results  have 
been  claimed  for  elevation  of  the  foot  of  the  bed,  on  the  theory  that  it 
removes  some  of  the  weight  of  the  urine  from  the  neck  of  the  bladder.  An 
old-established  method  sometimes  useful  is  the  administration  of  belladonna 
to  the  limit  of  tolerance. 

IN.JUEIES  AND  SURGICAL  DISEASES  OF  THE  KIDNEY. 

Injuries. — The  kidney  may  be  lacerated  and  its  capsule  ruptured  by  a 
severe  contusion  of  the  abdomen  or  loins,  or  it  may  be  wounded  by  pene- 
trating objects,  as  in  stab  or  gunshot  wounds.     Slight  contusions  cause  pain 


FLOATING  AND  MOVABLE  KIDNEY.  1045 

and  local  tenderness,  and  sometimes  a  transient  ha5maturia.  Severer  inju- 
ries cause  marked  htematuria,  sometimes  with  attacks  of  renal  colic  from 
blocking  of  the  ureter  by  clots.  "When  the  capsule  is  ruptured  the  uriuc- 
may  escajje  and  cause  iieriuephritic  abscesses  or  peritonitis,  according  to  the 
situation  of  the  rupture,  but  the  signs  of  urinary  extravasation  and  inflam- 
mation do  not  usually  appear  for  three  or  four  days.  Penetrating  wounds 
are  followed  by  free  hemorrhage,  and  later  by  an  escape  of  urine,  and, 
unless  the  wound  be  a  very  open  one,  urinary  extravasation  and  inflamma- 
tion of  the  surrounding  tissues  will  occur.  Injury  to  one  kidney  may  arrest 
the  secretion  of  the  other  by  reflex  action,  and  comjilete  anuria  is  seen  in 
rare  cases.  Treatment. — The  slight  Injuries  require  rest  in  bed,  and  wash- 
ing out  of  the  bladder  if  there  is  a  tendency  for  clots  to  accumulate  in  it. 
If  there  is  severe  hemorrhage,  the  kidney  should  be  exposed  and  the  lacera- 
tion closed  by  sutures  or  packed  with  gauze  in  order  to  arrest  it,  or,  if  this 
is  impracticable,  the  organ  should  be  removed.  Nephrectomy  is  also  indi- 
cated when  the  kidney  is  severely  crushed  or  lacerated,  and  especially  if 
there  is  a  liability  of  peritonitis  from  an  anterior  rent  in  the  capsule.  The 
most  dangerous  cases  are  those  with  internal  hemorrhage  and  extravasation 
of  urine,  without  much  bleeding  into  the  bladder.  Urinary  infiltration  and 
abscess  should  be  treated  by  free  incision,  and  small  punctured  wounds 
should  be  sufficiently  enlarged  to  afford  good  drainage.  Secondary  hemor- 
rhage is  very  common  after  renal  injuries. 

Anomalies. — One  kidney  may  be  very  small  and  atrophied,  or  even 
entirely  absent.  In  some  cases  there  is  but  a  single  kidney,  which  occupies 
the  middle  line,  and  is  made  up  of  the  two  kidneys,  more  or  less  fused 
together  or  connected  by  a  transverse  bar  of  kidney-substance,  and  often 
assuming  the  shape  of  a  horseshoe.  The  single  kidney  is  always  large.  It 
is  frequently  diseased,  so  that  this  anomaly  is  more  common  in  statistics 
embracing  only  persons  with  disease  of  the  kidney  than  in  those  based  on 
the  general  population. 

Floating  and  Movable  Kidney. — Anomalies  in  the  position  of  the 
kidney  are  exceedingly  frequent,  and  they  are  nearly  all  brought  about  by 
relaxation  of  the  peritoneal  ligaments  which  hold  the  organ  in  place,  and 
which  may  become  so  lax  as  to  form  a  mesouephron  and  allow  the  kidney  to 
move  to  all  parts  of  the  abdomen,  for  the  kidney  has  been  found  in  the  pelvis 
and  even  in  an  inguinal  hernial  sac.  The  term  floating  kidney  is  reserved 
for  cases  in  which  there  is  a  true  mesouephron,  those  in  which  the  kidney 
has  only  abnormal  mobility  behind  the  j)eritoueum  being  called  movable 
kidney.  A  true  floating  kidney  is  a  congenital  abnormality.  Descent  of 
the  kidney  is  favored  by  absorption  of  fat  in  stout  persons,  and  may  follow 
severe  muscular  efi'orts,  such  as  lifting  heavy  weights.  The  displacement  is 
five  times  more  common  in  women  than  in  men,  perhaps  on  account  of  the 
abdominal  changes  caused  by  pregnancy,  and  it  is  very  much  more  fretpient 
on  the  right  side.  In  estimating  the  amount  of  displacement  it  should  be 
noted  that  the  right  kidney  naturally  lies  a  little  lower  than  the  left,  owing 
to  the  bulk  of  the  li\'er,  and  that  in  patients  with  a  relaxed  abdomen  the 
lower  end  of  the  normal  kidney  can  be  felt  for  about  oue-thii-d  of  its  long 
diameter.  If  the  entire  kidney  can  be  palpated,  it  may  usually  be  consid- 
er 


1046  INFLAMMATIONS   OF  THE  KIDNEY. 

ered  pathologically  movable.  The  kidney  Is  more  easily  palpated  in  persons 
with  a  long  and  narrow  thorax  than  in  those  of  stouter  build.  To  feel  the 
kidney,  place  the  patient  reclining  in  a  half-sitting  position,  with  the  head 
supported  so  as  to  relax  the  abdominal  muscles. 

Symptoms. — The  symi^toms  are  by  no  means  proportionate  to  the 
amount  of  mobility.  A  congenital  floating  kidney  may  be  discovered  acci- 
dentally in  any  part  of  the  abdomen,  having  never  given  rise  to  any  evil 
effects.  On  the  other  hand,  even  a  slight  displacement  of  the  kidney, 
amounting  to  only  one-half  its  long  diameter,  may  cause  very  characteristic 
symptoms,  because  the  ligaments  drag  upon  the  duodenum.  These  symp- 
toms are  nausea,  a  tendency  to  vomiting,  and  distress  in  the  stomach,  with 
some  nervous  disturbance,  and  occasionally  pain  in  the  back  and  weakness 
on  exertion.  The  stomach  may  be  dilated.  A  floating  kidney  may  cause 
various  symptoms  by  interfering  with  the  function  of  other  organs  by  its 
pressure,  especially  if  it  descends  into  the  pelvis.  If  the  pedicle  becomes 
twisted,  the  ureter  will  be  compressed  and  the  flow  of  urine  interruj^ted,  the 
retention  of  the  latter  being  indicated  by  severe  pain  on  that  side,  the  tumor 
formed  by  the  distended  kidney,  and  a  diminished  quantity  of  urine.  There 
may  be  distention  of  the  intestine  in  the  neighborhood  of  the  affected  kidney. 
The  attack  usually  f)asses  oif  if  the  kidney  is  pushed  back  in  place  and  the 
patient  kept  in  bed.  The  diagnosis  between  these  attacks  and  impaction  of 
gall-stones  with  dilated  gall-bladder  may  be  very  difficult.  A  floating  kid- 
ney is  subject  to  all  the  diseases  of  the  normal  kidney,  and,  owing  to  the 
tendency  of  its  displacement  to  disturb  the  circulation  and  the  escape  of 
urine,  the  symptoms  are  often  more  sev^ere. 

Treatment. — The  treatment  of  a  movable  kidney  consists  in  the  first 
place  in  the  ajDplication  of  a  broad  binder,  and  a  "  straight-front"  corset  will 
assist.  Before  the  bandage  is  applied  it  is  well  to  have  the  patient  remain 
in  bed  on  his  back  for  some  days,  in  order  to  allow  the  kidney  to  settle  back 
into  its  proper  position.  If  this  treatment  fails,  the  operation  of  nephror- 
rhaphy  may  be  performed. 

Inflammations. — Nephritis  is  of  great  imi^ortance  as  affecting  the 
prognosis  of  any  surgical  condition,  especially  the  suppurative  form.  It 
has  been  observed  that  advanced  nou-suppurative  chronic  nephritis  can  be 
improved  or  even  cured  by  exposing  the  kidney,  and  dividing  and  stripping 
back  its  capsule,  and  this  treatment  is  now  being  given  a  systematic  trial. 
When  inflammation  attacks  the  glandular  portion  of  the  organ  it  is  called 
nephritis,  and  when  it  is  confined  to  the  pelvis  it  is  termed  pyelitis.  Pyo- 
nephrosis is  a  suppurative  inflammation  of  the  pelvis  of  the  kidney  with 
blocking  of  the  ureter,  converting  the  kidney  into  a  pus-sac.  Pyonephrosis 
may  result  from  infection  of  a  hydronephrosis. 

Suppurative  Nephritis. — Suppurative  inflammation  of  the  kidney 
may  be  caused  by  infection,  which  travels  up  the  ureter  from  the  bladder, 
or  may  reach  the  organ  by  way  of  the  blood-vessels.  Bacteria  are  excreted 
by  the  kidney  with  the  urine,  and,  as  we  have  already  seen,  may  occasion- 
ally be  thrown  out  without  damage  to  the  organ,  but  usually  thej^  form  foci 
of  infection.  The  ordinary  pyajmic  embolism  may  occur  in  the  kidney  and 
result  in  multiple  metastatic  abscesses.     The  kidney  may  also  be  attacked 


PYELITIS.  1047 

by  gonorrlKieal  infection  ascending  through  the  bladder.  Tuberculous  infec- 
tion may  take  place  by  the  same  route  or  through  the  blood-vessels.  Meta- 
static abscesses  of  the  kidney  are  usually  multiijle,  of  small  size,  and  occur 
in  both  kidneys,  so  that  they  are  not  generally  amenable  to  treatment. 
Metastatic  abscesses  are  occasionally  single  or  few  in  number,  and  limited 
to  one  kidney.  They  may  result  in  pyonephrosis.  An  abscess  of  the  kid- 
ney may  penetrate  into  the  pelvis  of  the  organ  and  discharge  through  the 
ureter,  it  maj'  rupture  into  the  cellular  tissue  around  it,  or  it  may  perforate 
the  peritoneum  and  give  rise  to  peritonitis. 

Symptoms. — The  symptoms  of  renal  suppuration  will  depend  upon  the 
cause  of  the  inflammation.  When  there  is  a  renal  calculus  some  pyogenic 
infection  must  take  place  in  order  to  produce  the  suppuration.  In  such 
cases  there  will  be  the  previous  symptoms  of  stone,  such  as  hematuria  and 
pain  in  the  kidney,  increased  by  motion,  and  to  them  will  be  added  the 
signs  of  acute  inflammation,  such  as  fever,  with  possibly  a  chill  and  the 
appearance  of  pus  in  the  urine.  The  metastatic  abscesses  usually  run  a 
course  without  symptoms  excei^t  an  irregular  elevation  of  temperature  and 
possibly  a  chill  occurring  with  the  development  of  a  fresh  pyemic  focus. 
The  local  symi3toms  of  suppuration  in  the  kidney  are  pain  in  the  loins  and 
tenderness  over  the  affected  organ,  which  is  easily  detected  by  passing  the 
hand  under  the  loin  as  the  patient  lies  upon  the  back  and  giving  a  sharp 
upward  movement  with  the  fingers.  The  organ  may  be  enlarged  percep- 
tibly, but  this  is  more  likely  to  be  the  case  in  pyonephrosis  than  in  abscess 
of  the  kidney-substance.  The  urine  will  be  diminished  in  quantity,  will 
have  a  high  specific  gravity,  and  will  sometimes  contain  albumin  in  con- 
siderable quantities.  There  are  usually  no  casts,  but  pus  or  blood  will 
appear  if  the  abscess  has  penetrated  the  pelvis.  The  general  symptoms 
of  the  condition  are  fever,  with  or  without  a  chill,  and  urtemic  symptoms. 
The  suppuration  may  follow  a  cystitis,  whether  pyogenic  or  gonorrhceal  in 
origin,  aud  is  frec^uent  from  infection  after  operations  on  the  urinary  organs, 
whence  the  name  surgical  kidney  given  to  the  condition. 

Pyelitis. — Pyelitis  is  an  inflammation  limited  to  the  pelvis  of  the  kid- 
ney, shown  by  desquamation  of  its  epithelial  lining,  the  peculiar  caudate 
cells  appeai'ing  in  the  urine,  sometimes  arranged  in  layers,  accompanied  by 
conical  plugs  of  pus-cells  discharged  from  the  mouths  of  the  urinary  tubules. 
When  infection  of  the  kidney  takes  place  from  below,  pyelitis  will  gen- 
erally precede  suppuration  in  the  kidney-substance,  and  is,  indeed,  the 
lesion  usually  known  under  the  name  of  surgical  kidney.  In  the  acute 
form  of  pyelitis  the  symptoms  are  similar  to  those  described  above.  In 
the  chronic  form  there  may  be  little  sign  of  the  disease  except  in  the  urine, 
which  is  acid  and  contains  large  amounts  of  albumin  with  the  character- 
istic epithelium  of  the  pelvis  and  the  groups  of  pus-cells  just  described, 
but  without  casts.  In  many  cases,  however,  the  epithelium  has  not  the 
characteristic  caudate  api^earauce,  and  there  is  also  danger  of  mistaking 
kite-shaped  epithelium  from  the  deeper  layers  of  the  bladder  for  the  pelvic 
cells.  The  general  disturbance  set  up  by  chronic  i^yelitis  is  usually  slight, 
although  there  may  be  a  little  hectic  fever,  and  auajmia  is  marked.  The 
inflammation  may  or  may  not  be  accompanied  by  pain  or  tenderness. 


1048  PYONEPHROSIS. 

Pyonephrosis. — By  pyoneplirosis  is  meant  a  condition  of  distention  of 
the  pelvis  and  of  the  kidney,  which  may  be  converted  into  a  thin  sac  filled 
with  pus.  It  occurs  in  suppurative  inflammation  when  there  is  obstruction 
of  the  ureter.  The  symptoms  do  not  differ  from  those  of  pyelitis,  as 
pyonephrosis  is  often  an  advanced  stage  of  that  affection,  but  the  kidney 
forms  a  large  tumor.  The  obstruction  to  the  ureter  may  be  complete, 
partial,  or  intermittent.  In  the  first  case  no  urine  from  the  diseased 
kidney  can  enter  the  bladder,  and  if  that  organ  and  the  other  kidney  be 
healthy  the  urine  will  be  normal.  In  the  majority  of  cases  the  obstruction 
is  not  complete,  and  some  purulent  urine  is  discharged.  Sometimes  the 
obstruction  is  intermittent,  and  if  the  other  kidney  be  healthy  there  will  be 
alternating  periods  of  clear  and  cloudy  urine,  according  as  the  secretion  of 
the  diseased  organ  is  shut  off  or  discharged  into  the  bladder.  The  prognosis 
of  abscess  of  the  kidney  is  very  bad,  as  is  also  that  of  suppurative  pyelitis 
originating  from  an  abscess  of  the  kidney  or  from  an  ascending  infection. 

Treatment. — In  a  simple  pyelitis  of  a  catarrhal  or  mildly  suppurative 
type  it  will  probably  be  sufficient  to  remove  the  cause,  such  as  a  calculus  in 
the  pelvis  or  a  suppurative  condition  of  the  bladder.  Prophylaxis  is  most 
important,  and  is  to  be  effected  by  observing  strict  asepsis  in  all  operative 
measures  upon  the  bladder,  including  the  ordinary  use  of  the  catheter,  and 
by  instituting  irrigation  of  that  organ  at  the  first  indication  of  renal  diffi- 
culty, such  as  a  rise  of  temperature  or  local  tenderness.  Catheterization  of 
the  ureters  in  the  female  is  easily  performed  by  Kelly's  method,  and  it  is 
possible  to  treat  cases  of  mild  pyelitis  by  introducing  the  catheter  into  the 
pelvis  of  the  kidney  and  irrigating  that  cavity.  This  has  already  been  done 
successfully  through  a  vesico- vaginal  fistula,  and  in  the  male  with  the  aid  of 
the  cystoscope.  But  if  immediate  improvement  is  not  obtained  these  con- 
servative efforts  must  not  be  allowed  to  delay  the  more  effective  operative 
treatment.  When  suppuration  has  begun  as  a  pyelitis  and  extended  to  the 
kidney-tissue,  or  a  ijyonephrosis  has  formed,  the  suppurating  cavity  may 
be  drained  by  an  external  incision  or  nephrotomy,  the  incision  being  made 
through  the  substance  of  the  kidney,  and  not  through  the  pelvis,  in  order  to 
give  it  the  best  opportunity  to  contract  later.  The  incision  should  be 
extensive,  and  some  surgeons  split  the  kidney  in  half.  These  cases,  how- 
ever, often  result  in  a  permanent  fistula,  which  is  a  source  of  annoyance  and 
danger  to  the  patient,  and  therefore  nephrectomy  is  preferable  when  the 
other  kidney  is  sound.  Drainage  is  particularly  suitable  for  those  cases  in 
which  the  kidney-substance  is  not  disorganized,  but  merely  distended 
around  the  pelvis  containing  the  pus.  Even  when  the  kidney  is  completely 
disorganized  it  should  not  be  removed  if  the  patient  is  in  bad  condition  or 
if  the  pyonephrosis  is  verj-  large  and  adherent  to  the  surrounding  parts  so 
that  the  operation  will  present  unusual  difficulty.  Nephrotomy,  followed 
by  nephrectomy  when  the  patient  has  recovered  his  strength,  is  the  safer 
procedure  in  such  cases.  Abscesses  which  have  formed  in  the  kidney-tissue 
may  be  treated  by  nephrotomy  and  drainage,  if  it  is  jjossible  to  make  a 
diagnosis  before  the  pelvis  is  involved  ;  after  that  time  they  must  be  treated 
on  the  same  principles  as  jDyonephi-osis  of  ordinary  origin.  In  metastatic 
suppuration  of  the  kidney  it  is  often  impossible  to  relieve  the  patient  by 


PERINEPHRITIS.  1049 

surgical  means,  but  we  have  obtained  a  cure  in  one  case  by  nephrotojny 
and  drainage.  Eecovery  has  even  followed  double  nephrotomy  when  both 
kidneys  contained  metastatic  abscesses. 

Perinephritis. — Suppurative  perinephritis  is  a  purulent  inflammation 
of  the  cellular  tissue  about  the  kidney  and  of  the  fatty  capsule.  It  may 
originate  from  inflammation  of  the  organ  extending  outward,  from  the 
rupture  of  a  renal  abscess,  or  from  secondary  infection  of  a  blood-clot 
surrounding  the  kidney  which  has  been  produced  by  some  injury  of  the 
organ.  In  the  traumatic  cases  the  infection  is  usually  derived  from  the 
kidney  itself.  Bacteria  are  commonly  found  in  the  kidney  (whether  elim- 
inated by  that  organ  or  not),  and  it  is  believed  that  they  can  penetrate  the 
capsule  and  cause  perinephritis  in  cases  in  which  the  kidney  itself  remains 
healthy.  The  perinephritis  may  also  be  the  result  of  other  inflammatory 
processes  in  that  neighborhood,  originating  in  the  bones  or  from  perforating 
ulcer  of  the  stomach  or  appendicitis.  Perinephritic  abscess  may  extend 
upward,  traversing  the  diaphragm  either  by  perforation  or  by  infection  of 
its  lymphatic  channels,  and  causing  an  empyema  or  even  perforating  the 
lung.  It  may  also  perforate  the  intestines  or  the  stomach,  and  much  more 
rarely  does  it  burst  into  the  pelvis  of  the  kidney  itself.  The  abscess 
frequently  descends  by  gravity  behind  the  peritoneum,  and  it  may  discharge 
in  the  groin  or  low  down  on  the  back.  The  infection  may  be  the  ordinary 
pyogenic  form,  or  it  may  be  tuberculous,  in  the  latter  cases  forming  the 
ordinary  cold  abscess. 

Symptoms. — The  symptoms  of  perinephritis  are  pain  in  the  back  and 
side,  and  fever  with  or  without  an  initial  chill.  Local  tenderness  is  marked, 
a  large  tumor  develops,  the  thigh  may  be  held  flexed  by  contraction  of  the 
psoas  muscle,  and  the  patient  may  bend  the  spine  towards  the  injured  side. 
Fever  may  precede  the  appearance  of  a  tumor.  If  it  be  purely  tuberculous 
in  origin  it  produces  no  symptoms  other  than  those  of  an  ordinary  cold 
abscess.  The  diagnosis  of  pei-inephritis  from  pyonephrosis  or  abscess  of  the 
kidney  is  made  by  the  more  superficial  situation  of  the  pus,  by  the  greater 
immobility  of  the  tumor,  and  in  some  cases  by  the  absence  of  urinary  signs 
of  kidney  disease.  The  urine  will  be  altered  in  pyonephrosis,  unless  that 
from  the  affected  side  is  entirely  shut  off  by  the  obliteration  of  the  ureter. 
The  swelling  of  the  perinephritic  abscess  is  more  obvious  in  the  back  and 
less  so  in  the  front  than  the  tumors  made  by  distention  of  the  kidney.  Neo- 
plasms of  the  kidney  are  usually  movable,  and  do  not  present  the  signs  of 
inflammation.  Aspiration  will  furnish  pus  in  cases  of  abscess.  It  should 
not  be  forgotten  that  iJeriuephritis  is  often  associated  with  suijpuration  in 
the  kidney.  A  perinephritic  abscess  might  easily  be  confounded  with  a 
subphi'enic  abscess  develoj)ing  from  a  i^erforation  of  the  stomach,  but  it  can 
usually  be  distinguished  by  the  fact  that  the  pus  lies  against  the  posterior 
wall  of  the  abdomen  rather  than  up  under  the  diaphragm,  although  in  some 
cases  perinephritic  suppuration  may  form  a  true  subphrenic  abscess.  The 
absence  of  stomach  symptoms  and  the  presence  of  disease  of  the  kidney 
would  assist  in  the  diagnosis.  Cold  abscesses  originating  in  the  bones  and 
forming  in  this  locality  may  be  distinguished  by  the  signs  of  disease  of  the 
vertebras,  the  pelvic  bones,  or  the  ribs,  and  also  by  the  absence  of  signs  of 


1050  TUBEECrLOSIS   OF  THE   KIDXEY. 

kidney  disease.  Psoas  abscesses  are  situated  near  the  middle  line,  whereas 
a  perinephi'itic  abscess  may  extend  well  out  into  the  flank.  The  diagnosis 
is  by  no  meaus  always  easy,  and  may  be  imjjossible. 

Treatment. — -The  treatment  of  perinephritis  consists  in  evacuation  of 
the  pus  by  incision  as  soon  as  the  diagnosis  can  be  made.  Unless  the  symp- 
toms of  kidney  disease  are  urgent,  that  organ  should  be  left  untouched  until 
the  external  abscess- cavity  has  contracted,  except  when  the  perinephritis  is 
secondary  to  a  pyonephrosis  with  complete  destruction  of  the  kidney,  iu 
which  case  the  organ  should  be  removed  at  once.  These  abscesses  should 
be  opened  by  a  large  incision  similar  to  that  used  in  nephi'otomy,  which 
will  allow  of  examination  of  the  condition  of  the  kidney.  In  the  tuber- 
cular cases,  after  removal  of  the  kidney  the  external  abscess  may  be  treated 
with  iodoform. 

Tuberculosis. — Tuberculosis  generally  infects  the  kidney  by  ascending 
from  the  bladder  along  the  ui-eter.  In  some  cases  it  is  primary  in  the 
kidney,  the  infection  being  carried  by  the  blood-vessels.  It  is  also  possible 
for  the  kidney  to  be  involved  by  a  local  extension  of  a  neighboring  tubercu- 
lous focus  in  the  bones  of  the  spine  or  the  ribs,  or  in  the  peritoneum  or 
intestine,  but  these  cases  are  exceedingly  rare.  Tuberculosis  of  the  kidney 
appears  under  several  forms,  probably  the  most  common  being  the  miliary 
form  corresponding  to  the  similar  condition  seen  in  other  organs,  and 
associated  with  so  many  lesions  elsewhere  that  it  has  no  practical  interest 
for  the  surgeon.  Single  primary  tubercular  foci  occasionally  develop  in 
the  kidney,  forming  cheesy  masses  which  sometimes  attain  a  large  size  or 
deoenerate  into  cold  abscesses.  In  rare  cases  the  changes  may  remain 
limited  to  one  part  of  the  kidney,  but  the  disease  usually  involves  the  entire 
oro-an  and  spreads  to  the  pelvis,  even  when  it  originates  in  the  parenchyma. 
A  common  variety  of  tuberculosis  of  the  kidney,  however,  is  that  due  to 
ascending  infection  from  tuberculous  disease  of  the  bladder.  In  these  cases 
the  gross  lesions  resemble  those  of  pyonephrosis  in  general,  except  that  the 
amount  of  granulation-tissue  and  cheesy  masses  makes  the  tumor  rather 
solid  than  cystic.  It  is  probable  that  a  large  number  of  cases  of  supposed 
ordinary  pyonephrosis  are  really  due  to  tubercular  infection,  as  it  is  often 
impossible  to  demonstrate  the  tuberculous  origin  of  such  advanced  lesions. 
A  perinephritis  may  exist  with  the  tuberculosis,  being  of  the  cold  abscess 
type  and  due  to  infection  from  the  kidney.  If  the  renal  disease  is  primary, 
it  is  likely  to  infect  the  bladder  at  an  early  date  by  extending  along  the 
ureter,  or,  without  involving  the  latter,  by  attacking  the  bladder  wall  at 
once.  The  renal  focus,  however,  may  be  the  primary  lesion  and  may  exist 
without  serious  tuberculous  disease  in  any  other  organ  of  the  body,  a  fact 
which  is  of  great  importance  in  estimating  the  prognosis  of  these  cases  and 
■  the  possibility  of  a  cure  by  removal  of  the  kidney. 

Symptoms. — The  symptoms  of  renal  tuberculosis  are  almost  invariably 
those  of  bladder  disturbance,  such  as  htematuria.  or  frequent  micturition. 
The  latter  is  due  to  increased  quantity  of  urine,  its  secretion  being  stimu- 
lated by  the  disease,  or  to  vesical  irritation,  which  may  be  present  before 
any  cystitis  develops.  It  is  seldom  that  the  diagnosis  can  be  made  (by  find- 
ing bacilli  in  the  urine,  for  instance)  before  any  lesion  has  developed  in  the 


TUMORS   OF  THE   KIDXEY.  1051 

bladder.  The  symptoms  referable  to  the  kidney  itself  are  the  presence  of  a 
tumor  and  a  feeling  of  lumbar  uneasiness,  together  witli  the  general  symp- 
toms of  anffimia  and  cachexia  characteristic  of  tuberculous  disease.  A 
cystoscopic  examination  of  the  bladder  should  always  be  made,  and  it  will 
sometimes  allow  of  a  very  early  diagnosis  by  the  discovery  of  minute 
tubercular  ulcerations  near  the  mouth  of  the  ureter  on  the  affected  side. 
But  catheterization  of  the  ureters  is  dangerous,  and  the  ' '  segregator' '  is  to  be 
preferred  for  separating  the  urines  of  the  two  kidneys.  The  prognosis  of 
tuberculosis  of  the  kidney  appears  to  be  uncertain.  Some  claim  that 
recovery  is  possible  in  certain  cases  without  operation.  Others  think  the 
condition  absolutely  hopeless.  Eadical  operation  has  effected  a  permanent 
cure,  and  even  in  advanced  cases  life  may  be  prolonged  by  proper  surgical 
treatment. 

Treatment. — The  treatment  of  renal  tuberculosis  depends  upon  the 
extent  of  the  disease  in  general.  If  it  is  practically  limited  to  one  kidney, 
the  lungs,  genitals,  or  glands  being  only  slightly  involved,  nephrectomy 
may  result  in  a  radical  cure.  A  slight  infection  of  the  bladder  or  of  the 
prostate  does  not  contraindicate  the  operation,  as  it  will  often  improve  or 
disappear  afterwards.  IsTephrectomy  may  be  satisfactory  even  when  a  well- 
marked  pyonephrosis  is  present,  if  the  other  organs  are  not  seriously  affected. 
Morris  obtained  a  cure  in  foiu-  cases  of  partial  disease  by  resection  of  the 
affected  portions,  but  this  treatment  seems  hazardous,  and  not  suited  for 
general  application.  When  the  ureter  is  diseased  it  should  be  entirely 
removed  with  the  kidney  or  later  at  a  second  operation.  If  not  removed  it 
should  be  cut  short,  curetted  as  far  as  possible,  and  secured  in  the  lower 
angle  of  the  wound.  In  cases  in  which  there  is  extensive  disease  elsewhere, 
and  especially  in  the  other  kidney,  nephrectomy  should  not  be  done,  and 
such  cases  are  best  treated  on  general  principles,  with  due  attention  to  the 
condition  of  the  bladder.  Nephrotomy  results  in  permanent  urinary  and 
tuberculous  sinuses,  and  is  apt  to  hasten  the  end  ;  but  when  the  iireters  are 
occluded  by  any  caiise,  or  when  the  suppuration  is  so  intense  as  to  threaten 
septicaemia  or  pyaemia,  the  surgeon  may  be  compelled  to  incise  and  drain  the 
abscesses  or  the  kidney  itself.  Some  surgeons  advocate  nephrotomy  as  a 
preliminary  operation,  delaying  nephrectomy  until  the  other  kidney  can  be 
proved  healthy.  Iodoform  treatment  must  then  be  instituted,  with  due 
care  to  avoid  ijoisoning. 

Tumors. — The  tumors  of  the  kidney  are  solid  or  cystic,  including  poly- 
cystic degeneration  of  the  kidney  and  hydronephrosis.  Hydatid  cysts  are 
so  rare  as  to  need  only  mention  here.  3Iinute  cysts  develop  in  the  kidney 
in  the  course  of  chronic  nephritis,  but  are  of  no  sm-gical  importance. 
Single  serous  cysts  are  occasionally  seen  in  kidneys  otherwise  healthy,  but 
rarely  attain  the  size  of  an  egg  or  an  orange. 

Polycystic  Degeneration. — The  entire  kidnej-  may  be  occuj^ied  by 
multiple  cysts  of  all  sizes  from  a  pin's  head  up  to  a  man's  fist,  and  j^et.  in  sjiiite 
of  this  change,  the  unaltered  parts  of  kidney-substance  may  continue  to 
secrete  ui'ine  until  they  become  atrophied  by  the  pressure  of  the  growing 
cysts.  This  condition  may  be  congenital  and  is  sometimes  associated  with 
cystic  degeneration  of  the  liver  and  ovary.     It  also  develops  in  adult  life. 


1052  TUMOES  OF  THE   KID^^EY. 

The  cysts  may  be  formed  by  obstruction  of  the  ducts  by  increase  of  the 
interstitial  connective-tissue,  forming  retention  cysts,  or  by  epithelial 
growth  as  in  adenoma  with  cystic  degeneration.  These  varieties  resemble 
chronic  interstitial  mastitis  and  cystoadenoma  of  the  mammary  gland.  In 
the  great  majority  of  cases  both  kidneys  are  affected.  The  condition  gives 
few  symptoms,  and  is  often  accidentally  discovered  at  autopsies,  having 
been  unnoticed  during  life.  The  tumors  grow  slowly.  In  the  acquired  form 
hsematuria  and  renal  colic  have  been  observed.  In  other  cases  the  tumors 
are  very  large  and  cause  symptoms  by  their  pressure,  and  we  have  been 
compelled  to  operate  on  one  such  tumor  which  extended  from  the  diaphragm 
to  the  crest  of  the  ilium  and  caused  vomiting  and  various  nervous  distui-b- 
ances  by  its  great  size.  As  the  condition  is  bilateral,  removal  of  the  kidney 
is  not  to  be  thought  of,  and  drainage  should  be  established  by  nephrotomy, 
one  cyst  being  broken  into  after  another,  converting  them  as  far  as  possible 
into  one  cavity  which  can  be  drained  through  the  wound.  A . j)ermanent 
urinary  fistula  results,  and  therefore  it  is  best  to  leave  these  kidneys 
untouched  unless  compelled  to  interfere  by  serious  symptoms. 

Hydronephrosis. — Hydronephrosis  is  a  dilatation  of  the  kidney  by 
accumulation  of  urine  in  its  pelvis  owing  to  obstruction  of  the  ureter. 
The  ureter  may  be  deficient  congenitally,  or  obstructed  by  cicatrices,  by  a 
stone,  by  the  pressure  of  a  tumor  in  the  pelvis,  or  simply  by  being  bent 
upon  itself,  as  may  occur  in  a  case  of  floating  oi-  movable  kidney.  By  far 
the  most  common  cause  is  movable  kidney,  and  hence  the  affection  is  four 
times  as  common  in  women  as  in  men.  Its  symptoms  are  frequently  first 
noticed  during  pregnancy.  Moderate  dilatation  of  the  kidneys  may  be  pro- 
duced by  any  obstruction  to  the  outflow  of  urine  in  the  bladder  or  urethra, 
and  is  then  bilateral  iu  most  cases.  The  symptoms  of  this  condition  when 
it  occurs  gradually  are  so  little  marked  as  to  be  unperceived  until  the  tumor 
reaches  a  considerable  size,  for  the  other  kidney  gradually  hypertrophies 
and  does  the  work  of  both.  When  a  ureter  is  suddenly  blocked  by  a  cal- 
culus or  by  a  twist,  the  patient  is  seized  with  intense  pain  in  the  renal  region, 
which  may  be  so  severe  as  to  be  uncontrollable  by  morj)hine,  and  urtemia 
may  develop.  The  kidney  can  be  felt  enlarged  and  tender.  In  a  case  of 
floating  kidney  repeated  attacks  of  obstruction  of  the  ureter  may  occur 
with  intervals  free  from  symjDtoms,  and  the  name  of  intermittent  hydro- 
nephrosis has  been  given  to  this  condition.  The  retention  may  jjass  .off 
with  a  sudden  rush  of  urine  to  the  bladder,  which  may  have  to  be  emptied 
three  or  four  times  at  shoi't  intervals,  the  flow  bringing  relief  from  pain  and 
causing  the  tumor  to  disappear.  When  the  obstruction  is  chronic  the  only 
sign  may  be  the  appearance  in  the  renal  region  of  a  tumor,  which  may 
attain  a  large  size,  extending  downward  to  the  pelvis  and  across  the  middle 
line.  This  tumor  seldom  is  tender  or  occasions  pain,  but  vomiting  may  be 
produced  by  direct  pressure  on  the  stomach  or  by  dragging  on  the  attach- 
ments of  the  pylorus.  The  fluid  of  the  cyst  is  of  low  specific  gravity,  and 
contains  but  little  urea.  The  result  of  chronic  hydronephrosis  is  the 
destruction  of  the  kidney-substance  as  it  is  flattened  out  in  the  wall  of  the 
cyst  until  scarcely  a  trace  of  it  is  left.  In  some  cases  the  tumor  has  ruptured 
and  caused  peritonitis,  which  is  usually  fatal. 


TUMORS   OF  THE  KIDNEY. 


1053 


Treatment. — The  treatment  of  intermittent  hydronephrosis,  if  it  is  due 
to  extreme  mobility  of  the  Icidney,  whicli  is  usually  the  case,  is  fixation  of 
the  organ  in  its  proper  position,  which  prevents  a  return  of  the  obstruction. 
In  the  chronic  form  the  cyst  may  be  drained,  either  extraperitoneally  or 
through  the  peritoneal  cavity  by  suture  of  the  sac  wall  to  the  parietal 
peritoneum,  and,  as  a  rule,  the  drainage  will  cease  spontaneously,  owing  to 
the  complete  destruction  of  the  kidney-tissue.  If  discharge  of  the  urine 
through  the  fistula  should  persist,  nephrectomy  may  be  performed  by  cut- 
ting down  on  the  remains  of  the  kidney  and  the  cyst  and  removing  the 
entire  mass.  If  operation  is  impossible  because  of  the  patient's  condition, 
the  cyst  may  be  emptied  by  aspiration,  and  cases  are  on  record  which  have 
been  cured  by  repeated  aspiration  ;  but  this  method  is  not  without  danger, 
for  infection  may  take  place  and  su^jpuration  result.  Good  results  have 
been  obtained  recently  by  various  operations  restoring  the  patency  of  the 
ureter,  as  described  below,  and  the  kidney  has  been  preserved. 

Solid.  Tumors. — The  solid  tumors  of  the  kidney  are  almost  invariably 
malignant,  although  adenomata  or  lipomata  are  occasionally  found,  as  well 
as  mixed  tumors  of  congenital  origin  containiug  lymphoid  tissue  and  often 
some  striped  muscular  fibres,  and  resembling  the  mixed  tumors  of  the 
parotid.  The  mixed  tumors  are  supposed  to  originate  from  misplaced  frag- 
ments of  the  suprarenal  bodies  lodged  in  the  kidney-substance. 

Lipoma  of  the  fatty  capsule  of  the  kidney  is  quite  rare,  and  forms 
large  retroxDcritoneal  tumors,  the  diagnosis  of  which  from  lipoma  of  the 
mesentery  is  not  easy.  The  situation  of  the  tumor,  however,  and  its  resem- 
blance to  the  kidney  in  shape,  will  aid  in  making  the  diagnosis.  These 
tumors  are  innocent,  and  may  be  left  untouched  unless  they  attain  a  large 
size  and  cause  symptoms  by  pressure  upon  various  organs. 

Suprarenal  Tumors. — In  the  foetus  the  suprarenal  bodies  almost 
entirely  cover  the  kidney,  their  tissues  separated  only  by  a  thin  layer  of 
cells  representing  the  later  capsule. 
Portions  of  suprarenal  tissue,  either  a 
few  cells  or  considerable  masses,  can 
therefore  be  easily  displaced  and  lodged 
within  the  kidney  capsule.  The  greater 
number  of  tumors  of  the  kidney  can  be 
referred  to  these  misplaced  fragments  of 
the  suprarenals.  As  they  develop  they 
may  produce  adenomata,  sarcomata,  or 
carcinomata.  Malignant  changes  may 
take  place  in  tumors  originally  adeno- 
matous. Tumors  may  also  develop  in 
the  suprarenal  bodies  entirely  outside 
of  the  kidney.  These  tumors  usually 
appear  in  middle  life  or  later. 

Symptoms. — The  symptoms  of  supra- 
renal   adenomata    are    usuallj^   vague 

until  they  attain  a  considerable  size,  whether  the  tumor  originates  within  or 
without  the  kidney  capsule.     Sometimes  hemorrhage  and  renal  colic  are 


Fig.  818. 


Suprarenal  tumor,  in  section  :  a,  tissue  of 
tumor  ;  6,  kidney ;  c,  pelvis  of  Icidney  ;  d,  fatty 
capsule ;  e,  fibrous  septa ;  /,  vessels  and  ureter, 
dotted  lines  showing  their  course. 


1054  DIAGNOSIS   OF  TUMORS   OF  THE   KIDNEY. 

observed  early.  If  the  tumor  grows  iu  the  suprarenal  body  it  may  displace 
the  kidney,  unaltered  in  shape,  downward.  It  may  develop  under  the 
capsule  of  the  kidnej^  and  push  the  latter  to  one  side,  or  deeper  in  the  organ 
and  distort  it  in  various  ways.  (Fig.  818.)  At  first  the  two  are  distinct, 
but  the  cells  of  the  tumor  are  likely  to  infiltrate  the  neighboring  kidney  in 
time,  and  then  malignant  degeneration  sets  in.  These  tumors  have  a  pecu- 
liar tendency  to  grow  into  the  veins  and  make  long  polypoid  masses  which 
may  extend  in  the  lumen  of  the  renal  veins  and  reach  the  vena  cava,  from 
which  emboli  may  be  broken  off  and  produce  metastatic  tumors. 

Treatment. — ^Nephrectomy  is  necessary,  as  it  will  seldom  be  possible  to 
separate  the  healthy  kidney  so  as  to  preserve  its  function  and  yet  remove  all 
the  new  growth  with  certainty. 

Sarcoma. — Sarcoma  is  the  most  common  tumor  of  the  kidney.  It  gen- 
erally develops  from  misplaced  suprarenal  fragments  and  consists  of  embry- 
onal tissues,  both  glandular  and  connective  tissue.  It  is  usually  encapsu- 
lated, displacing  the  kidney-tissue  and  not  infiltrating  it.  Sarcoma  may 
occur  in  adults,  usually  as  angiosarcoma,  but  is  less  frequent  than  carcinoma 
at  that  age  and  less  likely  to  cause  hismaturia.  It  generally  occurs  in  chil- 
dren in  the  first  two  or  three  years  of  life  and  forms  tumors  of  immense  size, 
more  than  half  filling  the  abdomen.  These  tumors  occasion  no  symptoms, 
as  a  rule,  until  they  have  reached  their  full  growth,  when  digestion  and 
respiration  are  embarrassed  by  their  pressure  and  the  child  falls  into 
cachexia.  The  tumors  may  be  hard  or  soft,  and  are  occasionally  cystic. 
They  retain  more  or  less  the  shape  of  the  kidney,  and  seldom  cause  urinary 
symptoms.  Both  kidneys  are  rarely  involved.  Late  in  the  disease  there 
may  be  htematuria  and  metastasis  to  other  organs.  Removal  is  the  only 
possible  treatment  for  these  tumors,  and  if  it  is  undertaken  early  a  perma- 
nent cure  may  be  hoped  for  ;  but  in  the  gi-eat  majority  of  cases  the  disease  is 
recognized  too  late  to  admit  of  a  cure,  and  if  extirpation  is  possible  at  all  it 
is  usually  incomplete,  and  recurrence  follows. 

Carcinoma. — Carcinoma  of  the  kidney  is  a  disease  of  later  life,  espe- 
cially after  the  fiftieth  year.  The  tumors  are  not  so  large  as  in  sarcoma,  but 
may  attain  a  considerable  size,  even  that  of  a  man's  head.  The  neoplasm 
almost  invariably  causes  profuse  hsematuria,  which  may  be  intermittent 
and  may  cause  renal  colic.  Pain  is  an  uncertain  and  late  symptom,  and 
cachexia  appears  in  the  later  stages.  Vesical  symj)toms  are  induced  by  the 
blood  in  the  urine,  and  if  infection  takes  place  an  acute  pyelitis  or  cystitis 
develops,  with  severe  symptoms.  Death  is  usually  the  result  of  the  exhaust- 
ing hemorrhages  or  the  infection.  Nephrectomy  for  malignant  disease  in 
the  adult,  while  giving  better  operative  results  than  in  children,  has  seldom 
effected  a  permanent  cure. 

Diagnosis  of  Tumors  of  the  Kidney. — The  kidney  is  accessible  to 
palpation,  when  the  patient  lies  upon  his  back  and  the  surgeon  faces  him 
at  the  side,  placing  one  hand  in  the  lumbar  region  to  lift  the  kidney  up 
towards  the  anterior  abdominal  wall,  while  the  other  hand  makes  firm 
pressure  in  front  and  maps  out  the  organ.  In  thin  individuals  with  lax 
abdominal  walls  quite  small  tumors  of  the  kidnej^  may  be  recognized,  while 
in  others  it  is  impossible  to  reach  the  normal  organ  without  an  ansesthetic. 


EENAL  CALCULUS.  1055 

As  a  rule,  tlie  lower  half  of  the  right  kidney  can  be  palpated  readily,  but 
the  left  kidney  not  so  easily.  Tumors  of  the  kidney  are  usually  rather  fixed 
in  the  lumbar  region  unless  the  kidney  from  which  the  tumor  has  developed 
is  itself  movable.  They  do  not  move  with  respiration  unless  they  attain 
such  a  size  as  to  press  upon  the  under  surface  of  the  liver  or  of  the  dia- 
phragm and  thus  have  movements  imparted  to  them.  When  firmly  held 
they  do  not  follow  the  ascent  of  the  diaphragm.  As  the  kidney  lies  behind 
the  peritoneum  at  the  attachment  of  the  ascending  and  descending  colon,  a 
tumor  growing  in  the  kidney  carries  this  part  of  the  intestine  forward  with 
it,  and  the  bowel  can  usually  be  recognized  as  a  sausage-like  mass  or  as  a  line 
of  tympanitic  resonance  on  percussion  crossing  the  front  of  the  tumor.  But 
the  hepatic  flexure  seldom  reaches  so  high  up  as  to  lie  in  front  of  the  right 
kidney.  The  area  of  percussion  dulness  of  the  tumor  and  its  relations  to 
the  liver  and  spleen  should  always  be  made  out.  Except  in  the  case  of 
floating  kidneys,  the  usual  dulness  in  the  lumbar  region  will  be  present. 

Polycystic  kidneys  may  be  recognized  by  the  fact  that  both  kidneys  are 
diseased,  by  the  uneven  surface  of  the  tumor,  some  of  the  cysts  standing  out 
above  the  general  level,  and  by  the  complete  absence  of  symptoms.  Hydro- 
nephrosis of  the  intermittent  variety  is  recognized  by  the  typical  symp- 
toms. Chronic  hydronephrosis  can  be  distinguished  from  ovarian  cyst  by 
the  fact  that  the  tumor  has  appeared  above  instead  of  below,  and  by  the 
area  of  dulness  on  percussion  extending  to  the  flank,  while  aspiration  will 
furnish  the  peculiar  fluid  of  these  cysts.  The  cyst  will  lie  uj^on  one  side 
rather  than  in  the  middle  line,  and  may  therefore  be  distinguished  from 
some  pancreatic  cysts,  and  there  will  be  none  of  the  signs  of  disturbance 
of  pancreatic  digestion.  On  the  right  side  of  the  body  they  may  resemble 
cysts  of  the  gall-bladder,  and  the  resemblance  may  be  increased  by  the  simi- 
larity of  symptoms  caused  by  the  passage  of  renal  and  biliary  calculi.  But 
the  extension  of  the  tumor  into  the  back,  the  dulness  on  percussion  over  an 
area  on  the  anterior  surface  of  the  cyst  and  continuing  into  the  lumbar 
region,  together  with  the  presence  of  the  colon  on  the  front  of  the  tumor, 
and  the  evident  independence  of  the  tumor  from  the  liver,  should  enable 
the  diagnosis  to  be  made.  The  solid  tumors  of  the  kidney  preserve  more 
or  less  the  shape  of  the  organ,  and  the  thick  rounded  border  and  hilum  can 
often  be  recognized.  The  shape  distinguishes  these  tumors  from  tumors  of 
the  spleen,  which  have  the  sharj)  edge  of  that  organ  and  an  angular  notch 
upon  the  inner  border.  Eenal  tumors  seldom  are  tender  or  give  rise  to  pain, 
except  in  the  malignant  varieties.  They  may  occasion  vomiting  by  pressure 
upon  the  stomach,  or  by  dragging  upon  the  attachments  of  the  pylorus  and 
the  duodenum.  Htematuria  is  characteristic  of  carcinoma,  and  fi-agments 
of  the  neoplasm  may  be  passed  with  the  urine.  The  excretion  of  the  two 
kidneys  should  always  be  studied  separately,  being  collected  by  the  ''segre- 
gator"  or  by  catheterization  of  the  ureters  by  means  of  the  cystoscoj)e,  or 
by  Kelly's  method.  As  many  of  these  cases  require  nephrectomy,  it  is  all- 
important  that  the  health  of  the  remaining  organ  should  be  perfect. 

Renal  Calculus. — Stone  in  the  kidney  is  often  of  congenital  origin, 
uric  acid  infarcts  of  the  renal  tubules  being  almost  the  rule  in  newly  born 
infants,  and  if  any  of  these  crystals  remain  in  place,  not  being  washed  out 


1056  SYMPTOMS   OF  RENAL   CALCULUS. 

by  the  first  flow  of  uriue,  they  form  a  nucleus  for  further  deposit  upon  which 
a  stone  may  grow,  although  it  may  cause  no  symptoms  until  later  in  life. 
Eenal  calculi  are  usually  of  branching  shape,  the  main  trunk  lying  in  the 
pelvis,  with  short  branches  extending  into  the  various  calyces.  Eenal  cal- 
culi are  composed  of  phosphates,  calcium  oxalate,  or  uric  acid.  Stones  are 
usually  confined  to  one  kidney,  but  they  may  be  single  or  multiple.  They 
are  more  common  in  males  than  in  females. 

Symptoms. — A  calculus  may  remain  in  the  kidney  and  attain  a  large 
size,  with  very  few  or  absolutely  no  symptoms,  but  in  the  majority  of  cases 
there  is  pain  in  the  kidney  and  blood  appears  in  the  urine.  The  symptoms 
are  increased  by  motion,  such  as  rough  jolting  in  a  wagon,  but  attacks  of 
pain  also  come  on  at  night  while  the  patient  is  resting  in  bed.  If  infection 
takes  place  through  the  bladder  and  ureter,  the  symptoms  of  pyelitis  are 
added  to  those  already  present.  Pus  is  then  found  in  the  urine,  there  may 
be  some  fever,  and  the  pain  and  tenderness  are  increased. 

The  stone  sometimes  becomes  lodged  in  the  entrance  to  the  ureter  and 
closes  it  temporarily,  giving  rise  to  severe  renal  colic,  which  may  last  until 
the  stone  works  its  way  back  again  into  the  pelvis  of  the  kidney.  Small 
stones  may  also  occasion  renal  colic  as  they  pass  down  the  ureter  into  the 
bladder  by  obstructing  the  flow  of  urine.  The  symf)toms  may  last  only  a 
few  hours,  or  may  recur  at  short  intervals  for  weeks  and  months  as  the  stone 
slowly  descends.  Eenal  colic  is  very  apt  to  come  on  after  severe  exertion, 
the  stone  being  thus  dislodged  from  the  kidney  and  entering  the  ureter,  but 
it  may  also  occur  while  the  patient  is  asleep.  If  the  calculus  is  large  enough 
to  block  the  ureter,  it  gives  rise  to  excruciating  pain,  with  a  feeling  of 
fulness  and  tenderness  in  the  loin,  and  neuralgic  pains  shooting  down  into 
the  testicle  with  retraction  of  the  cremaster,  or  extending  down  the  thighs. 
The  pain  may  also  resemble  intestinal  colic  and  be  associated  with  rectal 
tenesmus.  The  urine  is  acid,  often  contains  blood,  and  a  trace  of  albu- 
min and  pus  may  be  present  when  infection  has  occurred.  There  may 
be  a  rise  of  temperature,  the  heart-action  becomes  weak,  and  the  patient 
may  faint  or  vomit.  The  urine  may  be  clear  during  the  attack  when  that 
from  the  diseased  side  is  entirely  excluded,  or  it  may  be  bloody  if  the 
obstruction  is  incomplete.  Micturition  is  apt  to  be  frequent,  with  some 
tenesmus.  Complete  anuria  may  be  present  if  there  is  only  a  single  kidney, 
or  if  the  other  ureter  is  also  blocked  by  a  stone  or  some  other  cause. ,  In 
some  cases  of  calculous  impaction  the  secretion  of  the  other  kidney  is 
arrested  by  reflex  nervous  action.  There  are  a  number  of  these  spasmodic 
attacks,  until  the  stone  slips  back  into  the  pelvis  of  the  kidney  or  makes  its 
way  down  into  the  bladder,  when  it  may  be  passed  through  the  urethi-a  or 
may  form  a  nucleus  for  a  vesical  calculus.  Very  small  stones  sometimes 
give  rise  to  severe  attacks  of  renal  colic,  as  they  excite  spasmodic  muscular 
contraction  of  the  ureter  in  their  passage  down  the  canal.  Earely  the  stone 
remains  impacted  in  the  ureter,  ulcerates  its  walls,  and  forms  a  urinary 
abscess  around  it.  Cystitis  is  very  often  observed  as  a  secondary  conse- 
quence of  renal  calculi  when  some  external  infection  has  taken  place. 

Diagnosis. — The  diagnosis  of  renal  colic  is  made  by  the  renal  and 
vesical  symptoms,  the  retraction  of  the  testicle,  and  the  peculiar  direction 


OPERATIONS  UPON  TPIE  KIDNEY.  1057 

of  the  pain,  gall-stone  colic  causing  pain  in  the  right  shoulder  and  hepatic 
tenderness,  and  intestinal  colic  causing  f)ain  in  various  jiarts  of  the  abdomen. 
The  diagnosis  of  renal  calculus  depends  upon  the  urinary  symptoms,  the 
hrematuria  being  less  than  that  of  carcinoma  of  the  kidney  and  more  than 
that  of  pyelitis,  and  upon  the  local  pain  and  tenderness  and  the  intermittent 
character  of  the  symptoms.  The  stone  can  sometimes  be  demonstrated  by 
a  skiagraph.  Cases  with  indistinct  symptoms  often  escape  recognition. 
Malarial  attacks,  appendicitis,  and  neuralgia  of  the  kidney  sometimes  sim- 
ulate its  symptoms.  Renal  hemorrhage  from  any  cause  is  apt  to  be  accom- 
panied by  renal  colic  from  blocking  of  the  ureter  by  clots,  and  a  twist  of 
the  ureter  by  displacement  of  a  movable  kidney  will  also  cause  attacks  of 
colic.  In  any  case  in  which  there  is  very  severe  renal  pain  or  hemorrhage 
of  doubtful  origin,  an  exploratory  nephrotomy  should  be  undertaken, 
because,  even  if  no  stone  be  found,  tlie  operation  generally  imi:)roves  and 
may  even  cure  the  patient.  The  prognosis  of  a  renal  calculus  which  is  too 
large  to  pass  down  the  ureter  is  bad,  on  account  of  the  loss  of  blood,  the 
severe  attacks  of  pain,  and  the  tendency  to  inflammation  upon  the  least 
infection  of  the  uriaary  organs.  Smaller  stones  are  also  dangerous,  because 
they  are  apt  to  form  the  nuclei  for  vesical  calculus. 

Treatment. — The  treatment  of  renal  colic  consists  in  opiates,  warm 
apj>lications  to  the  abdomen  and  loins,  a  hot  bath,  warm  drinks  in  abun- 
dance, and  stimulants  in  moderation.  Opium  should  not  be  given  too  freely, 
for  toxic  symptoms  have  been  known  to  follow  large  doses  when  the  patient 
was  suddenly  relieved  of  pain  by  the  passing  of  the  calculus.  If  a  calculus 
is  passed  into  the  bladder  and  does  not  soon  appear  in  the  urine,  the  bladder 
should  be  washed  out  with  the  evacuator,  as  after  a  litholapaxy,  in  order  to 
avoid  the  danger  of  the  subsequent  development  of  a  vesical  calculus. 
When  there  is  proof  of  the  presence  of  a  calculus  in  the  kidney,  the  stone 
sliould  be  removed  by  exposing  and  incising  the  kidney,  as  in  the  operation 
of  nephrotomy.  When  the  kidney  is  exposed,  the  stone  can  usually  be  felt 
by  palliation  of  the  organ  between  the  fingers,  and  resembles  the  terminal 
phalanx  when  felt  through  the  pulp  of  the  finger.  If  there  should  be  any 
doubt  as  to  the  presence  of  a  stone,  the  kidney  may  be  exposed  and  explored 
with  a  long  needle.  The  use  of  the  needle,  however,  is  not  always  con- 
clusive, and  if  the  sufferings  of  the  patient  are  great  enough  to  warrant 
exposing  the  kidney,  it  is  wiser  to  incise  the  organ  and  insert  a  finger  into 
the  pelvis  for  thorough  palpation.  If  suppuration  is  present,  the  kidney 
must  be  drained,  otherwise  the  opening  in  it  should  be  sutured  after  removal 
of  the  stone  and  the  external  wound  closed  also,  a  gauze  drain  being  left  in 
one  angle  of  the  wound. 

Operations  upon  the  Kidney.— Incisions  for  exposing  the 
Kidney. — The  patient  should  lie  on  the  side  opposite  to  the  affected  kidney, 
with  a  large  firm  pillow  in  the  hollow  between  the  ribs  and  the  pelvis,  the 
body  being  inclined  slightly  forward.  The  pleura  extends  to  the  first 
lumbar  vertebra,  and  therefore  may  lie  beneath  the'  level  of  the  twelfth  rib 
near  the  spine,  and  the  incision  must  not  be  carried  too  far  inward  and 
upward.  The  kidney  can  be  reached  by  an  oblique  incision  beginning  at 
the  edge  of  the  quadratus  lumborum  at  its  attachment  to  the  twelfth  rib  and 


1058  NEPHEOKRHAPHY. 

passing  obliquely  forward  and  downward,  terminating  about  an  inch  above 
the  crest  of  the  ilium.  The  skin,  subcutaneous  fascia,  and  muscle  are 
divided  in  order,  and  the  peritoneum  exposed  in  the  anterior  angle  of  the 
incision.  Or  the  incision  can  be  placed  a  little  farther  forward  at  the  same 
level,  and  when  the  deep  fascia  has  been  divided  each  layer  of  muscle  and 
fascia  can  be  separately  split  in  the  direction  of  its  fibres  as  in  MacBurney's 
incision  for  appendectomy  without  dividing  any  fibres  transversely.  This 
incision  may  be  placed  so  as  to  pass  through  Petit' s  triangle  or  farther  for- 
ward through  the  external  oblique  muscle.  The  transverse  division  of  the 
lumbar  fascia  or  transversalis  secures  against  hernia  in  either  case.  "We 
have  found  this  incision  excellent  for  nephrorrhaphy  and  nephrotomy,  and 
it  is  possible  to  bring  a  kidney  out  through  this  wound.  The  incisions  for 
nephrectomy  are  described  below.  The  peritoneum  is  pushed  forward  and 
the  kidney,  surrounded  by  its  fatty  capsule,  appears  in  the  posterior  part  of 
the  wound. 

Nephrorrhaphy. — The  kidney  having  been  exposed,  its  fatty  capsule 
is  opened,  while  an  assistant  grasps  the  kidney  through  the  anterior  abdom- 
inal walls  and  forces  it  up  into  the  wound.  The  true  capsule  is  incised  on 
the  convex  border  for  the  entire  length  of  the  organ  and  peeled  far  back  on 
each  side,  making  two  flaps,  which  are  secured  by  sutures  so  placed  as  to 
draw  the  capsule  edges  apart  and  expose  the  surface  of  the  kidney  and 
approximate  it  to  the  abdominal  muscles  on  each  side  of  the  wound.  The 
external  wound  may  then  be  sutured  without  drainage,  or  packed  down  to 
the  bottom,  in  order  to  obtain  healing  by  granulation  and  thus  connect  the 
kidney  directly  with  the  external  surface  by  a  firm  mass  of  cicatricial  tissue. 
Some  surgeons  prefer  to  pass  the  sutures  directly  through  the  kidney  sub- 
stance as  well  as  the  capsule  ;  others  use  no  sutures,  but  suspend  the  kidney 
by  a  loop  of  gauze  passed  around  it,  with  the  ends  of  the  gauze  hanging 
from  the  wound.  The  patient  should  be  confined  to  bed  for  three  weeks,  in 
order  to  obtain  firm  cicatricial  tissue  in  the  wound  before  any  strain  is  put 
upon  it.  It  is  absolutely  necessary  to  open  the  fibrous  capsule  of  the  kidney 
in  doing  this  operation,  as  strong  adhesions  cannot  otherwise  be  obtained. 
The  sutures  do  not  seem  to  affect  the  renal  tissues,  and  cause  no  symptoms 
after  the  operation,  except  that  a  few  drops  of  blood  may  be  found  in  the 
urine.  It  is  seldom  possible  to  replace  the  kidney  exactly  in  its  normal 
position,  but  this  appears  to  be  of  little  importance  provided  that  it  be 
firmly  fixed.  Some  operators,  therefore,  have  united  it  to  the  abdominal 
wall  very  much  lower  down,  and  this  would  be  allowable  if  adhesions  existed 
which  prevented  the  return  of  the  organ  to  its  natural  situation.  It  can 
usually  be  secured  so  that  its  lower  pole  is  on  a  level  with  the  crest  of  the 
ilium.     The  results  of  nephrorrhaphy  ajipear  to  be  good  and  permanent. 

Nephrotomy. — Nephrotomy  is  the  operation  of  incising  the  kidney, 
and  is  performed  in  order  to  explore  the  interior  of  the  kidnej^,  to  remove 
calculi,  or  to  eifect  drainage  in  renal  suppuration.  The  kidney  is  exposed 
as  described  and  seized  by  its  fatty  capsule  and  brought  into  the  wound. 
An  opening  is  made  in  the  fatty  capsule,  which  readily  strips  off  the  kidney, 
and  the  organ  is  steadied  by  the  pressure  of  an  assistant's  hands  on  the 
abdomen  and  by  the  operator's  fingers  in  the  wound. 


NEPHRECTOMY.  1059 

The  kidney  should  be  incised  through  its  substance,  generally  on  the 
convex  border,  and  not  through  the  pelvis,  for  it  is  said  that  the  thin  walls 
of  the  pelvis  do  not  unite  as  readily  when  sutured,  and  that  oiienings  made 
in  them  for  drainage  are  less  likely  to  contract,  and  therefore  often  result  in 
permanent  urinary  fistulte.  The  hemorrhage  from  the  kidney  substance 
may  be  brisk  ;  but  if  the  wound  is  only  large  enough  to  admit  the  surgeon's 
finger,  the  pressure  of  the  latter  during  the  exploration  will  arrest  it. 
Zondek  has  shown  that  if  the  incision  is  placed  about  one-half  a  centimetre 
posterior  and  parallel  to  the  usual  autopsy  incision,  and  limited  to  the 
middle  two-thirds  of  the  kidney,  the  hemorrhage  will  be  least.  Should 
hemorrhage  persist  when  the  o^Deration  is  completed,  it  can  be  controlled  by 
suturing  or  packing  the  renal  wound.  All  hemorrhages  can  be  avoided  by 
stripping  the  kidney  out  of  the  fatty  capsule  and  applying  a  rubber  ligature 
around  the  pedicle  before  making  the  incision,  and  by  suturing  the  latter 
before  the  ligature  is  removed. 

When  the  pelvis  of  the  kidney  is  not  infected,  and  little  or  no  suppura- 
tion is  present,  the  renal  wound  can  be  sutured  and  primary  union  obtained. 
The  sutures  should  be  of  catgut,  placed  about  one-third  of  an  inch  apart, 
and  passed  with  a  round,  curved  needle,  introduced  some  distance  away 
from  the  edge  of  the  wound  on  each  side,  and  tied  only  just  firmly  enough  to 
arrest  the  oozing  of  blood,  so  that  they  will  not  cut  through  the  soft  and 
friable  tissue  of  the  kidney.  If  pyelitis  is  present,  however,  the  renal 
wound  should  be  left  open,  in  order  to  drain  the  pelvis,  a  large  drainage- 
tube  being  passed  into  the  latter,  and  left  long  enough  to  conduct  the  dis- 
charge into  the  external  dressings,  and  not  to  contaminate  the  abdominal 
wound.  If  the  renal  wound  is  sutured,  the  external  wound  can  also  be  closed  ; 
but  a  drainage-tube  or  a  wick  of  gauze  should  be  placed  in  the  posterior 
angle  down  to  the  surface  of  the  kidney,  in  case  there  should  be  any  leakage 
from  the  wound  in  that  organ.  The  external  wound  can  be  closed  by 
suturing  it  in  layers  with  chromic  acid  catgut,  or  by  silkworm-gut  sutures 
passing  through  the  entire  thickness  of  the  abdominal  wall,  with  due  care 
to  include  all  the  layers  of  the  latter  in  the  stitches.  Blood  may  be  present 
in  the  urine  for  some  days  after  a  nephrotomj^,  and  it  uiay  be  so  abundant  as 
to  form  clots  in  the  ureter  and  the  bladder,  with  colic  and  other  symptoms 
of  blocking  of  the  ureter  or  of  the  urethra  by  the  clots. 

Nephrectomy.— The  kidney  may  be  removed  by  an  anterior  incision 
(traversing  the  peritoneal  cavity),  or  by  an  extraperitoneal  operation.  A 
small  kidney  may  be  removed  by  the  incisions  described  above,  and  for 
larger  tumors  the  incision  may  be  begun  at  the  edge  of  the  quadratus  and 
carried  parallel  to  the  twelfth  rib  forward  as  far  as  necessary  (Fig.  751,  U), 
or  it  may  be  carried  more  downward  as  it  passes  forward,  so  that  its 
lower  part  will  give  good  access  to  the  ureter.  These  incisions  can  be 
carried  well  forward  towards  the  middle  line  without  opening  the  peri- 
toneal cavity,  if  the  peritotieum  be  stripped  off  the  anterior  abdominal 
wall  as  the  incision  is  extended.  In  cases  of  pyonephrosis  it  is  necessary  to 
operate  extraperitoneally,  on  account  of  the  danger  of  infecting  the  peri- 
toneal cavity.  For  tumors,  especially  large  tumors,  the  transperitoneal 
method  has  been  used  with  success,  the  mortality  being  but  little  higher 


1060  NEPHRECTOMY. 

than  that  of  the  extraperitoneal  method,  and  abundance  of  room  and  good 
control  of  the  pedicle  being  obtained  by  this  operation. 

It  has  been  claimed  that  the  transperitoneal  method  allows  the  surgeon 
to  examine  the  other  kidney ;  but  a  preliminary  laparotomy  incision  to 
ascertain  the  condition  of  the  other  kidney  can  be  made,  and  if  the  kidney 
seems  healthy,  this  incision  can  be  closed  and  the  extraperitoneal  operation 
performed.  It  is  true  that  the  principal  danger  in  nephrectomy  is  the  risk 
incurred  in  throwing  all  the  work  of  elimination  upon  the  remaining  kidney, 
which  may  be  insufficient  or  even  absent.  But  manual  examination  of  the 
organ  is  not  enough,  to  establish  its  healthy  condition,  and  it  is  desirable  to 
obtain  urine  from  it  by  catheterization  of  the  ureter  with  the  assistance  of 
one  of  the  methods  of  cystoscopy,  in  order  that  the  functional  ability  of  the 
remaining  organ  can  be  ascertained  before  the  operation.  The  function  of 
the  kidneys  can  be  estimated  also  by  determining  the  freezing-point  of 
tlie  blood  (Koranyi)  and  studying  the  artificial  glycosuria  produced  by 
administration  of  phloridzin.     (Caspar.) 

Nephrectomy  for  all  causes  taken  together  has  a  mortality  of  about  forty 
per  cent.,  but  the  mortality  varies  very  much  according  to  the  condition  for 
which  the  operation  is  done  and  the  state  of  the  patient  at  the  time.  The 
immediate  results  are  best  in  cases  of  extirpation  of  floating,  or  injured 
kidneys,  or  those  in  which  the  accidental  injury  of  a  ureter  compels  the 
sacrifice  of  a  kidney.  They  are  worst  in  suppurative  disease,  because  of 
the  poor  condition  of  the  patient  and  the  probability  of  disease  existing  in 
the  other  kidney,  and  in  malignant  tumors  because  the  latter  are  usually 
large  and  accompanied  by  cachexia  when  they  come  to  operation.  Ex- 
perience has  shown  that  the  j)atient  who  survives  the  removal  of  one 
kidney  long  enough  to  prove  that  the  other  kidney  is  healthy  is  not 
much  more  exposed  to  disease  in  the  remaining  organ  than  normal 
individuals. 

Transperitoneal  Nephrectomy. — The  kidney  may  be  removed  trans- 
peritoneally  by  an  incision  in  the  median  line,  or  by  Langenbuch's  incision 
at  the  edge  of  the  rectus  muscle,  the  peritoneum  being  opened  at  once.  The 
abdominal  contents  are  pressed  over  to  the  opposite  side  of  the  abdomen  and 
thoroughly  i^rotected  by  sponges  or  pads  of  gauze.  The  colon  will  be  found 
lying  in  front  of  the  kidney,  and  the  peritoneum  covering  the  latter  is 
incised  longitudinally  on  the  outer  side  of  the  bowel,  and  stripped  off  the 
tumor,  carrying  the  colon  inward  as  the  internal  flap  of  the  membrane  is 
dissected  back,  with  care  to  avoid  injury  to  the  vessels  of  the  mesocolon. 
The  kidney  is  then  dissected  bluntly  from  its  bed.  If  the  case  is  one  of 
inflammatory  disease  and  the  adhesions  are  very  extensive  and  firm,  the 
fibrous  capsule  can  also  be  opened  and  the  organ  shelled  out.  But  if  the 
nephrectomy  is  done  on  account  of  malignant  disease,  the  fibrous  capsule 
should  always  be  removed,  and  as  much  of  the  fatty  capsule  as  possible,  for 
secondary  deposits  are  likely  to  exist  in  the  lymphatics,  and  especially  in 
small  glands  in  the  neighborhood  of  the  hilum.  When  the  kidney  has  been 
freed,  the  pedicle  is  to  be  carefully  dissected,  and  the  ureter  separated  from 
the  vessels  if  possible.  Separate  ligatures  are  then  to  be  applied  to  each. 
If,  however,  it  is  difficult  to  do  this,  it  need  not  be  insisted  upon,  for  the 


NEPHEECTOMY.  1061 

wound  heals  well  when  both  are  included  in  a  common  ligature,  and  even 
when  portions  of  kidney  tissue  are  left  in  the  pedicle.  In  some  cases  an 
abnormal  branch  of  the  renal  artery  enters  one  pole  of  the  kidney  instead  of 
passing  to  the  hilum.  If  the  ureter  contains  infectious  material,  it  can  be 
secured  in  the  anterior  wound.  A  dressing-forceps  can  be  thrust  through 
the  abdominal  wall  from  within  at  the  edge  of  the  quadratus  lumborum,  and 
a  small  incision  made  upon  it,  through  which  a  drainage-tube  can  be  drawn. 
The  posterior  layer  of  peritoneum  is  then  sutured  over  the  raw  surface 
behind  it,  shutting  the  latter  off  from  the  general  cavity  of  the  peritoneum. 
The  anterior  laparotomy  wound  is  closed  as  usual,  without  drainage,  unless 
there  is  reason  to  fear  that  the  peritoneal  cavity  has  been  infected. 

Extraperitoneal  nephrectomy  is  performed  through  one  of  the  pos- 
terior or  lateral  incisions  described  above.  The  peritoneum  is  to  be  sepa- 
rated, the  fatty  capsule  of  the  kidney  divided,  and,  when  the  fibrous  capsule 
has  been  reached,  the  kidney  is  to  be  shelled  out  by  blunt  dissection.  When 
there  has  been  long- continued  suppuration,  it  may  be  so  difficult  to  isolate 
the  kidney  on  account  of  adhesions  that  the  fibrous  capsule  must  be  opened 
also  and  the  organ  shelled  out  of  it.  Both  fibrous  and  fatty  capsules  must 
be  removed  with  the  kidney,  if  the  latter  is  the  seat  of  malignant  disease. 
In  cases  of  very  large  suppurating  or  cystic  kidneys,  the  bulk  of  the  mass 
can  be  much  reduced  by  aspirating  the  fluid  contents.  The  kidney  should 
be  brought  outside  of  the  wound  if  possible  before  ligating  the  pedicle  ;  but 
often  this  cannot  be  done,  and  the  latter  must  be  dealt  with  by  touch  rather 
than  sight.  The  pedicle  having  been  dissected  out  as  far  as  possible,  a  stout 
double  ligature  is  passed  through  it  with  a  blunt  aneurism  needle  and  tied. 
The  ureter  is  tied  separately,  if  possible.  If  the  pedicle  is  very  short  and 
out  of  reach,  a  ligature  should  be  passed  as  well  as  possible,  tied  very 
tightly,  and  the  kidney  cut  away,  leaving  a  portion  of  the  latter  to  make  a 
large  stump  and  to  prevent  slipping  of  the  ligature.  After  removal  of  the 
kidney,  the  pedicle  can  then  be  more  carefully  dissected  out,  tied  farther 
back,  and  trimmed  off,  as  it  is  undesirable  to  leave  any  kidney  tissue. 

In  cases  of  tuberculosis  the  ureter  should  be  followed  down  towards  the 
bladder  as  far  as  possible,  and  removed  after  ligation  at  that  point.  If  pus 
or  urine  has  escaped  into  the  wound  during  the  operation,  the  cavity  is  to 
be  very  carefully  wiped  out  and  irrigated  with  salt  solution.  Any  rent 
which  has  been  made  in  the  peritoneum  is  to  be  closed  as  soon  as  discovered, 
or  protected  by  sponges  or  gauze,  and  sutured  at  the  end  of  the  oj)eration. 
The  external  wound  is  closed  with  deep  or  buried  sutures,  the  different 
layers  being  brought  accurately  together.  Unless  the  conditions  are  abso- 
lutely aseptic,  drainage  should  be  made  at  the  posterior  angle  ;  but  the  tube 
or  drainage- wick  should  be  removed  as  soon  as  it  is  certain  that  no  inflam- 
matory reaction  has  taken  place,  for  the  drainage  sinuses  are  often  trouble- 
some and  refuse  to  heal  until  the  pedicle-ligature  has  made  its  way  out. 

Partial  Nephrectomy  or  Resection  of  the  Kidney. — Portions  of 
the  kidney  have  been  successfully  excised  in  quite  a  number  of  conditions 
such  as  injury,  limited  suppuration  or  tuberculosis,  and  benign  tumors. 
The  lines  of  excision  must  depend  upon  the  condition  found.  Hemorrhage 
is  controlled  by  placing  a  temporary  rubber  ligature  around  the  pedicle  of 

6S 


1062  INJURIES  AJ^D  DISEASES  OF  THE  URETERS. 

tlie  isolated  kidney,  and  later  by  suture  of  the  edges  of  the  renal  wound, 
securing  a  tampon  in  the  wound  by  sutures,  or  by  displacing  the  kidney 
and  securing  it  in  the  superficial  part  of  the  muscular  wound  where  effective 
pressure  can  be  applied  to  it  for  a  couple  of  days,  and  then  restoring  it  to  its 
place.  One-half  of  a  horseshoe  kidney  has  been  successfully  removed  in  a 
few  cases,  the  principal  difliculty  being  the  control  of  the  hemorrhage. 

INJURIES  AND  DISEASES  OF  THE  URETERS. 

Congenital  Abnormalities. — The  ureters  are  liable  to  many  abnor- 
malities, the  most  frequent  being  their  reduplication  on  each  side,  the  pelvis 
of  the  kidney  being  also  double  in  some  cases.  These  variations,  however, 
are  of  little  importance  surgically,  except  when  congenital  occlusion  results 
in  the  conversion  of  the  kidney  into  a  cyst,  producing  hydronephrosis.  The 
ureters  are  often  dilated  when  there  is  obstruction  of  the  urinary  passages 
at  some  lower  point.  The  ureter  can  sometimes  be  palpated  at  the  brim  of 
the  true  pelvis  at  the  junction  of  the  middle  and  outer  thirds  of  a  line 
drawn  between  the  two  anterior  superior  iliac  spines.  The  diseases  of  the 
ureter  are  generally  masked  by  the  symptoms  of  kidney  or  bladder  disease 
which  are  antecedent  or  secondary  to  them.  The  most  important  lesions  of 
the  ureter  are  injuries  in  the  course  of  operations,  strictures,  impacted  cal- 
culi, and  tuberculosis.  (For  catheterization  of  the  ureters  by  cystoscopy  see 
page  1042.) 

Wounds. — The  ureter  is  not  infrequently  wounded  in  operations  upon 
the  uterus  and  other  pelvic  organs,  being  either  directly  incised  or  torn  or 
included  in  a  ligature,  and  a  fistula  forms,  through  which  the  upper  end  of 
the  ureter  discharges  urine.  When  the  ureter  has  been  wounded  in  an 
operation,  the  proximal  or  renal  end  of  it  may  be  secured  in  the  abdominal 
wound,  so  as  to  prevent  the  discharge  of  the  urine  into  the  abdominal 
cavity.  To  this  operation  might  be  given  the  name  ureterostomy.  Wounds 
of  the  ureter  have  been  treated  successfully  by  suture.  In  cases  of  circular 
division,  a  catheter  may  be  placed  in  the  canal  and  pushed  down  into  the 
bladder  and  the  divided  ends  united  over  it,  or  a  lateral  implantation  of  the 
upper  into  the  lower  end  or  into  the  bladder  may  be  made.  In  some  cases 
the  end  of  the  divided  ureter  has  been  simply  ligated  without  evil  effects, 
the  kidney  becoming  atrophied,  but  this  expedient  is  dangerous,  for  death 
has  followed  accidental  ligature. 

Ureteral  Fistula. — Fistula  of  the  ureter  has  often  been  treated  by  the 
removal  of  the  kidney,  the  healthy  kidney  being  sacrificed  in  order  to  rid 
the  patient  of  the  annoyance  of  the  urinary  discharge,  but  recently  suc- 
cessful attempts  have  been  made  to  save  the  kidney  bj^  grafting  the  irreter 
into  the  bladder  or  even  by  closing  the  fistulous  opening  by  uniting  the 
divided  ends  of  the  ureter.  Grafting  into  the  rectum  is  feasible,  but  is 
likely  to  result  in  pyelitis  due  to  ascending  infection  from  the  faeces,  and  is 
not  to  be  recommended. 

Stricture.— Stricture  of  the  ureter  may  be  the  result  of  inflammatory 
processes,  but  it  is  most  frequently  due  to  a  bend  in  the  duct  caused  by  a  dis- 
placed kidney.  These  cases  seldom  come  under  the  care  of  the  surgeon 
until  a  hydronephrosis  has  been  produced  and  the  kidney  is  too  far  destroyed 


URETERAL  CALCULUS.  1063 

to  admit  of  saving  it  by  treatment.  Strictures  have  been  successfully  dilated 
by  instruments  introduced  from  the  bladder  by  cystoscopy,  or  even  from 
above  after  nephrotomy.  They  have  also  been  divided  longitudinally  and  the 
wound  united  transversely,  on  the  same  principle  as  the  operation  of  pyloro- 
plasty. Strictures  low  down  have  been  treated  by  resection  and  implanta- 
tion of  the  ureter  into  the  bladder,  and  those  high  up  have  been  excised 
and  the  lower  end  of  the  duct  implanted  into  the  pelvis  of  the  kidney. 
Lateral  anastomosis  of  the  portions  of  the  ureter  above  and  below  the  stric- 
ture has  also  been  successful. 

Calculus. — A  calculus  sometimes  becomes  impacted  in  the  ureter,  having 
descended  from  the  kidney,  causing  complete  or  partial  obstruction  of  the 
caaal.  The  situation  of  the  stone  can  be  ascertained  by  palpation,  by  cathe- 
terization of  the  ureter,  or  by  the  X-ray.  In  such  cases  the  ureter  may  be 
exjjosed  and  the  calculus  removed,  the  external  incision  to  be  employed 
depending  upon  the  situation  of  the  stone.  The  upper  portion  of  the  canal 
can  be  reached  by  opening  the  abdomen  at  the  external  border  of  the  rectus. 
The  ureter  can  be  incised,  the  calculus  removed,  and  the  wound  in  the  canal 
closed  with  sutures.  The  posterior  layer  of  the  peritoneum  should  be  united 
over  the  ureter,  and  if  there  is  danger  of  leakage  a  drain  should  be  intro- 
duced through  a  small  wound  in  the  lumbar  region,  so  that  the  anterior 
abdominal  wound  can  be  closed.  To  expose  the  ureter  lower  down  an 
oblique  incision  is  made  parallel  to  Poupart's  ligament,  but  an  inch  above 
it,  the  peritoneum  being  separated  from  the  pelvic  wall  as  in  the  operation 
for  ligature  of  the  iliac  artery,  until  the  pelvic  portion  of  the  ureter  is 
reached.  The  upper  part  of  the  ureter  is  adherent  t»  the  peritoneum,  and 
follows  that  membrane  when  it  is  sti'ipped  up.  The  extreme  lower  feud  may 
be  reached  by  the  vagina  in  the  female  or  by  resection  of  the  sacrum,  as  in 
Kraske's  operation. 


CHAPTEK    XL. 

SURGERY  OF  THE  MALE  GENITALS. 
By  B.  Pabqxjhab  Cuetis,  M.D. 

DISEASES   AND   INJURIES   OP   THE  PENIS. 

The  genital  apparatus  is  very  closely  associated  with  the  urinary ;  in 
fact,  the  functions  of  both  are  i^artly  united  in  some  organs,  as  in  the  penis. 
Certain  malformations,  therefore,  interfere  with  both  functions,  and  many 
diseases  affect  both  sets  of  organs.  The  intimate  relations  existing  between 
the  genitals  and  the  urinary  apparatus  must  be  kept  in  mind  constantly, 
although  it  is  more  convenient  to  study  them  apart. 

Congenital  Malformations. — The  penis  may  be  absent  in  very 
rare  cases,  and  it  is  occasionally  found  in  a  rudimentary  condition  buried 
under  the  integument  of  the  pubes  or  of  the  scrotum.  In  extreme  cases  of 
this  deformity  castration  may  be  advisable  in  order  to  free  the  individual 
from  tormenting  sexual  desire  and  its  resulting  nervous  disturbances. 
Milder  forms  of  undeveloped  penis  sometimes  correct  themselves  at  puberty 
or  even  later  in  life,  and  only  require  some  care  as  to  sexual  hygiene. 
Cases  of  double  penis  have  been  reported,  but  usually  with  a  supernu- 
merary limb  between  the  two  sets  of  genitals.  The  double  penis  may  be 
merely  a  cleft  penis,  or  may  be  double  in  the  whole  or  in  part  of  its  length, 
the  two  parts  being  sometimes  included  in  a  common  sheath  of  the  skin,  some- 
tirnes  separate.  The  deformity  is  very  rare.  The  penis  may  also  be  twisted 
upon  itself,  so  that  the  urethra  winds  about  the  organ  and  opens  iipon  its 
upper  side.  Among  the  commonest  deforrnities  of  the  penis  is  an  unnatural 
narrowing  of  the  meatus  or  of  the  opening  in  the  foreskin.  An  imperforate 
meatus  is  occasionally  seen,  the  opening  being  closed  by  a  very  thin  mem- 
brane. The  narrow  and  the  imperforate  meatus  have  been  described  in  the 
chapter  on  the  Urethra.  (See  page  996.)  Besides  the  urinary  obstruction, 
a  narrow  meatus  may  occasion  sexual  hypertesthesia. 

Phimosis. — Phimosis  is  a  term  applied  to  a  redundant  foreskin  with  a 
contracted  orifice.  (Figs.  819  and  820.)  The  foreskin  may  be  redundant  and 
yet  its  orifice  be  sufficiently  large,  a  condition  which  is  not  a  true  phimosis. 
At  birth  the  opening  in  the  foreskin  is  minute  and  the  inner  layer  of  the 
membrane  is  usually  adherent  to  the  outer  surface  of  the  glans.  During 
childhood  the  orifice  enlarges  and  the  adhesions  slowly  separate,  and  at 
puberty  the  former  should  be  large  enough  to  give  free  exit  to  the  glans. 
In  some  cases  the  opening  in  the  foreskin  remains  very  small,  so  that  even 
the  urine  escapes  with  difficulty,  and  instances  have  been  known  in  which 
individuals  have  reached  adult  life  in  this  condition,  the  foreskin  ballooning 
out  at  each  act  of  urination,  and  being  evacuated  by  pressure  with  the 
hands.  The  retention  of  urine  causes  great  inflammation  of  the  parts,  and 
calculi  may  form  between  the  foreskin  and  the  glans.  A  narrow  preputial 
1064 


PHIMOSIS. 


1065 


orifice  is  followed  by  the  same  consequences  as  a  narrow  meatus, — distention 
of  the  urinary  channels  and  various  nervous  conditions.  The  milder  forms 
interfere  with  the  cleanliness  of  the  glans  because  the  foreskin  cannot  be 
retracted,  and  the  sticky  secretion  known  as  smegma  collects  and  gives  rise  to 

balanitis  or  intensifies  any  vene- 
real inflammation.  A  foreskin 
with  an  orifice  of  good  size  but 

Fig.  820. 


Fig.  819. 


Phimosis — the  orifice. 


Phimosis— the  redundancy. 


adherent  to  the  glans  may  also  cause  frequent  micturition  or  sexual  hyper- 
sesthesia,  and  may  give  rise  to  the  habit  of  masturbation  on  account  of  the 
local  irritation. 

Treatment. — A  narrow  preputial  orifice  should  be  enlarged  by  the 
operation  of  circumcision,  which  consists  in  removing  a  portion  of  the  fore- 
skin, or  by  a  simple  dorsal  incision.  The  latter  expedient  is  useful  in  cases 
of  extensive  venereal  disease,  in  which  it  is  desirable  to  make  the  wound  as 
small  as  possible,  for  fear  of  infection  of  the  fresh  wound  surfaces,  but  even 
in  such  cases  it  should  be  followed  later  by  a  typical  circumcision.  In  the 
adherent  prepuce  of  children,  if  the  orifice  is  fairly  large  and  the  foreskin 
not  redundant,  it  is  allowable  to  separate  the  adhesions  without  any  cutting 
operation.  The  mother  must  then  be  taught  to  draw  the  foreskin  back  daily 
and  to  cleanse  the  glans,  replacing  the  foreskin  to  avoid  paraphimosis. 

Circumcision. — The  operation  of  circumcision  is  begun  by  seizing  the 
edges  of  the  preputial  orifice  with  two  or  three  artery  clamps  and  thus 
putting  the  inner  layer  of  the  foreskin  upon  the  stretch.  A  special  pre- 
putial clamp,  or  the  handles  of  a  pair  of  scissors  which  come  together 
flatly,  are  then  placed  upon  the  prepuce  so  as  to  grasp  it  from  side  to  side, 
the  clamp  being  at  an  angle  of  about  forty-five  degrees  with  the  long  axis 
of  the  organ  and  parallel  with  the  dorsum  of  the  glans.  The  redundant 
part  of  the  foreskin  is  then  cut  away  with  a  sharp  knife  or  with  a  pair  of 
scissors,  keeping  close  to  the  clamp  on  the  side  next  to  the  glans.  Unless 
the  knife  is  very  sharp,  it  is  best  to  transfix  the  flap  of  skin  in  the  centre 
and  cut  outward  in  order  to  make  a  smooth  cut.     The  cutaneous  layer  of  the 


1066  CIECUMCISIOyr. 

prepuce  then  retracts,  leaving  the  raw  surface  of  the  inner  layer  exposed. 
The  opening  in  the  inner  layer  must  then  be  enlarged  by  a  dorsal  median 
incision  extending  to  the  corona,  and  the  two  triangular  flaps  thus  made  are 
peeled  off  the  surface  of  the  glans  by  tearing  the  adhesions  or  dissecting 
them  away  with  a  knife  if  they  are  very  strong.  In  infants,  as  a  rule,  the 
inner  layer  of  the  prepuce  can  be  split  by  seizing  it  with  the  thumb-nails 
so  as  to  tear  it  and  separate  the  adhesions  at  the  same  time.  The  accumu- 
lated smegma  must  be  thoroughly  removed,  the  sharp  corners  of  the  inner 
flaps  cut  away  and  rounded,  and  then  the  inner  layer  united  to  the  outer  by 
interrupted  sutures.  (Fig.  821.)  There  is  usually  no  hemorrhage  of 
moment,  and  if  the  artery  at  the  frenum  should  be  troublesome  it  may  be 
included  in  one  of  the  sutures.  Special  care  must  be  taken  in  making  the 
incision  not  to  slice  off  the  end  of  the  glans,  an  accident  which  may  readily 
occur  if  strong  adhesions  exist,  and  not  to 
Fig-  821.  shorten  the  frenum  too  much,  because  of  the 

disagreeable  dragging  a  short  frenum  causes 
during  erection.  The  oblique  incision  avoids 
the  latter  error,  and  also  makes  the  opening 
larger.  Thorough  asepsis  should  be  observed, 
and  at  the  conclusion  of  the  operation  the 
wound  is  dressed  by  winding  a  strip  of  gauze 
around  the  penis.  This  may  be  secured  in 
place  by  collodion  or  by  strips  of  rubber 
plaster.  In  infants  the  dressings  will  be 
constantly  wet  with  urine,  and  should  be 
removed  after  the  first  twenty-four  hours, 
the  mother  applying  sterilized  gauze  covered  with  boric  acid  ointment  after 
each  urination.  In  nervous  individuals  and  in  children  it  is  wise  to  employ 
general  anaesthesia  for  circumcision,  but  in  the  ordinary  adult  the  operation 
can  be  performed  under  local  antesthesia.  In  infants  anaesthesia  is  not 
necessary,  as  the  operation  may  be  completed  in  a  few  minutes. 

Paraphimosis. — If  a  iirepuce  with  a  moderately  tight  orifice  be  drawn 
backward  over  the  glans  in  plaj',  in  violent  coitus,  or  in  attempts  to  uncover 
the  glans  for  washing,  especially  during  the  existence  of  venereal  disease, 
the  narrow  band  may  be  caught  behind  the  corona,  and  the  individual  will 
be  unable  to  draw  it  forward  again.  To  this  condition  the  name  of  para- 
phimosis has  been  given.  The  constriction  of  the  narrow  band  around  the 
organ  impedes  the  circulation  of  the  glans,  and  the  inner  layer  of  the  pre- 
puce, which  is  usually  everted  as  the  prepuce  is  retracted,  then  becomes 
cedematous,  and  may  slough  if  the  pressure  is  not  relieved  in  time.  As  a 
rule,  the  constricting  bands  slough  first,  and  the  circulation  is  thus  restored 
sufficiently  to  prevent  complete  gangrene  of  the  parts  beyond.  As  the 
result  of  the  swelling  the  inner  layer  of  the  prepuce  forms  a  series  of  trans- 
verse folds  with  deep  fissures  between  them,  but  the  greatest  constriction 
will  always  be  made  by  the  edge  of  the  preputial  orifice,  and  is  usually 
found  at  the  uppermost  of  the  transverse  fissures. 

Treatment. — To  reduce  a  paraphimosis  the  parts  should  be  immersed 
in  very  hot  water  for  some  time  ;  then  the  surgeon  takes  the  organ,  well 


PARAPHIMOSIS. 


1067 


Fig.  822. 


lubricated,  between  his  hands,  placing  the  forefingers  and  middle  fingers 
around  it  behind  the  constriction,  and  compressing  the  glans  and  swollen 
layer  of  the  prepuce  svith  the  thumbs,  while  at  the  same  time  he  endeavors 
to  force  the  glans  back  and  draw  the  sheath  forward  with  the  interlocked 
fingers.  Or  the  organ  may  be  seized  in  one  hand  and  the  swollen  parts 
compressed  between  the  fingers  and  the  thumb  of  the  other,  forcing  them  at 
the  same  time  backward.  (Fig.  822.)  All  attempts  at  reduction  sliould 
be  preceded  by  concentric  pressure  or  the 
application  of  an  elastic  bandage,  in  order  to 
reduce  the  oedema  as  far  as  possible.  Multiple 
scarification  may  be  employed  with  the  same 
end  in  view.  The  reduction  may  be  so  painful 
that  general  antesthesia  will  be  necessary.  If 
the  operator  can  pass  his  thumb-nail  under 
the  constricting  band  he  can  usually  succeed 
in  reducing  the  displacement  by  lifting  the 
band  and  sliding  it  forward  over  the  nail. 
The  loop  of  a  hair-pin  or  a  bent  wire  will 
also  be  found  a  very  useful  instrument,  as  it 
can  be  inserted  under  a  very  tight  band,  and 
then  by  sweeping  it  around  the  glans  the  fore- 
skin may  be  drawn  forward  over  it  in  a  similar 
fashion.  If  the  i^araphimosis  proves  irredu- 
cible, an  incision  should  be  made  in  the 
median  line  of  the  dorsum  over  the  deei^est 
of  the  transverse  fissures,  and  carried  down  until  the  constricting  band  Is 
divided.  This  can  easily  be  done  under  local  anaesthesia,  but  it  is  wise  to 
make  a  long  incision  and  not  attempt  to  divide  the  band  with  the  point  of 
the  knife,  for  infection  is  less  likely  to  occur  if  the  parts  are  thoroughly 
exposed.  In  many  cases  where  the  extent  of  the  strangulation  is  not  suffi- 
cient to  cause  sloughing,  the  parts  become  habituated  to  the  impeded  circu- 
lation, the  oedematous  folds  become  filled  with  newly  formed  connective 
tissue,  and  a  permanent  enlargement  of  the  end  of  the  organ  is  produced, 
which  resembles  elephantiasis.  The  treatment  of  this  condition  consists  in 
multiple  scarification,  hot  baths,  massage,  and  the  elastic  bandage.  If  these 
measures  fail,  the  hypertrophied  tissue  may  be  cut  away. 

Injuries. — Accidental  injuries  of  the  penis  are  rare.  Contusions,  and 
lacerated,  incised,  and  gunshot  wounds  may  be  accompanied  by  serious 
external  hemorrhage,  or  by  the  formation  of  a  large  hsematoma.  Sloughing 
seldom  occurs,  and  even  if  the  entire  skin  of  the  penis  and  the  scrotum  be 
torn  away,  as  occasionally  results  from  the  bite  of  a  hoi'se  or  when  the  organs 
are  caught  with  the  clothing  in  machinery,  the  skin  is  restored  with  astonish- 
ing rapidity.  (Fig.  823.)  These  injiu-ies  are  often  complicated  with  injuries 
to  the  urethra  and  extravasation  of  urine,  and  this  is  their  principal  danger. 
If  a  plastic  operation  is  necessary  to  provide  a  covering  for  the  penis,  it  may 
be  done  by  forming  a  bridge-like  flap  from  the  skin  of  the  lower  part  of  the 
abdomen,  between  two  horizontal  incisions,  one  at  the  pubes  and  the  other 
several  inches  higher,  and  slipping  the  denuded  organ  under  this  bridge. 


Reduction  of  paraphimosis.     (Agnew.) 


1068 


INJURIES  OF  THE  PENIS. 


Spontaneous  restoration  of  scrotum  aft 
sloughing. 


One  -week  later  one  end  of  tlie  flap  is  divided  and  the  end  turned  in  and 

secured  around  tlie  penis.     After  another  week  the  other  pedicle  may  also 

be  divided  and  secured  in  like 
Fic   S"'? 

manner.     The   only  difficulty  in 

the  operation  consists  in  the  lia- 
bility of  the  wound  to  infection 
from  the  urine. 

Ablation. — The  penis  has  often 
beeu  amputated  by  insane  persons 
or  in  savage  warfare  without  any 
attem^jt  to  control  hemorrhage, 
and  recovery  has  ensued  in  spite 
of  the  great  loss  of  blood. 

The  forcible  bending  of  the 
penis  while  in  erection,  by  a  se- 
vere blow,  by  awkward  attempts 
at  coitus,  or  in  trying  to  straighten 
with  the  hands  the  curve  pro- 
duced in  chordee,  results  in  an 
injury  to  which  has  been  given  the 
name  of  fracture  of  the  penis.  The  fibrous  coat  of  the  corpus  caveruosum 
is  ruj)tured  by  these  means,  and  a  hsematoma  is  formed.  Eecovery  takes 
place  with  permanent  destruction  of  some  of  the  erectile  tissue  in  the  neigh- 
borhood of  the  injury,  and  results  in  a  curve  in  the  organ  during  erection 
on  account  of  the  difference  between  the  two  sides.  This  deformity  may 
remain  permanently.  A  severe  blow  upon  the  penis  when  in  a  flaccid  con- 
dition may  cause  it  to  be  displaced  under  the  skin  of  the  pubes,  its  loose 
connections  with  the  sheath  being  broken,  and  even  the  firmer  union  of  the 
glans  and  the  foreskin  giving  way.  This  accident,  which  is  called  disloca- 
tion of  the  penis,  most  frequently  happens  in  children.  Micturition 
becomes  diificult,  coition  is  impossible,  and  very  often  the  power  of  erec- 
tion is  also  lost.  If  seen  early,  these  dislocations  may  be  reduced  and 
the  penis  restored  to  its  natural  position,  but  if  neglected  it  may  be  very 
difficult  to  obtain  proper  coverings  for  the  organ,  even  when  it  has  been 
freed  by  open  incision,  as  the  original  cutaneous  sheath  will  have  become 
atrophied. 

Laceration  of  the  Frenum. — The  frenum  is  frequently  torn  during 
coitus,  and  dangerous  hemorrhage  has  been  known  to  follow,  but  the  acci- 
dent is  usually  of  importance  only  because  it  i^roduces  a  raw  surface,  which 
is  very  liable  to  venereal  infection. 

Constriction. — A  very  common  injury  of  the  penis  is  that  produced  by 
placing  upon  it  some  tight  constricting  object,  such  as  a  ring,  or  by  tying  a 
string  around  it  in  its  flaccid  state,  which  cannot  be  removed  when  erection 
follows.  The  erection  is  succeeded  by  permanent  swelling  of  the  parts 
beyond  from  cedema,  and,  as  shame  is  apt  to  prevent  the  immediate  dis- 
closure of  the  fact,  the  removal  of  the  object  may  become  exceedingly 
difficult.  Extraordinary  cases  are  on  record  in  which  a  cord  tied  tightly 
about  the  organ  has  been  left  in  place  for  years,  and  has  even  cut  its  way 


BALANOPOSTHITIS.  1069 

across  the  urethra  and  become  entirely  buried  in  the  tissues  of  the  organ, 
which  have  healed  over  it.  Treatment. — The  oedema  should  be  treated  by 
an  elastic  bandage,  or  by  multiple  punctures  or  scarification  under  aseptic 
precautions.  A  ring  can  sometimes  be  removed  by  winding  a  narrow 
bandage  tightly  over  the  distal  part,  then  passing  the  end  of  the  bandage 
under  the  ring  and  pulling  upon  it,  thus  forcing  the  ring  off  as  the  bandage 
unwinds.  If  this  fails,  a  long  incision  should  be  made,  giving  free  access, 
so  that  the  surgeon  may  see  distinctly  what  he  is  doing,  and  the  string  or 
ring  divided  with  scissors,  cutting  pliers,  or  file.  It  may  be  necessary  to 
call  in  a  mechanic  to  complete  the  work  where  heavy  metal  objects  have  to 
be  removed. 

Inflammations. — Cellulitis  and  erysipelas  are  observed  in  the 
penis,  but  usually  as  the  result  of  urinary  extravasation  or  v-enereal  infec- 
tion, and  they  do  not  differ  from  those  inflammations  in  general,  except 
that  very  early  incision  is  necessary  in  order  to  prevent  sloughing. 

Balanoposthitis. — FosthUis  is  an  inflammation  of  the  prepuce  usually 
confined  to  its  internal  lining,  and  balanitis  is  a  superficial  inflammation  of 
the  glans.  As  a  rule,  these  two  structiu-es  are  attacked  at  the  same  time  by 
inflammation,  and  the  common  cause  is  the  retention  by  the  foreskin  of  urine, 
smegma,  or  pus.  Diabetic  urine  is  a  frequent  cause.  The  inflammation 
may  be  merely  hypersemia  with  increased  secretion,  or  it  may  be  suppura- 
tive or  ulcerative.  Lupus  and  diphtheritic  inflammations  have  also  been 
described.  Ulceration  of  the  glans  and  prepuce  is  most  frequently  of 
venereal  origin,  but  it  may  be  due  merely  to  the  intense  infection  caused  by 
the  retained  secretion.  Herpetic  vesicles,  similar  to  those  so  frequently 
seen  about  the  mouth,  also  attack  the  glans  and  are  exceedingly  difficult  to 
cure,  as  relapse  is  the  rule.  They  are  small  vesicles,  about  the  size  of  a 
pin's  head,  filled  with  clear  serum,  which  becomes  cloudy  later,  and  on 
bursting  they  leave  a  superficial  ulcer  with  a  white  base  and  a  pink  inflam- 
matory areola. 

Treatment. — If  the  foreskin  can  be  retracted,  balanoposthitis  can  easily 
be  cured  in  most  cases  by  due  attention  to  cleanliness,  by  carefully  drawing 
back  the  foreskin,  cleansing  the  parts  without  rubbing,  and  laying  small 
pieces  of  dry  gauze  between  the  glans  and  the  prepuce,  drawing  the  latter 
down  over  it  to  hold  the  gauze  in  place.  The  patient  should  wear  a  pair 
of  swimming-tights  so  that  the  organ  shall  be  held  upward  against  the 
abdomen.  Bandages  are  difficult  to  retain  upon  the  penis,  and  bags  for 
holding  the  dressings  in  place  are  apt  to  become  foul,  as  they  are  not 
changed  frequently  enough.  A  fine  dry  powder,  such  as  bismuth,  calomel, 
or  aristol,  may  be  sprinkled  over  the  parts  in  addition  to  the  dry  gauze. 
In  some  cases  dry  dressings  are  not  successful,  and  recourse  must  be  had  to 
wet  dressings,  such  as  weak  solutions  of  chloride  of  zinc  or  aluminum 
acetate,  or  a  mixture  of  balsam  of  Peru  and  castor  oil.  In  other  cases  the 
ointments  answer  best, — those  of  boric  acid,  zinc  oxide,  and  ichthyol,  all 
about  ten  per  cent.  When  the  foreskin  cannot  be  retracted,  the  cavity 
beneath  it  must  be  kept  clean  by  irrigation  with  a  syringe  with  a  long 
flat  beak.  Considerable  force  must  be  used  in  the  injection  in  order  thor- 
oughly to  wash  out  all  the  crevices,  and  a  large  quantity  of  water  should 


1070  TUMORS  OF  THE  PENIS. 

be  employed.  Plain  warm  water  answers  the  purpose,  but  a  solution  of  1 
to  50  carbolic  acid,  or  of  sulphate  of  zinc  three  grains  to  the  ounce,  may 
be  tried.  In  all  cases  that  do  not  respond  at  once  to  this  treatment  the 
patients  should  be  urged  to  submit  to  circumcision,  and  even  when  a  case 
does  well  it  is  wise  to  perform  a  circumcision  afterwards  in  order  to  prevent 
a  relapse. 

Syphilis. — Syphilitic  lesions  of  the  penis  are  described  elsewhere. 

Tuberculosis. — A  rare  form  of  tuberculosis  is  one  which  causes  necrotic 
cavities  in  the  centre  of  the  cavernous  tissue  of  the  glans,  the  mucous 
membrane  giving  way  over  it  and  forming  a  deep  ragged  ulcer  somewhat 
resembling  a  gumma. 

The  cavernous  tissue  is  liable  to  an  interstitial  inflammation,  forming 
hard  fibrous  nodules  which  interfere  with  erection  by  shutting  o&  the  blood- 
supply  or  preventing  uniform  distention,  which  produces  curvature  of  the 
organ.  These  fibrous  indurations  are  most  common  in  men  of  gouty  habit, 
and  occur  late  in  life.  There  is  no  really  satisfactory  method  of  treatment. 
Lymphangitis  and  plebitis  are  seen  in  the  penis,  usually  as  the  result  of 
venereal  infection.  Lymphangitis  may  assume  a  chronic  form  that  results  in 
an  cedematous  thickening  resembling  elephantiasis,  but  true  elephantiasis 
of  the  penis  is  rare  in  America. 

Varicose  Veins. — Varicose  veins  are  seen  in  the  penis,  and  in  some 
cases  they  apparently  interfere  with  erection  by  removing  the  blood  too 
freely.  We  have  succeeded  in  restoring  the  power  of  erection  in  such  cases 
by  ligature  of  the  large  dorsal  vein.  The  real  value  of  this  procedure, 
however,  is  uncertain,  on  account  of  the  rather  hysterical  nature  of  the 
individuals  affected,  and  the  result  may  be  due  to  its  psychical  effect. 

Priapism. — Priapism  is  a  condition  of  prolonged  erection  of  the  penis 
without  sexual  desire.  It  is  usually  a  symi^tom  of  vesical  or  pelvic  irrita- 
tion, or  of  some  obscure  brain  or  spinal  cord  lesion,  and  in  some  cases  it 
appears  to  be  due  to  exhaustion  of  the  lumbar  centres  of  the  spinal  cord 
from  sexual  excess.  It  is  also  seen  in  leukaemia.  In  many  cases,  however, 
its  cause  is  not  evident,  and  it  therefore  requires  descrij)tion  among  the 
diseases  of  the  penis.  The  erection  is  usually  painful  and  always  uncom- 
fortable, and  may  last  from  twenty  days  to  as  many  weeks.  Antispasmodics 
are  of  little  avail,  and  the  application  of  ice  locally  and  the  protection  of 
the  organ  from  contact  with  the  clothing  and  bedclothes  is  all  that  can  be 
done  in  the  way  of  treatment.  In  some  cases  an  incision  into  the  corpora 
cavernosa  has  been  of  benefit.  This  operation  has  sometimes  been  followed 
by  loss  of  erectile  power,  but  the  same  result  has  also  been  seen  in  cases  not 
subjected  to  it. 

Tumors. — With  the  exception  of  papillomata,  the  benign  tumors  of  the 
penis  are  rare.  Fibroma  and  lipoma  occur,  as  well  as  sebaceous  cysts, 
the  last-named  originating  from  the  sebaceous  glands  of  the  skin,  and  also 
from  those  behind  the  corona.  These  tumors  sometimes  attain  the  size  of  a 
hen's  egg  and  are  a  serious  inconvenience  in  coition.  Angioma  is  quite 
common,  and  usually  originates  from  the  blood-vessels,  although  lymphan- 
gioma is  also  met  with.  Angioma  is  not  so  common  as  upon  the  female 
genitals,  however,  and  is  most  frequently  found  in  infants.     When  of  large 


PAPILLOMATA  OF  THE  PENIS. 


1071 


size  it  has  been  known  to  interfere  witli  erection  by  the  copious  venous 
anastomosis,  which  conducts  the  blood  away  too  rapidly.  Sarcoma  of  the 
penis  is  rare,  but  may  be  found  at  any  period  of  life. 

Papillomata. — Warts  are  most  frequent  on  the  inner  layer  of  the 
prepuce  and  on  the  frenum,  but  they  may  be  found  upon  any  part  of  the 
organ.  When  they  lie  under  the  prepuce  they  are  soft  and  moist,  but  when 
exposed  to  the  air  they  become  dry  and  hard  (Fig.  824),  and  in  some  cases 
the  epithelium  collects  upon  them  in  thick 
layers  so  as  to  form  a  true  cutaneous  horn, 
which  occasionally  attains  a  very  large  size. 
Papillomata  are  generally  due  to  the  irrita- 

FiG   S25 


Fig.  824. 


Horny  warts  of  the  prepuce.  Warts  of  the  vulTa.     (Deaver.) 

tion  excited  by  retained  secretions  caused  by  venereal  infection  or  mere  lack 
of  cleanliness.  When  caused  by  venereal  disease  they  are  sometimes  very 
numerous,  covering  the  head  of  the  i^enis  or  the  vulva  comiiletely,  and  attain- 
ing a  large  size.  (Fig.  825.)  Papillomata  appear  to  have  contagious  qualities 
even  when  there  is  no  evident  venereal  disease  in  certain  rare  cases,  and  have 
been  known  to  be  transmitted  from  husband  to  wife.  They  are  also  not 
unlikely  to  be  the  origin  of  malignant  disease  later  in  life,  and  for  these 
reasons  they  demand  prompt  and  thorough  treatment. 

Treatment. — In  some  cases  proper  attention  to  the  cleansing  of  the 
parts  and  keeping  them  dry  with  a  dusting  powder  of  calomel,  bismuth, 
and  oxide  of  zinc  will  produce  a  cure  without  further  treatment.  Warts 
should  not  be  ligated,  on  account  of  the  danger  of  infection  from  the 
sloughing  tumor  beyond  the  ligature.  When  they  are  small  and  soft 
they  can  be  readily  destroyed  by  any  of  the  milder  caustics,  such  as  pow- 
dered alum  or  acetic  acid,  and  if  they  resist  these  agents,  fuming  nitric  acid 
or  chromic  acid  should  be  freely  applied  until  the  base  has  been  well  burned. 
The  operation  may  be  rendered  painless  by  the  application  of  cocaine. 
When  they  have  existed  for  some  time  the  warts  may  become  very  hard, 
and  their  removal  by  excision  is  then  indicated,  the  hemorrhage  being  read- 
ily controlled  by  pressure  and  the  i^aiu  being  slight. 

Epithelioma. — Cancer  of  the  penis  is  almost  invariably  epithelioma, 
although  other  varieties  are  seen  in  rare  instances.  It  occurs  in  all  parts  of 
the  organ,  but  is  most  frequent  on  the  glans  and  inner  side  of  the  prepuce. 


1072 


EPITHELIOMA  OF  THE  PENIS. 


Some  authorities  claim  that  phimosis  is  a  frequent  predisposing  factor,  but 
this  is  denied  by  others.  It  frequently  originates  in  a  wart,  and  if  a  wart 
appears  indurated  at  its  base,  the  induration  tending  to  spread  to  the  sur- 
rounding tissues,  it  should  be  looked  upon  with  suspicion.  Epithelioma 
also  develops  upon  chronic  ulcers,  such  as  Tcnereal  or  simple  herpetic  ulcera- 
tions or  the  tertiary  lesions  of  syphilis,  as  well  as  at  the  borders  of  old 
fistulse.  Malignant  disease  is  most  frequently  seen  after  the  fiftieth  year, 
and  is  very  rare  before  thirty,  although  it  has  been  observed  at  eighteen 
years  of  age. 

Symptoms. — The  tumor  when  first  seen  is  usually  of  considerable  size, 
and  may  be  of  the  papillomatous  or  of  the  ulcerative  form.  In  the  first 
case  there  is  a  cauliflower  growth,  with  deej)  grooves  between  the  papillo- 
matous projections,  from  which  exudes  a  foul  discharge.    (Fig.  826.)    In  the 

ulcerating  form  an  indurated  ulcer 
Fig.  826.  jg  seen,  which  frequently  perforates 

the  urethra,  and  may  entirely  destroy 
the  glans.  In  the  later  stages,  when 
the  inguinal  glands  are  involved,  they 
too  may  ulcerate,  and  severe  hemor- 
rhage may  take  place  from  the  fem- 
oral vessels.  This  glandular  ulcera- 
tion occurs  early  in  the  disease,  and  is 
undoubtedly  the  result  of  pyogenic 
infection  taking  place  from  the  foul 
tumor  on  the  penis  in  addition  to  the 
malignant  contagion.  The  pressure 
of  the  enlarged  glands  may  obstruct 
the  return  of  blood  and  lymph  and 
cause  oedema  of  the  lower  extremi- 
ties. In  the  early  stages  the  patient  is  merely  annoyed  by  the  presence  of  the 
tumor  and  the  foul  discharge,  but  suffers  comparatively  little,  for  the  pain  is 
generally  caused  by  secondary  involvement  of  the  glands  in  the  groin  or  in 
the  pelvis.  Metastatic  deposits  are  rare  in  this  disease,  but  they  have  been 
observed  in  various  organs,  and  we  have  seen  extensive  secondary  growths 
in  the  lungs.  The  diagnosis  in  the  initial  stages  is  difficult,  but  the  malig- 
nant nature  of  the  disease  should  be  suspected  whenever  an  ulcer  shows  a 
tendency  to  bleed,  when  granulations  appear  which  are  rather  brittle,  and 
when  the  induration  at  the  base  of  the  ulcer  tends  to  spread  into  the  sur- 
rounding parts.  A  foul  discharge  from  under  a  narrow  foreskin  in  an 
elderly  man  should  awaken  suspicion  of  concealed  malignant  disease.  The 
diagnosis  should  be  made  before  the  inguinal  glands  are  enlarged,  for  a 
permanent  cure  wiU  seldom  be  possible  if  operation  is  delayed  until  the 
lymj)hatics  are  diseased,  and  it  is  wrong  to  wait  for  enlarged  glands  to  con- 
firm the  diagnosis.  A  microscopic  examination  of  a  small  fragment  of  the 
suspected  tissues  should  be  made  in  all  doubtful  cases. 

Treatment. — The  only  hope  for  cure  lies  in  very  early  and  radical 
operation.  The  entire  organ  should  be  sacrificed,  at  least  up  to  the  pnbes, 
no  matter  how  superficial  the  disease  may  be,  and  the  glands  in  the  groin 


Epithelioma  of  the  peuls. 


AMPUTATION  AND  EXTIRPATION  OF  THE  PENIS.  1073 

thoroughly  removed  at  the  same  time.  In  extensive  cases,  and  even  when 
the  tumor  is  small,  if  it  has  involved  the  corpora  cavernosa,  these  bodies 
should  be  followed  back  to  their  attachments  to  the  pubic  bone  and  com- 
pletely removed.  The  pubes  and  scrotum  should  be  shaved  and  the  parts 
sterilized  before  all  of  these  operations. 

Amputation. — The  ordinary  operation  of  amjjutation  of  the  penis,  which 
may  be  emploj^ed  for  mild  cases  or  those  of  an  uncertain  diagnosis,  is  per- 
formed by  cutting  a  circular  flap  of  skin  about  an  inch  anterior  to  where  it 
is  proposed  to  divide  the  body  of  the  organ.  The  circular  flap  is  retracted, 
and,  tension  being  made  on  the  penis,  the  surgeon  slowly  di^ides  the  cor- 
pora on  each  side  in  turn,  catching  the  main  vessels  before  or  immediately 
after  division.  The  corpus  spongiosum  should  be  dissected  from  the  corpora 
cavernosa  anterior  to  the  j)oint  of  division  of  the  latter  and  left  somewhat 
longer.  After  the  larger  vessels  are  ligated,  further  hemorrhage  from  the 
erectile  tissue  is  prevented  by  two  or  three  deep  sutures,  drawing  the  edges 
of  the  sheath  together  over  the  divided  tissues.  The  circular  flap  may  be 
united  over  the  end  of  the  stump  in  a  transverse  or  in  a  vertical  direction. 
In  the  latter  case,  which  we  consider  the  better  method,  the  urethra  is 
secured  in  the  lower  angle  of  the  wound  after  having  been  slit  up  on  its  floor 
for  at  least  half  an  inch  in  order  to  secure  a  wide  meatus  and  to  allow  for 
subsequent  contraction.  If  the  transverse  line  of  union  is  preferred,  a 
puncture  should  be  made  in  the  lower  flap  at  its  base,  and  the  end  of  the 
urethra  secured  in  this  opening,  while  the  flaps  are  completely  united  above. 

When  amputation  is  x^erformed  for  malignant  disease,  a  complete  and 
thorough  dissection  of  the  inguinal  and  femoral  regions  should  be  made  at 
the  same  time,  removing  in  one  mass  all  glands,  whether  enlarged  or  not. 
We  prefer  to  make  this  operation  a  part  of  the  former,  and  extend  the 
inguinal  incisions  well  down  to  the  root  of  the  penis,  so  as  to  remove  with 
the  glands  the  fat  and  all  the  lymphatics  running  between  that  organ  and 
the  groin.  The  control  of  hemorrhage  during  amputation  of  the  penis  by 
an  elastic  bandage  applied  at  the  base  has  been  recommended,  but  we  have 
found  it  unnecessary,  and  it  interferes  with  the  complete  removal  of  the 
organ.  The  secret  of  controlling  the  hemorrhage  is  the  deliberate  division 
of  the  parts,  picking  up  the  bleeding  vessels  with  the  artery  clamps  as  soon 
as  they  are  divided.  Particular  care  must  be  taken  that  all  hemorrhage  is 
arrested  before  the  wound  is  closed,  as  ligatures  may  loosen  or  slip  off,  or 
oozing  points  may  give  trouble  a  few  hours  after  the  operation. 

Extirpation. — In  the  more  complete  operation,  called  extirj)ation  of  the 
penis,  the  corpora  cavernosa  are  dissected  from  the  rami  of  the  pubes. 
Removal  of  the  contents  of  both  groins  may  be  combined  with  it,  the 
incisions  in  the  groins  being  made  to  meet  at  the  root  of  the  penis,  and  the 
glands  and  fat  being  removed  in  one  mass  and  left  attached  to  the  root  of 
the  organ.  (Fig.  827.)  The  penis  is  then  circumscribed  by  a  circular 
incision,  dividing  only  the  skin,  and  the  scrotum  is  then  split  in  two  by 
raj)id  strokes  with  stout  scissors  following  the  raphe.  By  blunt  dissection 
the  testicles,  remaining  in  their  tunics,  are  readily  separated,  and  the  two 
halves  of  the  scrotum  are  held  aside  by  assistants  while  the  operator  dis- 
sects out  and  lays  bare  the  attachments  of  the  cor^jora  cavernosa  to  the 


1074 


EXTIRPATION   OF  THE  PENIS. 


pubic  bone  on  each  side.  The  root  of  the  penis  with  the  masses  of  lym- 
phatic glands  attached  is  then  seized  and  drawn  forward,  and  the  suspen- 
sory ligament  is  divided  so  that  the  whole  mass  comes  away  from  the  pubes. 


Extirpation  of  penis.    Flap  of  skin  retracted  upward,  entire  contents  of  groin  dissected  out  cleanly. 

The  operator  separates  the  attachments  of  the  corpora  cavernosa  downward 
along  the  pubic  bones  with  a  periosteal  elevator.     The  main  vessels  may 

Fig.  828. 


Extirpation  of  penis.    Dissection  completed  and  penis  and  glands  removed  In  one  mass  after  division 
of  the  urethra. 

o-ive  some  difficulty,  but  are  generally  secured  with  ease  with  clamps,  and 
can  then  be  ligated.  The  penis  then  remains  attached  to  the  body  only  by 
the  urethra,  and  this  is  divided.     (Fig.  828.)    The  stump  of  the  ui-ethra  is 


INJURIES  OF  THE  SCROTUM.  1075 

split  as  described  above,  and  tlie  edges  of  the  mucous  membrane  secured  to 
the  skin  of  the  j)erineum  just  behind  the  scrotum  by  sutures.  The  edges 
of  the  skin  are  united  throughout  the  wound,  two  or  three  deep  sutures 
being  placed  in  the  middle  line  to  hold  the  two  halves  of  the  scrotum  in 
position. 

When  the  disease  has  not  attacked  the  corpus  spongiosum,  we  have  found 
it  of  advantage  to  the  patient  to  dissect  it  from  the  cavernosa  and  to  leave  the 
ui'ethra  long  enough  to  bring  the  end  of  that  canal  forward  between  the  two 
halves  of  the  scrotum  and  secure  it  upon  the  anterior  surface  of  the  latter. 
When  the  wound  has  healed,  micturition  is  very  much  easier  with  the  meatus 
in  this  position,  because  the  patient  can  stand  up,  and  by  supporting  the 
scrotum  with  one  hand  he  has  a  natural  funnel  to  direct  the  flow  of  urine 
beyond  his  feet.  When  the  opening  is  in  the  perineum  he  is  compelled  to 
adopt  the  sitting  posture  in  order  to  empty  the  bladder.  If  the  penis  is 
amputated  at  the  pubic  bone,  the  patient  should  carry  a  small  funnel  with 
him,  which  can  be  placed  over  the  stump  of  the  organ  in  order  to  direct  the 
stream  beyond  the  feet.  The  after-treatment  of  these  cases  presents  nothing 
unusual.  If  the  consent  of  the  patient  can  be  obtained,  castration  should 
always  be  performed  a,t  the  same  time  as  amputation  of  the  penis,  for  sexual 
desire  is  sometimes  troublesome  afterwards,  and  it  has  been  abundantly 
shown  that  the  removal  of  the  testicles  late  in  life  does  not  affect  the  char- 
acter or  mental  qualities  of  the  individual.  The  patient,  however,  will 
usually  refuse  to  consent  to  further  mutilation. 

The  percentage  of  cures  after  these  operations  for  malignant  disease  of 
the  penis  is  as  yet  uncertain,  too  few  cases  being  on  record  that  have  been 
followed  sufficiently  long  to  determine  this  point.  It  would  appear  possible, 
however,  to  obtain  cures  by  thorough  operations  in  thirty  or  forty  per  cent, 
of  the  cases  at  the  time  when  they  are  usually  seen.  Partial  operations 
offer  no  hope  whatever  of  a  cure. 

INJURIES   AND   DISEASES   OF   THE   SCROTUM. 

Injuries. — Injuries  of  the  scrotum,  with  the  exception  of  contusions, 
are  not  common,  and  these  are  remarkable  for  the  size  of  the  htematoma 
which  may  form  on  account  of  the  rupture  of  large  veins  and  the  loose  char- 
acter of  the  cellular  tissue,  which  allows  great  effusion  of  blood.  The 
extravasation  may  be  in  the  connective  tissue,  forming  a  htematocele  of  the 
scrotum,  which  frequently  reaches  the  size  of  a  man's  head,  and  the  ecchy- 
mosis  may  extend  well  up  on  the  abdomen.  The  blood  may  also  be  confined 
in  the  tunica  vaginalis,  and  then  the  tumor  is  smaller  and  the  skin  not 
adherent.  It  may  occupy  both  situations  at  once.  The  treatment  of  these 
injuries  consists  in  the  application  of  ice  and  compression  in  the  early 
stages,  followed  by  massage.  Any  abrasions  ijresent  must  be  cleansed  and 
dressed  in  the  most  careful  and  aseptic  manner,  lest  cellulitis  occur,  with 
breaking  down  of  the  blood- clot.  Should  suppuration  begin,  a  free  incision 
must  be  made  and  the  broken-down  blood-clot  turned  out.  Lacerated  and 
incised  wounds  also  need  careful  treatment  for  similar  reasons. 

Inflammations. — The  tissues  of  the  scrotum  are  unusually  liable  to 
infection  and  to  cause  severe  sepsis.     They  slough  very  readilj^,  but  are 


1076 


CO^fGENITAL  ANO:\IALIES   OF  THE  TESTICLE. 


Fig.  S29. 


readily  restored,  the  entire  skin  of  the  scrotum  being  reproduced  in  three  or 
four  months  by  new  growth  and  by  cicatricial  contraction,  which  di'aws  the 
skin  of  the  neighboring  parts  over  the  testicles.  Cellulitis  of  the  scrotum 
requires  very  free  and  deep  incisions  down  to  the  tunica  vaginalis  or  in  the 
raphe  between  the  two  sacs.  The  scrotum  is  liable  to  the  ordinary  diseases 
of  the  skin,  and  they  are  unusually  difficult  to  treat  because  of  the  natural 
moisture  and  constant  friction. 

Tumors. — Tumors  appear  on  the  skin  here  as  elsewhere,  and  epithe- 
lioma is  very  common  in  persons  of  uncleanly  habits,   often  developing 

upon  a  chronic  eczema  or  psoriasis  which 
has  been  neglected.  It  has  been  shown  that 
chimney  -  sweep' s  cancer,  which  is  an  epithe- 
lioma of  the  scrotum,  is  dependent  upon 
uncleanly  habits  as  well  as  upon  the  irrita- 
tion of  the  soot,  for  the  disease  was  extremely 
common  among  the  chimney-sweeps  of  Lon- 
don, while  the  same  class  of  men  in  Belgium, 
who  took  greater  care  of  their  persons,  were 
free  from  it.  Similar  epitheliomata  occur 
on  other  parts  of  the  body  among  the  work- 
men in  paraffin  factories.  Fatty  tumors 
develop  in  the  scrotum,  especially  in  con- 
nection with  the  cord,  and  may  attain  a 
very  large  size  and  entirely  surround  the 
testicle.  Elephantiasis  of  the  scrotum  is 
common  in  connection  with  elefyhantiasis  of 
the  penis  and  lower  extremities,  and  is  due 
to  the  same  causes.  (Fig.  829.)  In  this  coun- 
try we  rarely  see  the  elephantiasis  due  to 
the  filaria  parasite,  but  similar  changes  are 
produced  by  chronic  inflammatory  fibrous 
thickening  of  the  tissues,  when  oedema  from  any  cause  persists  for  a  long 
time.     (See  page  317. ) 

INJUEIES   AND   DISEASES   OF   THE  TESTICLE. 

Congenital  Anomalies. — The  congenital  abnormalities  of  the  testicles 
consist  almost  entirely  in  vai'iations  from  their  normal  position,  although  in 
rare  cases  complete  absence  of  at  least  one  of  the  glands  has  been  observed. 
The  testicle  is  sometimes  found  reversed  in  its  po.sition  in  the  scrotum,  the 
epididymis  being  turned  forward  and  the  tunica  vaginalis  lying  posteriorly, 
so  that  the  gland  would  be  in  danger  of  injury  when  tapping  a  hydrocele. 

Normal  Descent  of  the  Testicle. — In  early  foetal  life  the  testicle 
occupies  a  position  within  the  abdomen  near  the  posterior  crest  of  the 
ilium,  in  close  relation  to  the  kidney,  the  latter  ascending  as  development 
proceeds,  and  the  testicle  descending  towards  the  inguinal  ring.  A  fibrous 
band  containing  some  muscular  fibres,  known  as  the  gubernaculum,  passes 
from  the  lower  end  of  the  testicle  to  the  inguinal  ring,  and  is  divided  into 
three  branches,  one  of  which  goes  to  the  bottom  of  the  scrotum,  one  to  the 


Elephantiasis  of  tbe  scrotum. 


ECTOPIC  AND  UNDESCENDED  TESTICLE. 


1077 


perineum,  aud  one  to  the  femoral  region,  the  first  being  usually  the  most 
powerful.  The  exact  mechanics  of  the  descent  of  the  testicle  are  not  under- 
stood, but  as  it  proceeds  the  gubernaculum  shortens,  and  the  latter  is  sup- 
posed to  guide  the  gland  to  its  proper  position.  The  testicle  enters  the 
inguinal  canal  by  the  internal  ring,  traverses  its  whole  extent,  and  passes 
into  the  scrotum  through  the  external  ring,  bringing  down  the  spermatic 
cord  and  leaving  it  in  its  track.  As  the  testicle  advances  it  pushes  before 
it  a  pouch  of  peritoneum  which  covers  its  anterior  surface  and  is  known  as 
the  vaginal  process.  When  the  testicle  has  reached  the  scrotum  the  neck 
of  this  process  of  peritoneum  is  completely  obliterated  by  natural  contrac- 
tion, and  the  serous  lining  of  the  abdomen,  seen  from  within,  normally 
presents  a  flat  surface  at  the  internal  ring,  with  no  trace  of  its  previous 
connection  with  the  pouch.  The  lower  end  of  the  protruded  mucous  mem- 
brane forms  the  tunica  vaginalis,  surrounding  the  testicle  and  extending  a 
variable  distance  up  the  cord  towards  the  external  ring.  A  thorough 
understanding  of  this  method  of  descent  is  also  important  for  a  proper  com- 
prehension of  the  varieties  of  hernia. 

Ectopic  and  Undescended  Testicle. — The  testicle  should  have 
reached  the  scrotum  and  the  vaginal  process  should  be  closed  at  birth.  The 
descent  of  the  testicle  may,  however,  be  delayed  so  that  it  will  lie  at  the 
external  ring  or  in  the  inguinal  canal  until  much  later,  and  in  some  cases  it 
is  retained  there,  or  even  within 

the   abdomen,   throughout   life.  ^"^-  S^*^- 

In  still  other  cases  it  may  be 
found  lodged  in  the  perineum  or 
in  the  groin  (Fig.  830),  probably 
because  it  has  followed  the  fibres 
of  the  gubernaculum  leading 
thither.  When  the  testicle  re- 
mains within  the  abdomen  it  is 
said  to  be  retained  or  undescended. 
When  it  is  not  in  its  natural  po- 
sition, but  has  passed  out  of  the 
abdomen,  it  is  said  to  be  ectopic. 
An  ectopic  or  retained  testicle  is 
usually  more  or  less  atrophic  or 
undeveloped,  being  composed 
largely  of  connective  tissue.     A  W*' 

rstlined  testicle  is  more  likelv  to  Ectopic  testicle.    Tine  left  testicle  is  on  the  fascia  lata 

■^  below  Poupart's  ligament,  and  the  right  half  of  the  scro- 

be  well  developed  than  an  ectopic     tum  contains  the  right  testicle  and  an  inguinal  hemia. 

one.    Inflammation  of  an  ectopic 

testicle,  especially  if  it  lies  in  the  inguinal  canal,  is  apt  to  be  very  severe 
aud  to  cause  great  pain  on  account  of  the  additional  tension  diie  to  its  con- 
finement by  strong  fibrous  structures.  The  ectopic  or  undescended  testicle 
is  very  liable  to  malignant  disease.  Undescended  testis  is  fi'equently  com- 
bined with  hernia,  as  has  already  been  mentioned. 

Treatment. — An  ectopic  testicle  which  causes  no  symptoms  is  best 
left  untouched  unless  there  appears  to  be  a  reasonable  chance  of  placing 

69 


1078  INJURIES   OF  THE  TESTICLE. 

it  in  the  scrotum.  If  inflamed,  or  threatening  to  form  a  tumor,  it  should  be 
removed.  To  replace  the  organ  in  the  scrotum,  it  is  exposed  by  free  incision 
and  dissected  out,  the  cord  being  drawn  out  as  much  as  possible.  The 
gland  is  then  placed  in  a  bed  made  for  it  in  the  scrotum,  and  secured  by 
sutures  passing  through  its  capsule.  In  these  cases  the  corresponding  half 
of  the  scrotum  is  liable  to  be  small  and  atrophic,  but  it  is  usually  large 
enough  to  contain  the  small  gland.  When  the  testicle  is  situated  at  the 
internal  ring  or  just  within  the  inguinal  canal,  it  can  sometimes  be  pushed 
downward  by  the  pressure  of  a  truss  properly  applied.  The  pad  should 
have  a  slight  concavity  on  the  end  for  the  testicle,  and  should  be  worn 
day  and  night.  These  means  of  treatment  are,  however,  very  unsatisfactory 
in  extreme  cases,  for  the  testicle  is  so  small  as  to  be  of  little  value,  and  the 
necessary  manipulation  is  apt  to  impair  its  vitality  still  further.  If  the 
other  testicle  is  in  good  condition,  and  the  patient  has  passed  the  age  of 
puberty,  and  his  consent  can  be  obtained,  it  is  wiser  to  sacrifice  the  ectopic 
gland.  For  the  testicle  retained  in  the  abdomen  nothing  can  be  done,  but 
the  patient  should  be  kept  under  observation,  in  order  that  the  testicle  may 
be  removed  promptly  at  the  first  sign  of  enlargement,  on  account  of  the 
tendency  to  malignant  disease. 

Injtiries. — 'Wounds  of  the  testicle  are  very  rare  and  scarcely  need 
mention.  Contusions,  however,  are  exceedingly  common,  and  are  fol- 
lowed, as  a  rule,  by  extensive  hsematocele,  which  may  result  in  complete 
disorganization  of  the  gland  and  be  followed  by  its  complete  atrophy.  The 
injury  to  the  gland  will  often  be  masked  at  first  by  hsematocele  of  the  scro- 
tum or  of  the  tunica  vaginalis.  Hsematocele  of  the  testicle  may  be  the  result 
of  severe  muscular  effort,  although  the  explanation  of  these  cases  is  difficult. 
The  most  widely  accepted  theory  is  that  the  intense  contraction  of  the 
cremaster  muscles  during  violent  muscular  exertion  compresses  the  testicle 
so  strongly  against  the  pubic  arch  or  the  inguinal  ring  as  to  ruj^ture  a  blood- 
vessel in  the  gland.  It  is  probable,  however,  that  in  many  cases  some 
sudden  and  severe  pressure  of  the  clothing  occasions  the  injury.  The 
symptoms  of  a  severe  contusion  of  the  testicle  are  a  feeling  of  faintness, 
caused  by  the  pressure,  like  the  well-known  testicular  sensation,  followed 
by  intense  pain  in  the  testicle  or  a  dull,  heavy  ache,  which  may  become 
throbbing  and  be  accompanied  by  considerable  lumbar  pain.  The  injury 
is  marked  by  very  severe  shock,  which  has  sometimes  caused  death. 

Treatment. — The  treatment  of  these  cases  consists  of  rest  in  bed,  the 
scrotum  being  supported  on  a  platform  made  of  a  bandage  or  a  towel 
stretched  across  the  thighs,  and  the  application  of  an  ice-bag.  In  the  later 
stages  careful  massage  and  the  application  of  an  elastic  bandage  will  hasten 
the  absorption  of  the  effusion,  and  a  suspensory  should  be  worn  afterwards 
until  the  testicle  has  reached  its  normal  size.  The  preservation  of  the  func- 
tion of  the  organ  is  best  assured  by  complete  rest  during  the  early  stages,  so 
that  the  blood-clot  may  be  absorbed  as  rapidly  as  possible. 

Torsion. — A  peculiar  displacement  of  the  testicle,  known  as  torsion, 
consisting  of  rotation,  with  twisting  of  the  cord,  sometimes  occm-s.  It  is 
rendered  possible  by  an  abnormal  arrangement  of  the  tunica  vaginalis,  which 
forms  a  sort  of  mesentery  to  the  testicle  and  cord  in  these  cases  and  leaves 


INFLAMMATION  OF  THE  TESTICLE.  1079 

the  gland  much  freer  in  its  movements  within  the  cavity  than  is  natural, 
and  a  sudden  movement  may  rotate  the  testicle  upon  its  long  axis,  twisting 
the  cord  and  suspending  the  circulation.  In  slight  cases  a  momentary  pain 
is  felt,  but  the  testicle  soon  returns  to  its  position  and  the  symptoms  disap- 
pear. In  severe  cases,  however,  the  testicle  does  not  return,  and  the  twist 
may  increase,  the  circulation  may  be  cut  off  entirely,  and  gangrene  of  the 
gland  result.  The  symptoms  are  similar  to  those  of  acute  inflammation. 
When  they  are  severe,  spontaneous  reduction  does  not  take  place. 

Treatment. — The  testicle  should  be  exposed  by  an  incision  into  the 
tunica  vaginalis  and  the  twist  reduced  if  the  gland  is  not  necrotic,  but  if 
gangrene  threatens,  the  testicle  should  be  removed  at  once.  In  cases  in 
which  slight  attacks  occur  repeatedly,  the  testicle  may  be  secured  in  place 
by  a  suture,  the  needle  picking  up  the  skin  of  the  scrotum  and  the  anterior 
surface  of  the  capsule  of  the  testicle,  either  catgut  or  fine  silk  being  used. 
It  is  not  necessary  to  make  an  incision  for  thi^  pui-pose,  and  the  adhesion 
produced  by  a  single  stitch  should  be  sufficient,  for  we  have  followed  a  case 
so  treated  years  ago  and  there  has  been  no  relapse. 

Dislocation. — A  rare  accident  is  traumatic  dislocation  of  the  testicle, 
the  latter  being  driven  from  its  place  in  the  scrotum  into  the  subcutaneous 
tissue  in  front  of  the  pubes,  or  on  the  side,  or  even  into  the  sheath  of  the 
penis.  If  the  testicle  ca,nnot  be  restored  by  manipulation,  it  should  be 
exposed  by  incision  and  replaced  or  removed. 

Hernia  Testis. — A  protrusion  of  the  substance  of  the  testicle  through 
an  opening  in  the  tunica  albuginea,  or  a  mass  of  exuberant  granulations 
forming  upon  the  latter  are  known  as  hernia  or  fungus  of  the  testicle. 
These  conditions  may  follow  an  injury  in  rare  cases,  but  are  most  frequently 
the  result  of  ulceration,  either  tuberculous  or  syphilitic. 

Treatment. — The  superficial  form  can  be  treated  by  excising  or  cauter- 
izing the  granulations  and  strapping  the  testicle.  When  the  substance  of, 
the  testicle  protrudes,  the  projecting  part  is  to  be  excised  with  its  base, 
making  a  wedge-shaped  wound,  and  the  tunica  united  by  sutures.  In 
extreme  cases,  when  nearly  the  entire  testicle  protrudes  or  has  been 
destroyed,  castration  is  the  proper  treatment.  The  protrusion  of  a  malig- 
nant tumor  must  not  be  confused  with  hernia  testis. 

Inflammations. — Inflammation  of  the  body  of  the  testicle  is  called 
orchitis,  and  that  of  the  epididymis  epididymitis.  The  inflammation  may  be 
acute  or  chronic,  and  in  some  cases  results  in  suppuration.  It  may  be  due  to 
gonorrhoea,  to  metastasis  in  mumps  or  epidemic  parotitis  or  in  pyaemia, 
to  tuberculosis,  and  to  syphilis.  Orchitis  is  also  observed  in  typhoid  and 
malarial  fevers  and  in  gout.  Gonorrhceal  inflammation  may  be  observed  in 
the  acute  stage,  and  may  even  follow  the  passage  of  a  sound  for  any  purpose 
years  after.     (See  section  on  Gonorrhoea.) 

The  inflammation  of  mumps  is  usually  an  orchitis,  and  causes  a 
tender  swelling  of  the  gland  of  moderate  size,  the  pain  not  being  so  acute  as 
in  the  gonorrhceal  form.  In  some  cases,  however,  there  are  high  fever  and 
great  constitutional  disturbance.  This  inflammation  runs  a  course  of  a  week 
or  a  fortnight,  gradually  subsiding,  and  generally  has  no  evil  consequences, 
although  atrophy  has  occasionally  been  observed.     The  treatment  consists 


1080  TUBERCULOSIS  OF  THE  TESTICLE. 

in  rest  in  bed,  laxatives,  light  diet,  and  tlie  application  of  an  ice-bag  to  the 
parts.  A  suspensory  bandage  should  be  used  when  the  j)atient  is  up  and 
about.  Metastatic  abscesses  develop  in  the  testicle  in  cases  of  pygemia, 
and  have  the  usual  subacute  character  of  abscesses  of  this  nature,  the  gland 
being  moderately  enlarged  and  tender,  but  without  great  pain,  and  giving 
no  distinct  evidence  of  pus  until  quite  late.  The  treatment  should  consist 
in  incision  as  soon  as  supj)uration  can  be  demonstrated. 

Tuberculosis. — Tuberculosis  of  the  testicle  is  generally  due  to  blood 
infection,  being  the  primary  lesion  in  tuberculosis  of  the  male  genitals,  but 
in  some  cases  it  is  secondary  to  tuberculosis  of  the  prostate  or  other  parts, 
the  infection  reaching  the  testicle  by  the  vas  deferens.  The  pathological 
changes  consist  in  the  appearance  of  tubercles,  which  become  cheesy 
and  calcareous  or  break  down  into  cold  abscesses.  They  almost  invariably 
appear  first  in  the  epididymis.  Earely  a  miliary  form  is  observed.  Symp- 
toms.— The  disease  may  be  acute  or  chronic  in  its  beginning  and  course, 
but  it  is  usually  subacute.  The  patient  is  seized  with  a  slight  pain  in  the 
testicle  and  a  slight  swelling  appears  in  the  epididymis,  with  which  some 
hydrocele  may  be  associated.  An  abscess  of  small  size  slowly  forms  with- 
out much  pain  and  then  discharges,  leaving  a  sinus.  The  symptoms  disai^- 
pear,  but  an  indurated  nodule  and  the  sinus  persist.  In  some  cases  the 
attack  may  begin  as  acutely  as  a  gonorrhceal  epididymitis,  while  in  others  a 
small  i^ainless  induration  is  observed  in  the  epididymis,  which  causes  no 
symptoms,  but  steadily  increases  in  size,  and  at  the  end  of  some  months 
may  produce  a  small  abscess.  A  nodular  or  uniform  infiltration  of  the 
spermatic  cord  is  frequently  observed.  If  the  disease  is  limited  to  the  tes- 
ticle the  patient  will  suffer  very  little  in  general  health,  but,  as  a  rule,  it  is 
found  associated  with  similar  disease  of  the  prostate  and  seminal  vesicles. 
The  disease  attacks  young  adults  from  twenty  to  thirty  years  of  age,  and 
not  infrequently  follows  an  acute  attack  of  gonorrhoea.  Diagnosis. — In  the 
acute  cases  its  diagnosis  from  gonorrhceal  epididymitis  may  be  very  difficult. 
In  the  early  stages  the  small,  hard  nodules  resemble  those  left  by  a  gonor- 
rhceal epididymitis,  but  the  latter  are  usually  in  the  globus  minor,  while 
the  tuberculous  infiltration  is  apt  to  attack  the  globus  major.  The  presence 
of  tuberculous  nodules  in  the  prostate  will  assist  in  the  diagnosis.  The 
tendency  to  break  down  into  abscesses  will  distinguish  the  rapidly  growing- 
forms  from  malignant  tumors.  The  diagnosis  of  the  chronic  form  depends 
upon  the  combination  of  induration  with  spots  of  softening,  and  the  pres- 
ence of  sinuses  or  sluggish  abscesses.  Eectal  examination  should  never  be 
omitted,  for  evidences  of  disease  of  the  prostate  or  seminal  vesicles  may  be 
obtained  in  the  majority  of  cases. 

Prognosis. — The  course  of  tuberculosis  is  usually  very  slow,  even  in 
those  cases  which  begin  acutely,  and  there  can  be  no  question  that  sijonta- 
neous  recovery  takes  place  in  many  instances.  The  chances  are  best  when 
there  are  no  other  tuberculous  lesions. 

Treatment. — Eecovery  sometimes  follows  proper  attention  to  diet,  and 
a  life  in  the  open  air  in  a  good  climate,  with  freedom  from  care  and  respon- 
sibility. The  administration  of  tonics,  cod-liver  oil,  and  creosote  may  also 
be  tried.     If  the  disease  in  the  testicle  is  very  troublesome,  with  profuse 


TUMORS   OF  THE  TESTICI.E.  1081 

discliarge,  mauy  sinuses,  or  considerable  pain,  the  organ  should  be  removed. 
It  may  also  be  i-emoved  with  the  hope  of  a  radical  cure  when  there  is  no 
advanced  disease  elsewhere  in  the  genital  organs,  but  some  small  deposit  is 
very  likely  to  be  felt  in  the  prostate  or  the  seminal  vesicles.  Partial  opera- 
tions, limited  to  removal  of  the  tuberculous  mass  by  the  curette  or  excision, 
may  result  in  a  cure,  and  primary  union  may  often  be  obtained  in  such 
wounds.  We  have  operated  upon  a  number  of  cases  in  which  the  testicle 
could  be  partially  preserved,  and,  even  although  the  destruction  of  the 
epididymis  and  its  ducts  was  considerable,  some  of  these  patients  have 
lived  active  sexual  lives  afterwards.  The  decision  of  this  question  will 
vary  with  the  individual  surgeon,  but  our  personal  preference  is  for  the 
removal  of  entirely  disorganized  testicles  in  any  case,  and  removal  of 
one  testicle  when  that  is  the  only  discoverable  tuberculous  lesion  in  the 
body,  or  even  when  there  is  a  slight  lesion  of  one  lung.  Tuberculosis 
of  the  prostate  and  seminal  vesicles,  if  extensive  enough  to  be  recog- 
nized, usually  contraindicates  castration  for  the  sake  of  a  radical  cure.  In 
all  other  cases  partial  operations  are  to  be  attempted,  especially  when  both 
testicles  are  affected.  In  every  case  it  is  very  important  that  the  patient 
should  have  the  advantages  of  a  healthy  life  in  a  good  climate. 

Syphilitic  disease  of  the  testicle  has  been  sufficiently  described  elsewhere. 
It  is  almost  invariably  an  orchitis,  and  produces  large,  hard,  smooth  tumors, 
heavy  but  not  painful  or  tender,  and  of  very  slow  growth. 

Tumors. — Benign  tumors  of  the  testicle  are  rare,  but  fibroma,  myoma, 
lipoma,  and  chondroma  have  been  reported,  the  latter  being  the  most 
common.  These  tumors  are  either  of  such  small  size  that  they  are  of  no 
clinical  importance  or  come  to  the  surgeon  with  no  other  symjatoms  than 
the  weight  of  the  heavy  tumor  which  inconveniences  the  patient.  The  large 
tumors  are  almost  invariably  chondroma,  and  are  undoubtedly  due  to  the 
development  of  congenitallj'  misplaced  fragments  of  foetal  tissues.  They  are 
often  mixed  in  character,  and  tend  to  sarcomatous  degeneration.  Small 
myomata,  both  of  striped  and  unstriped  muscular  fibres,  making  nodules 
from  the  size  of  a  hazel-nut  to  a  walnut,  have  been  observed  attached  to  the 
epididymis,  where,  in  their  early  stages,  they  may  be  mistaken  for  a  chronic 
epididymitis.  Small  lipomata  have  been  observed  in  the  substance  of  the 
testicle,  but  most  of  the  cases  of  lipoma  reijorted  are,  isroperly  speaking, 
lipoma  of  the  cord,  having  developed  from  the  cord  and  surrounded  the 
testicle,  which  is  often  found  practically  unchanged  in  the  centre  of  a  huge 
mass  of  fat. 

Cysts. — Large  cysts  of  the  testicle  are  almost  invariably  a  part  of 
sarcomatous  disease,  and  require  removal  of  the  testicle.  Small  serous 
cysts  with  thin  walls,  sessile  or  pedunculated,  often  multiple,  are  found 
connected  with  the  epididymis,  containing  a  thin  serous  fluid,  and  very 
rarely  spermatozoa.  They  occur  after  middle  life,  and  never  attain  a 
diameter  of  over  half  an  inch.  They  appear  to  be  similar  in  pathology  to 
the  involution  cysts  of  the  mamma,  and  are  of  little  imi^ortance.  Sper- 
matic cysts  or  spermatoceles  are  larger  than  these  subserous  cysts,  and 
attain  a  diameter  of  two  inches  or  more.  They  are  sometimes  multilocular, 
also  originate  from  the  epididymis,  usually  between  its  upi^er  part  and  the 


1082  SARCOMA  AND   CARCINOIMA  OF  THE  TESTICLE. 

body  of  the  testicle,  and  contain  a  milky  fluid  with  spermatozoa.  They  are 
either  retention  cysts  or  arise  from  some  foetal  remains  of  testicular  sub- 
stance. Cysts  also  originate  from  the  organ  of  Giraldes,  containing  a  milky 
fluid  but  no  spermatozoa.  The  treatment  of  these  cysts  consists  in  evacua- 
tion vrith  a  hypodermic  syringe  and  the  injection  of  a  drop  of  iodine  or  half 
a  drop  of  carbolic  acid.  Teratoid  tumors,  cystic  or  solid,  are  rare.  They 
are  remarkable  for  containing  tissues  representing  the  three  layers  of  the  ovum, 
proving  their  development  from  a  germinal  cell  of  the  gland  as  in  the  ovary. 

Malignant  tumors  of  the  testicle  may  be  either  sarcoma  or  carcinoma. 

Sarcoma. — Sarcoma  of  the  testicle  appears  at  any  age,  although  it  is 
most  frequent  in  early  adult  life.  It  begins  in  the  body  of  the  organ,  and 
all  histological  varieties  of  the  tumor  are  found.  It  presents  a  rapidly 
growing  tumor,  which  retains  the  shape  of  the  testicle,  but  is  apt  to  be  of 
varying  consistency  in  different  parts,  being  partly  hard  and  partly  soft, 
with  a  tendency  to  the  production  of  cysts  or  cartilaginous  plates.  The 
scrotum  is  evenly  distended  over  the  mass,  and  not  adherent  even  when  it 
attains  a  large  size.  The  cord  is  evenly  thickened  and  its  vessels  swollen, 
and  the  inguinal  glands  are  enlarged  more  frequently  than  is  usual  in 
sarcoma  elsewhere.  The  softer  tumors  may  grow  quite  rapidly,  and  both 
testicles  may  be  involved.  They  are  apt  to  break  down,  and,  if  the  skin  of 
the  scrotum  sloughs,  the  tumor  projects  through  the  opening.  The  firmer 
tumors  progress  much  more  slowly.  The  patient  at  first  complains  only  of 
the  weight  and  size  of  the  tumor,  but  in  the  later  stages  pain  sets  in,  and 
there  may  be  symptoms  from  metastatic  deposits  in  other  parts  of  the  body. 
The  only  treatment  is  removal  by  castration,  which  must  be  done  early  to 
secure  a  radical  cure. 

Carcinoma. — Carcinoma  of  the  testicle  usually  originates  from  the  body 
of  the  organ,  and  is  almost  invariably  composed  of  spheroidal  cells.  It 
occurs  comparatively  early  in  life,  before  the  forty-fifth  year,  and  even  in 
childhood.  It  is  a  more  slowly  growing  tumor  than  sarcoma,  is  much  softer 
to  the  touch,  and  may  feel  as  elastic  as  a  hydrocele.  The  skin  becomes 
adherent  early,  and  ulceration  sets  in  after  a  year's  duration.  The  tumor  at 
this  time  is  usually  as  large  as  a  man's  fist,  and  the  pelvic  and  inguinal 
glands  become  enlarged  within  the  first  year.  The  patient  complains  of 
pain  more  than  in  sarcoma,  and  pain  is  also  felt  in  the  lumbar  region,  with 
a  dull  aching  in  the  groin.  With  the  infection  of  the  glands  severe  neural- 
gic pains  in  the  lower  extremities  set  in,  and  the  venous  circulation  may  be 
obstructed.  The  treatment  is  early  and  thorough  operation,  removing  not 
only  the  testicle  but  as  much  of  the  cord  as  possible,  for  the  latter  is 
usually  involved  in  the  process. 

Diagnosis  of  Tumors. — Tumors  of  the  testicle  when  lifted  in  the  hand 
feel  heavier  than  hernia  or  hydrocele.  They  are  not  translucent,  and  have 
no  impulse  on  coughing.  The  patient  may  state  that  the  tumor  first 
appeared  in  the  lower  part  of  the  scrotum,  or  even  that  it  originated  in  the 
testicle.  Tumors  of  the  scrotum  are  differentiated  by  ascertaining  that  the 
testicle  is  not  involved  ;  but  this  is  sometimes  impossible  because  the  testicle 
is  surrounded  by  the  mass.  (For  further  facts  to  be  considered  in  the  diag- 
nosis of  hernia  and  hydrocele  see  pages  979  and  1084.) 


HYDROCELE.  1083 

Castration. — The  operation  for  removal  of  the  testicle  is  a  simple 
ODe,  the  skin  being  incised  longitudinally  over  the  gland  and  the  latter 
shelled  out  of  the  tissues  of  the  scrotum,  removing  the  tunica  vaginalis,  in 
cases  of  tumor,  as  it  is  advisable  to  make  as  wide  an  excision  of  the  neoplasm 
as  possible.  The  testicle  and  tunica  being  shelled  out  of  their  bed,  the  cord 
is  followed  up  well  to  the  external  inguinal  ring,  and  if  it  be  involved  even 
at  that  point  the  inguinal  canal  should  be  oi^ened  and  the  cord  drawn  down, 
if  possible,  until  a  healthy  part  is  reached.  A  ligature  is  made  to  transfix 
the  cord,  and  is  then  passed  around  it  and  tied  and  the  cord  divided.  The 
spermatic  artery  and  the  artery  of  the  vas  are  then  separately  ligated.  The 
canal  of  the  vas  is  touched  with  the  cautery  to  destroy  the  mucous  mem- 
brane, and  the  wound  is  closed  with  sutures. 

Hydrocele. — Hydrocele  is  the  distention  of  the  serous  sac  surrounding 
the  testicle  or  cord  with  a  serous  effusion.  It  usually  follows  some  injury  to 
the  scrotum  or  an  epididymitis.  In  rare  cases  the  fluid  is  milky,  like  chyle, 
with  fatty  granules  sus^jended  in  it,  owing  to  lymphatic  obstruction  by 
parasitic  filaria  or  to  a  wounded  lymphatic  vessel.  Hydroceles  having  opal- 
escent or  milky  contents  may  contain  spermatozoa  coming  from  the  rupture 
of  spermatoceles  into  the  sac.  The  changes  in  the  tunica  vaginalis  in  cases  of 
hydrocele  consist  in  thickening  of  the  walls  by  a  deposit  of  fibrin  and  an 
overgrowth  of  the  endothelial  cells.  Adhesions  may  take  place  between 
different  parts  of  the  membranes,  forming  cavities,  which  in  their  ■  turn 
become  dilated,  so  that  a  multilocular  hydrocele  is  formed.  In  other  cases 
it  is  evident  that  the  multilocular  hydroceles  have  originated  from  con- 
genital subdivisions  of  the  tunica  vaginalis.  Hydrocele  may  be  acute  or 
chronic.  Acute  hydrocele  accompanies  inflammations  of  the  testicle, 
seldom  attaining  a  large  size,  and  very  rarely  suppui'atiug.  Chronic 
hydrocele  may  occupy  the  cavity  of  the  tunica  vaginalis,  or  the  remains 
of  the  funicular  process  along  the  cord,  or  may  surround  an  ectopic  testi- 
cle in  any  situation.  When  the  funicular  process  is  shut  off  from  the  vaginal 
cavity  below  and  from  the  peritoneum  above,  and  serum  accumulates,  cysts 
may  be  formed  anywhere  between  the  internal  inguinal  ring  and  the  testicle, 
which  are  known  as  encysted  hydroceles  of  the  cord.  If  the  funicular 
process  remains  open  abo^-e  but  is  shut  off  from  the  tunica  vaginalis  below, 
a  congenital  hydrocele  of  the  cord  may  foi'm, — a  very  rare  condition. 
The  encysted  hydroceles  are  rather  small,  but  may  extend  well  up  into  the 
inguinal  canal.  The  testicle  is  felt  free  below  them,  but  the  irreducibility 
and  translucency  of  the  tumor  make  the  diagnosis  from  hernia  simple. 
There  may  be  more  than  one  of  these  cysts.  As  a  rule,  they  are  thin-walled, 
but  we  have  seen  one  case  with  a  wall  as  thick  as  the  tunica  vaginalis.  They 
are  most  common  in  children,  and  probably  often  disappear  spontaneously 
before  adult  life.  They  should  be  aspirated,  and  if  they  return  they  should 
be  treated  by  carbolic  acid  injection,  by  incision,  or  by  excision,  according 
to  the  methods  described  below. 

Hydrocele  of  the  Tunica  Vaginalis. — The  most  common  variety  of 
hydrocele  is  that  of  the  tunica  vaginalis.  In  some  cases  it  has  a  continua- 
tion into  the  inguinal  canal  in  the  funicular  process,  which  has  closed  above 
but  remained  open  towards  the  tunica  vaginalis ;  this  condition  is  called 


1084 


DIAGNOSIS  or  HYDROCELE. 


infantile  hydrocele.  In  rare  instances  the  sac  may  even  extend  into  the 
abdomen  and  form  a  cyst  there  in  connection  with  the  tunica,  known  by 
the  name  of  hydrocele  en  bis-sac.  Hydrocele  is  found  at  all  ages,  but  is 
most  frequent  at  the  two  extremes  of  life.  In  some  cases  the  funicular  canal 
which  connects  the  peritoneum  with  the  tunica  vaginalis  in  the  foetus  remains 
open,  and  any  fluid  confined  in  the  peritoneum  will  descend  into  the  cavity 
of  the  latter.  Hydroceles  thus  formed  are  called  congenital,  and  are 
reducible,  the  contents  returning  into  the  abdomen  when  the  patient  lies 
down  or  when  the  sac  is  compressed.  It  is  said  that  tuberculosis  of  the 
peritoneum  and  tuberculosis  of  the  tunica  vaginalis  are  frequently  associated 
in  these  cases,  on  account  of  the  free  communication  between  the  cavities. 
A  serous  effusion  into  the  tunica  is  a  frequent  accompaniment  of  inflam- 
mation of  the  testicles,  whether  it  be  gonorrhoeal,  traumatic,  or  tubercular, 
but  this  symptomatic  hydrocele  seldom  reaches  a  considerable  size  or 
demands  treatment  unless  the  tension  is  so 
Fig.  8?.].  great  as  to  cause  pain  and  necessitate  aspira- 

tion. 

The  actual  beginning  of  the  accumulation 
of  fluid  iu  the  sac  cannot  be  ascertained  in 
the  great  majority  of  cases  of  hydrocele. 
Without  pain  or  other  sensations,  the  iDatient 
notices  that  one  side  of  the  scrotum  is  a  little 
fuller  than  the  other,  and  that  the  swelling 
has  begun  at  the  bottom  of  the  scrotum  about 
the  testicle.  The  swelling  at  first  is  soft,  but 
soon  becomes  tense,  and  increases  in  size, 
until  in  some  cases  the  scrotum  extends  nearly 
to  the  knees.  The  increase  is  usually  very 
slow,  and  a  year  is  required  for  the  swelling 
to  attain  the  size  of  a  man's  fist.  The  pa- 
tient is  disturbed  only  by  its  weight  and 
bulk,  although  iu  rare  instances  the  sac  may 
rupture  or  suppurate,  and  he  seldom  consults  the  surgeon  until  it  has  been 
in  existence  for  some  time.  In  about  one-fifth  of  the  cases  there  is  a  hydrocele 
on  both  sides.     (Fig.  831.) 

Diagnosis. — Examination  shows  a  tense  or  fluctuating  swelling,  occupy- 
ing one-half  of  the  scrotum,  rather  pear-shaped,  with  no  impulse  on  cough- 
ing, and  the  tumor  weighed  in  the  hand  feels  rather  light.  If  a  light  is 
held  close  to  one  side  of  the  scrotum,  the  swelling  is  found  to  be  trans- 
lucent. As  a  rule,  it  will  be  necessary  to  use  an  opaque  tube  of  paste- 
board or  other  material  in  order  to  shut  out  the  diffused  light,  or  even 
to  make  the  test  in  a  dark  room,  to  obtain  satisfactory  resultvS  if  the  sac  is 
thick.  The  trauslucency  of  a  hydrocele  varies  according  to  the  thickness 
of  the  sac  wall,  and  when  it  is  very  translucent  the  shadow  of  the  testicle  is 
distinctly  seen.  The  normal  position  of  the  testicle  is  at  the  lower  back  part 
of  the  sac,  the  natural  position  of  the  epididymis  and  of  the  cord  being 
X)osterior.  In  some  cases,  however,  the  gland  is  congeuitally  placed  anterior 
to  the  tunica,  the  epididymis  being  in  front  of  the  sac  and  the  cord  running 


Double  hydrocele. 


TREATMENT  OF  HYDROCELE.  1085 

down  its  anterior  surface.  Occasionally  the  testicle  can  be  felt  through  the 
sac  wall.  The  diagnosis  of  hydrocele  from  hernia  and  from  tumors  of  the 
testicle  and  scrotum  has  been  fully  given  in  the  chapter  on  hernia.  It 
should  be  borne  in  mind  that  hydrocele  and  hernia  are  often  associated.  In 
the  ordinary  cases  no  difficulty  should  be  met  with  in  making  the  diagnosis, 
for  the  symptom  of  translucency  is  not  present  in  hernia,  htematocele,  or 
any  other  scrotal  tumor,  except  in  the  very  thin-walled  intestinal  hernia  of 
infants.  The  last  named  condition  is  not  likely  to  be  mistaken  for  hydro- 
cele, because  only  an  irreducible  hernia  would  resemble  hydrocele,  and  an 
irreducible  hernia  almost  invariably  contains  omentum,  and  is  therefore 
opaque. 

Treatment. — Aspiratmi  and  Injection. — The  first  attempt  in  the  treat- 
ment of  hydrocele  should  always  be  aspiration  and  injection  of  carbolic  acid. 
Cutting  operations  should  be  reserved  for  severe  cases,  as  the  injection 
treatment  will  cure  at  least  three-fourths  of  the  patients.  In  very  young  chil- 
dren mere  aspiration  of  the  contents  and  scratching  the  inside  of  the  sac 
with  the  point  of  the  needle  will  often  suffice  for  a  cure.  To  tap  a  hydrocele 
the  surgeon  takes  the  tumor  in  his  left  hand  and  the  trocar  in  his  right,  his 
finger  being  placed  on  the  trocar  half  an  inch  from  the  point,  in  order  to 
prevent  too  deep  penetration.  The  point  of  the  trocar  is  placed  lightly  on 
the  skin  over  the  most  prominent  part  of  the  tumor,  about  one-third  of  the 
distance  from  the  bottom  to  the  top,  and  then  with  a  sudden  thrust  the  in- 
strument is  driven  through  the  sac  wall.  If  it  is  intended  to  inject  carbolic 
acid,  the  needle  of  the  hypodermic  syringe,  containing  from  ten  to  twenty 
drops  of  pure  carbolic  acid,  liquefied  with  glycerin,  is  inserted  into  the 
sac  just  above  where  the  trocar  enters,  and  the  points  of  the  two  instru- 
ments are  made  to  touch  each  other  in  the  cavity  of  the  sac,  in  order  to 
prove  that  the  point  of  the  hypodermic  needle  is  really  in  the  hydrocele. 
The  trocar  is  then  withdrawn,  and  the  fluid  flows  out  of  the  canula,  the 
fingers  squeezing  the  sac  together  so  as  to  evacuate  the  last  drops,  but  the 
needle  must  be  kept  constantly  in  contact  with  the  canula.  The  canula  is 
then  withdrawn,  the  carbolic  acid  injected,  and  the  syringe  also  withdrawn. 
The  pain  of  the  proceeding  is  slight,  but  in  some  instances  there  is  consid- 
erable burning  from  the  carbolic  acid.  The  sac  is  to  be  rubbed  between  the 
hands,  so  as  to  diffuse  the  acid  equally  over  its  internal  surface.  The  scro- 
tum, the  surgeon's  hands,  and  all  instruments  must  be  carefully  sterilized. 

Some  surgeons  prefer  the  injection  of  iodine,  but  its  action  is  much  more 
painful  and  no  more  certain  than  that  of  carbolic  acid.  When  iodine  is 
employed,  from  half  an  ounce  to  an  ounce  of  the  fluid  is  injected  through 
the  canula,  retained  a  moment,  and  then  allowed  to  escape,  or  a  less  quan- 
tity is  used  and  allowed  to  remain  in  the  sac.  On  account  of  the  pain  it  is 
generally  necessary  to  use  cocaine  or  eucaine  before  making  the  injection, 
injecting  a  two  per  cent,  solution,  and  allowing  it  to  escape  aftei"  being  in 
the  sac  two  or  three  minutes.  This  is  an  added  danger,  for  cocaine  poison- 
ing has  followed  this  procedure,  more  than  once,  as  it  is  difficult  to  jirove 
that  all  of  the  fluid  has  escaped. 

After  the  injection  of  either  reagent  the  fluid  reaccumulates  and  the 
patient  may  be  uncomfortable  for  a  few  days,  but  within  a  week  the  hydro- 


1086  OPERATION  FOK   HYDEOCELE. 

cele  becomes  smaller,  and  soon  disappears.  In  some  cases  a  second  injec- 
tion is  necessary,  and  in  any  case  in  which  absorption  does  not  begin  in 
the  first  week  it  is  well  to  draw  off  a  couple  of  drachms  of  the  fluid,  in 
order  to  lessen  the  tension  and  assist  absorption.  If  there  is  much  pain, 
the  patient  should  be  kept  in  bed,  the  scrotum  elevated  upon  a  folded 
towel,  an  ice-bag  applied,  and  morphine  administered.  Pull  aseptic  pre- 
cautions must  be  taken  in  preparing  the  skin  and  the  instruments,  in 
order  to  avoid  infection,  which  would  result  in  suppuration  of  the  sac. 
If  it  is  found  on  aspiration  that  the  sac  is  multilocular,  each  sac  must  be 
evacuated  and  injected  in  turn,  only  a  very  small  quantity  of  the  car- 
bolic acid  being  thrown  into  each  cavity.  For  a  hydrocele  the  size  of  a 
man's  fist  fifteen  drops  will  usually  be  sufficient.  In  smaller  hydroceles 
a  less  quantity  should  be  employed,  and  in  infants  only  from  two  to  five 
drops.  In  large  hydroceles  the  sac  is  to  be  emptied  first  and  the  injection 
postponed  until  it  refills  to  the  size  of  a  man's  fist.  The  only  dangers 
to  be  feared  in  this  operation  are  septic  infection  and  the  injection  of 
the  carbolic  acid  into  the  tissues.  The  first  of-  these  can  be  avoided  by 
asepsis,  and  the  second  by  making  sure  that  the  needle  is  kept  in  contact 
with  the  canula.  A  hydrocele  with  a  very  thick  wall  and  some  multi- 
locular hydroceles  will  resist  the  treatment  by  injection  and  require  cutting 
operations. 

Incision. — Volkmann  suggests  an  incision  into  the  sac  upon  its  anterior 
surface  for  its  entire  length.  The  fluid  is  allowed  to  escape,  a  drainage-tube 
or  strip  of  gauze  is  placed  in  the  sac,  and  a  continuous  suture  is  made, 
uniting  the  skin  to  the  edge  of  the  sac  wall  entirely  around  the  opening, 
thus  covering  in  all  the  raw  tissues.  A  couple  of  deep  sutures  are  then 
passed  through  the  scrotum  and  wall  of  the  sac  so  as  to  hold  the  two  edges 
in  apposition,  and  a  firm  dressing  is  applied  in  such  a  manner  as  to  press 
the  sides  of  the  sac  together  over  the  testicle.  Adhesion  of  the  two  walls 
of  the  sac  takes  place,  the  exposure  to  the  air  being  sufficient  to  excite  the 
necessary  irritation.  In  a  week  or  ten  days  the  wound  is  reduced  to  a 
granulating  strip,  but  this  may  require  five  or  six  weeks  to  heal  completely. 
The  patient  need  not  be  confined  to  bed  after  the  first  week,  but  the  slow 
healing  of  the  wound  is  an  objection  to  the  treatment. 

Inversion. — When  the  tunica  has  been  incised  as  described  above,  the 
testicle  can  be  lifted  up  so  as  to  turn  the  sac  inside  out.  A  few  loose  super- 
ficial catgut  sutures  can  then  be  passed  through  the  sac  so  as  to  gather  it  up 
into  a  roll  close  to  its  insertion  into  the  testicle,  similar  to  furling  a  sail. 
The  testicle  with  the  rolled-up  tunica  around  it  like  a  collar  is  replaced  in 
the  scrotum  and  the  skin  united  over  it,  a  small  gauze  drain  being  inserted 
for  a  couple  of  days.  Primary  union  can  thus  be  obtained  and  the  patient 
need  not  be  kept  long  in  bed. 

Extirpation. — Von  Bergmann  recommended  the  extirpation  of  the  sac 
of  the  hydrocele,  exposing  it  by  an  anterior  incision  and  stripping  it  out  of 
its  bed  in  the  scrotum  by  blunt  dissection  as  far  back  as  the  junction  of  the 
serous  membrane  to  the  testicle  and  the  cord.  The  sac  is  opened  and  its 
wall  cut  away  from  the  testicle  close  to  its  attachments.  There  may  be  a 
little  hemorrhage  from  the  scrotal  veins  and  troublesome  oozing  from  the 


VARICOCELE.  1087 

small  vessels  at  the  attachment  of  the  sac  near  the  epididymis.  lu  simple 
cases  the  operation  is  very  easy,  but  in  the  long-standing  cases  with  very 
thick  sacs,  for  which  the  operation  is  really  necessary,  there  may  be  numer- 
ous adhesions  and  considerable  difficulty  in  cutting  away  the  sac  from  the 
testicle.  When  hemorrhage  has  been  controlled,  the  scrotal  tissues  are 
united  over  the  testicle  with  two  or  three  mattress  sutures  and  a  continuous 
suture  of  the  skin.  Union  takes  place  in  a  week  or  ten  days,  during  which 
the  patient  should  be  kept  in  bed.  Thorough  as  this  operation  is,  recurrence 
has  been  known  to  follow  it,  as  well  as  Volkmann's,  arising  from  the  serous 
membrane  left  on  the  outer  surface  of  the  testicle.  Both  of  these  operations 
may  be  done  with  the  aid  of  local  ansesthesia,  but  a  general  anaesthetic  is 
preferable  unless  the  patient  be  unusually  phlegmatic.  Perfect  asepsis  must 
be  maintained,  as  any  infection  in  the  loose  tissues  of  the  scrotum  would  be 
fatal  to  primary  union,  and  might  have  troublesome  and  dangerous  conse- 
quences. These  operative  measures  should  be  limited  to  cases  in  which  the 
walls  of  the  hydrocele  are  very  thick,  or  in  which  some  complication  exists, 
such  as  a  hernia,  which  may  be  treated  at  the  same  time.  They  are  also 
suited  to  cases  of  doubtful  diagnosis,  when  tuberculosis  or  a  tumor  of  the 
testicle  is  suspected. 

Hsematocele  of  the  Tunica  Vaginalis. — As  the  result  of  a  trauma, 
a  previous  hydrocele,  and  in  some  cases  without  known  cause,  an  effusion  of 
blood  takes  place  in  the  tunica  vaginalis.  The  membrane  is  covered  with 
layers  of  fibrin,  a  vascular  granulation-tissue  forms,  the  endothelium  disap- 
pears, and  the  structure  of  the  membrane  is  altered  to  dense  cicatricial 
tissue  in  which  calcification  or  fresh  hemorrhage  may  take  place.  The  tes- 
ticle is  at  first  unaffected,  beiiig  simply  surrounded  by  these  dense  layers  of 
clot  and  connective  tissue,  but  later  it  may  undergo  atrophy.  Similar 
tumors  develop  in  the  course  of  the  spermatic  cord,  like  the  hydroceles  of 
the  cord.  Symptoms. — The  affected  part  slowly  increases  in  size,  some- 
times with  distinct  intermissions.  The  tumor  is  painless,  pear-shaped,  and 
smooth  externally.  It  fluctuates  less  readily  than  hydrocele  and  feels  harder 
and  is  not  translucent.  It  is  not  so  heavy  as  a  malignant  or  syphilitic 
tumor  of  the  testicle.  The  calcification  may  produce  an  almost  bony  shell 
a  quarter  of  an  inch  thick  around  the  testicle.  Treatment. — If  operation' 
is  undertaken  early  the  sac  may  be  freely  incised,  extirpated  as  far  as  possi- 
ble, and  the  testicle  saved.  If  the  sac  is  very  thick  or  calcified  both  sac  and 
testicle  should  be  removed,  the  gland  being  then  generally  useless. 

INJTJKIES  AND  DISEASES  OP  THE  SPERMATIC  COED. 

Injuries. — A  wound  of  the  cord  with  division  of  the  vas  deferens  may 
result  in  the  formation  of  a  fistula  with  external  discharge  of  the  semen. 
Torsion  of  the  cord  has  already  been  described  in  the  section  on  the  testicle. 

Tumors  of  the  spermatic  cord  are  too  rare  to  require  description. 

Varicocele. — The  most  common  disease  of  the  spermatic  cord  is  vari- 
cose dilatation  of  its  veins,  a  condition  known  as  varicocele.  The  dilated 
veins  sometimes  form  a  tumor  of  considerable  size,  extending  from  the 
inguinal  ring  to  the  testicle,  and  feeling  like  a  bunch  of  angle- worms.  The 
vessels  may  have  thickened  and  hardened  walls  or  may  be  very  thin  and  soft 


1088 


TREATMENT  OF  VARICOCELE. 


r 


Fig.  832. 


1 


to  the  touch.  When  the  patient  lies  down  the  veins  are  emptied  and  the 
tumor  disappears.  A  varicose  condition  of  the  veins  of  the  scrotum  is 
usually  associated  with  varicocele  of  long  standing.  The  scrotum  is  elon- 
gated, and  the  testicle  upon  the  affected  side  hangs  lower  than  the  other. 

(Pig.  832.)  The  testicle  in  cases  of 
long  standing  feels  very  soft  and  re- 
laxed, sometimes  undergoing  atrophy, 
and  if  the  varicocele  is  cured  the 
testicle  may  become  even  smaller,  a 
large  part  of  its  previous  bulk  having 
been  made  up  of  the  swollen  veins. 
This  atrophy,  however,  may  be  tem- 
porary, and  the  gland  may  regain  its 
normal  size.  Varicocele  attacks  both 
sides  of  the  scrotum  in  about  one- 
twelfth  of  the  cases,  and  in  about  the 
same  proportion  of  the  unilateral  cases 
it  occurs  on  the  right  side.  The 
greater  frequency  of  varicocele  on  the 
left  side  has  been  ascribed  to  certain 
anatomical  facts, — that  the  spermatic 
vein  is  crossed  by  the  sigmoid  flexure, 
that  it  receives  branches  from  the  colic  veins,  and  that  it  enters  the  left  renal 
vein  at  right  angles  to  its  course.  The  predisposing  causes  of  varicocele  are 
a  sedentary  life,  neglect  of  the  bowels,  and  sexual  over-stimidation,  especially 
soon  after  j)uberty.  It  is  a  disease  of  early  adult  life,  and  usually  disappears 
in  middle  age.  The  patients  are  apt  to  be  young  men  of  relaxed  fibre, 
and  are  often  neurasthenic,  but  varicocele  may  occur  in  very  vigorous  men. 
The  patient  feels  a  dragging  sensation  in  the  testicle,  and  complains  of  its 
weight,  but  otherwise  the  health  is  not  affected,  although  the  sexual  powers 
are  apt  to  be  slightly  impaired. 

Treatment. — Slight  varicocele  needs  no  treatment  but  the  wearing  of  a 
suspensory  bandage  to  support  the  testicle,  a  change  from  sedentary  habits  to 
active  out-door  life,  and  the  avoidance  of  everything  which  tends  to  produce 
sexual  excitement.  More  serious  cases  may  be  treated  by  ligation  of  the 
veins,  either  subcutaneously  or  in  an  open  wound,  or  by  shortening  of  the 
scrotum.  It  may,  however,  be  necessary  to  operate  in  some  individuals 
when  the  disease  is  slight,  because  they  are  hypochondriacal  or  because  they 
are  liable  to  rejection  in  the  physical  examination  required  before  admission 
to  military  or  other  services. 

Subcutaneous  Ligation  of  the  Veins. — The  hair  should  be  shaved 
from  the  scrotum  and  the  pubes  around  the  point  intended  for  operation 
for  a  distance  of  two  or  three  inches.  The  surgeon  takes  the  root  of  the 
scrotum  between  his  fingers  and  feels  the  cord,  recognizing  the  vas  deferens 
by  its  hardness,  separating  it  from  the  other  j)arts  of  the  cord  as  far  as 
possible,  and  holding  it  towards  the  median  line,  while  the  veins  and  other 
tissues  are  pushed  to  the  outer  side  of  the  scrotal  fold.  The  vas  being  held 
out  of  the  way  by  the  thumb-nail,  a  needle  carrying  fine  silk  or  catgut  is 


OPEEATION  FOR  VARICOCELE.  1089 

made  to  transfix  the  scrotum  close  to  the  thumb.  It  is  then  re-entered  at 
the  point  of  exit,  and  carried  subcutaneously  to  the  outer  side  of  the  veins 
and  around  them,  and  made  to  issue  from  the  original  puncture  of  entrance 
in  front.  The  thread  is  drawn  tight,  pulled  away  from  the  skin  on  all  sides, 
and  tied  with  a  square  knot.  The  ends  are  cut  short  and  the  knot  allowed 
to  slip  under  the  skin.  The  object  of  this  operation  is  to  secure  in  the 
ligature  all  the  tissues  of  the  cord  except  the  vas  deferens.  Another  liga- 
ture should  be  applied  lower  down  in  bad  cases.  If  the  operation  has  been 
properly  performed,  all  the  vessels  will  be  ligated  except  the  artery  of  the 
vas,  which  lies  close  to  that  duct,  and  possibly  one  or  two  small  veins  in  its 
neighborhood.  The  ligated  veins  become  obliterated.  The  iiatient  should 
be  kept  quiet  for  a  few  days,  to  make  sure  that  the  asepsis  has  been  success- 
ful, and  to  avoid  any  accident  from  thronabosis  originating  at  the  point  of 
ligature.  This  operation  will  cure  a  large  majority  of  the  cases,  and  it  is  so 
simple  that  it  scarcely  needs  an  anaesthetic,  although  in  nervous  patients 
the  injection  of  a  drop  of  cocaine  may  be  advisable.  There  is  little  or  no 
pain  afterwards,  although  in  some  cases  the  testicle  becomes  swollen. 
Although  the  spermatic  artery  is  intentionally  included  in  the  ligature, 
atrophy  of  the  testicle  does  not  follow  the  procedure,  but  if  the  testicle 
is  very  small  the  patient's  attention  should  be  drawn  to  that  fact  before  the 
ofieration,  in  order  to  avoid  later  disappointment. 

Incision  and  Resection. — A  more  certain  method  is  the  operation  by 
open  incision,  which  is  performed  at  the  same  point,  the  skin  being  incised 
for  the  length  of  an  inch,  the  cord  drawn  out  of  the  wound,  including  all  the 
vessels  in  its  neighborhood,  and  a  blunt  instrument  passed  beneath  it.  The 
operator  separates  the  vas  and  its  adherent  artery  from  the  other  vessels, 
and  the  latter  are  surrounded  by  two  ligatm-es  about  an  inch  apart  and 
divided  between  the  ligatures.  A  separate  ligature  may  be  applied  to  the 
proximal  end  of  the  spermatic  artery  if  it  is  visible  in  the  stump.  If  the 
cord  is  long,  an  inch  or  more  may  be  cut  away  between  the  ligatures,  an 
end  of  each  ligature  tied  together  to  shorten  the  cord,  and  the  wound 
closed  with  a  few  stitches.  A  compressive  dressing  should  be  applied,  to 
prevent  swelling  of  the  testicle,  relieve  pain,  and  keep  the  ijatieut  quieter. 

Ablation  of  the  Scrotum. — The  scrotum  has  been  amputated  for  vari- 
cocele, and  fair  results  have  been  claimed,  but  in  our  experience  it  is 
insufficient  without  ligature  of  the  veins.  Foi-  this  operation  the  patient  is 
an£Esthetized,  although  it  may  also  be  done  with  cocaine.  The  scrotum  is 
held  up  by  the  raphe  by  an  assistant  while  the  surgeon  adjusts  to  it  a  long, 
slender  curved  clamp  below  the  testicles,  so  as  to  compress  it  laterally.  To 
prevent  the  clamp  from  slipping,  it  is  well  to  pass  two  or  three  needles 
through  the  scrotum  on  the  outer  side  of  the  clamp.  The  scrotum  is  then 
cut  away  a  quarter  of  an  inch  below  the  clamp,  and  half  a  dozen  mattress 
sutures  inserted  to  hold  the  parts  in  apposition.  A  continuous  suture  of 
fine  catgut  is  then  run  over  the  edge,  bringing  the  skin-edges  together. 
This  apposition  may  be  difficult  with  the  clamp  in  place,  in  which  case  the 
sutures  may  be  left  loose  and  drawn  up  after  the  instrument  has  been 
removed.  The  use  of  the  clamp  is  of  assistance  to  the  operator,  as  it  makes 
the  operation  a  bloodless  one  and  holds  the  lax  parts  firmly  in  position,  and 


1090  CATAERHAL  PROSTATITIS. 

it  also  draws  all  the  layers  of  the  scrotal  tissues  Into  the  wound,  and  thus 
the  natural  raphe  is  i^reserved,  whereas  if  only  skin-union  is  obtained  it 
easily  stretches  afterwards.  The  clami^  may,  however,  be  dispensed  with  if 
half  a  dozen  mattress  sutures  are  applied  while  an  assistant  holds  up  the 
scrotum  by  the  raphe.  These  sutures  must  be  placed  just  within  the  line  of 
the  proposed  incision,  and  must  not  be  tied  too  tightly,  for  fear  of  gangrene 
of  the  edges  of  the  wound.  It  need  scarcely  be  noted  that  thorough  shaving 
and  preliminary  sterilization  of  the  parts  are  necessary,  with  a  fij^m  occlusive 
dressing  afterwards,  if  primary  union  is  to  be  obtained.  The  latter  is  par- 
ticularly difficult  to  achieve  in  the  scrotum. 

DISEASES    OE    THE    PROSTATE. 

Inflammation. — The  prostate  is  liable  to  certain  inflammations,  which 
may  be  either  catarrhal  or  suppurative,  and  are  pyogenic,  gonorrhceal,  or 
tuberculous  in  origin. 

Catarrhal  Prostatitis. — Catarrhal  prostatitis,  often  called  prostator- 
rhcEa,  may  be  due  to  excessive  sexual  excitement  (although  it  is  more 
commonly  seen  as  the  result  of  masturbation  than  of  coition),  to  infection 
by  unclean  instruments,  or  to  mechanical  irritation  by  riding  astride 
narrow  seats.  The  symptoms  of  catarrhal  prostatitis  are  a  sensation  of 
weight  and  discomfort  in  the  perineum,  rarely  amounting  to  actual  pain, 
with  hyperesthesia  of  the  prostatic  urethra,  and  an  increase  in  the  fre- 
quency of  micturition.  There  is  a  feeling  of  weakness  in  the  lumbar 
region,  sometimes  a  dull,  aching  pain.  There  is  undue  sexual  irritability 
and  premature  ejaculation  of  the  semen.  A  slight  mucous  discharge  also 
shows  itself  by  gluing  together  the  lips  of  the  meatus  in  the  morning,  and  a 
few  drops  of  the  fluid  may  be  passed  at  stool,  or  an  unusual  amount  of  this 
discharge  may  take  place  during  sexual  excitement.  This  symptom  is  called 
spermatorrhoea  by  the  laity,  but  the  fluid  contains  no  spermatozoa.  By 
expression  of  the  prostate,  which  is  carried  oiit  by  inserting  one  finger  in  the 
rectum  and  making  i^ressure  upon  the  gland  from  behind,  a  considerable 
amount  of  this  fluid  can  sometimes  be  obtained  for  examination,  and  it  con- 
tains characteristic  needle-shaped  crystals,  somewhat  resembling  the  simple 
phosphatic  crystals  in  the  urine. 

Treatment. — Complete  abstinence  from  sexual  thoughts  should  be 
advised,  with  a  regular  life  and  plenty  of  out-door  exercise  as  the  foundation 
of  all  treatment.  The  occasional  passage  of  a  cold  urethral  sound  of  large 
size,  introduced  fully  into  the  bladder,  so  as  to  straighten  the  urethral  curve, 
is  very  useful.  This  treatment  is  also  to  be  recommended  as  an  aid  in 
lessening  the  sexual  discomfort  of  men  who  are  beginning  a  celibate  life, 
having  recently  been  separated  from  their  wives  after  active  marital  rela- 
tions,— a  class  of  cases  in  which  mere  hypertemia  of  the  prostate  causes 
symptoms  similar  to  those  of  catarrhal  prostatitis.  Systematic  massage 
and  expression  of  the  prostate  and  seminal  vesicles  may  be  useful.  Oc- 
casionally applications  of  nitrate  of  silver  to  the  prostatic  urethra  relieve 
the  congestion  and  lessen  the  irritation  and  tenderness.  The  applications 
are  made  by  the  Ultzmann  syringe  (Fig.  833),  1  to  10  drops  of  a  solution  of 
nitrate  of  silver,  10  grains  to  the  ounce,  being  injected  into  the  prostatic 


TUBERCULOSIS   OF  THE  PROSTATE. 


1091 


urethra,  and  the  patient  being  directed  to  pass  water  immediately  or  after 

the  lapse  of  two  or  three  minutes,  according  to  the  amount  of  stimulation 

deemed  necessary.   The  injection  should  alternate  with  the 

use  of  the  sound  once  or  twice  a  week  in  order  to  produce         Fig.  833. 

the  best  effect.     Very  hot  irrigation  of  the  rectum  (Kemp's 

tube)  will  be  found  useful. 

Gonorrhoeal  Prostatitis. — When  gonorrhoea  pene- 
trates to  the  deep  urethra  it  involves  the  prostate,  and  may 
leave  a  chronic  gleety  or  muco-purulent  discharge  which  is 
exceedingly  difficult  to  cure.  There  will  be  shreds  in  the 
iirst  part  of  the  urine  passed,  and  gonococci  may  be  found 
in  them.  In  this  form  of  gonorrhoeal  prostatitis  the  sexual 
irritability  is  lessened  instead  of  increased,  but  the  pain  and 
tenderness  may  be  greater  than  in  the  catarrhal  form,  and 
abscess  occasionally  results,  the  previous  history  and  the 
purulent  discharge  distinguishing  it  from  the  catarrhal  form. 
Treatment. — Deep  injections  may  be  given  by  the  Ultz- 
mann  method,  by  passing  a  metal  catheter  with  long  slits  at 
the  sides  near  the  tip,  so  that  it  shall  be  within  the  grasp  of 
the  sphincter,  and  then  injecting  a  considerable  quantity  of 
warm  sulphocarbolate  of  zinc  solution  (alum,  sulphate  of 
zinc,  carbolic  acid,  each,  1  part ;  distilled  water,  200  to  500 
parts),  which  passes  backward  into  the  bladder,  and  should 
be  evacuated  at  once  by  the  patient.  Or  a  retrojection  may 
be  applied  with  an  instrument  the  knob-like  tip  of  which 
closes  the  vesical  end  of  the  urethra  while  the  fluid 
directed  backward  towards  the  meatus,  thus  washing  the 
discharge  out  of  the  urethra.  The  regular  passage  of  the  sound  should 
never  be  omitted  in  these  cases,  both  for  its  immediate  effect  and  to  prevent 
the  possible  formation  of  a  stricture. 

Tuberculosis. — Tuberculous  infection  of  the  prostate  is  probably  more 
common  and  more  easily  recognized  than  that  of  any  other  part  of  the 
genito-urinary  tract  except  the  testicle.  The  lesions  consist  in  the  develop- 
ment of  tuberculous  nodules  in  the  gland,  which  go  on  to  caseation  or  to 
the  development  of  abscesses,  although  in  rare  cases  spontaneous  recovery 
may  take  place  under  favorable  conditions.  If  the  disease  is  not  near  the 
urethra,  it  may  run  an  absolutely  latent  course,  giving  no  symptoms  until 
it  is  very  far  advanced  or  until  the  testicle  or  the  bladder  is  involved.  If 
the  lesions  are  near  the  urethra,  it  will  begin  with  symptoms  like  those  of 
an  ordinary  catarrhal  prostatitis,  but,  as  a  rule,  with  less  hypertesthesia. 
There  may  be  threads  of  mucus  and  tubercle  bacilli  in  the  urine.  Micturi- 
tion may  be  impeded  by  the  swelling,  especially  if  an  abscess  forms.  Eectal 
examination  reveals  a  slightly  enlarged  prostate  with  small  hard  nodules 
scattered  through  it  in  the  early  stages,  but  the  outlines  of  the  gland  may 
be  rendered  indistinct  by  an  accompanying  periprostatitis.  The  seminal 
vesicles  will  also  be  found  to  be  thickened  and  nodular  in  many  cases. 
When  the  deposits  break  down  the  prostate  feels  soft,  and  it  may  be  entirely 
converted  into  a  sac  of  pus.      Pus  may  also  form  around  the  gland  and 


Ultzmann  prostatic 
syringe. 


1092  ABSCESS   OF  THE  PROSTATE. 

make  its  way  outward  through  the  triangular  ligament  to  the  i^erineum, 
into  the  urethra,  or  into  the  rectum.  Sinuses  remain  when  the  pus  has 
been  discharged. 

Treatment. — When  pus  has  formed  it  must  be  evacuated  by  incision  ; 
the  remains  of  the  prostate  should  be  removed  with  a  sharp  curette  if 
possible.  The  prostate  may  be  exposed  by  a  horseshoe-shaped  incision, 
the  anterior  curve  crossing  the  median  line  just  behind  the  bulb  of  the 
urethra,  and  the  ends  running  down  on  the  sides  of  the  sphincter  ani  so 
that  that  muscle  will  be  raised  in  the  flap.  As  the  incision  is  deepened, 
the  bulb  of  the  ui-ethra  is  drawn  forward  and  the  flap  dissected  backward 
nntil  the  capsule  of  the  prostate  is  reached.  The  capsule  may  be  incised 
and  the  disorganized  gland  removed  by  the  curette  and  the  finger.  The 
urethra  is  often  found  dissected  out,  the  remainder  of  the  prostate  having 
broken  down  into  pus.  The  urethra  may  be  opened  or  may  slough  after  a 
short  interval,  but  the  urinary  fistula  generally  closes  as  the  cavity  contracts. 
The  wound  should  be  packed,  and  if  the  urethra  is  opened  a  catheter  is 
introduced  and  left  in  the  bladder  for  two  or  three  days. 

Abscess  of  the  Prostate. — Suppurative  inflammation  of  the  prostate 
may  occur  in  the  shape  of  small  follicular  abscesses  or  extensive  cavities  in 
the  substance  of  the  gland,  or  the  inflammation  may  extend  beyond  the  cap- 
sule and  produce  an  abscess  outside  the  gland.  These  abscesses  may  have 
an  acute  course  when  they  are  due  to  pyogenic  infection  resulting  from 
stricture,  severe  cystitis,  or  infection  by  iinclean  instruments.  On  the 
other  hand,  thej^  may  be  slow  and  chronic  when  they  occur  in  the  course  of 
tubercular  disease.  In  the  acute  form  there  will  be  intense  pain  and  a  feel- 
ing of  weight  and  throbbing  in  the  perineum,  perhaps  associated  with  vesi- 
cal and  rectal  tenesmus,  and  even  with  retention  of  urine.  There  may  be  a 
chill,  and  the  patient  may  become  profoundly  septic.  The  abscesses  most 
frequently  burst  into  the  urethra,  but  often  make  their  way  into  the  j)eri- 
neum,  and  may  also  discharge  into  the  rectum.  The  gland,  examined  per 
rectum,  will  be  found  distended  and  very  tender,  and  in  the  later  stages 
a  fluctuating  swelling  will  be  present. 

Treatment. — Hot  applications  to  the  perineum  and  hypogastrium  and 
hot  rectal  injections  afford  the  best  method  of  treatment  in  the  early  stages, 
but  as  soon  as  the  presence  of  pus  is  probable  an  incision  should  be  made. 
The  pus  may  be  reached  by  an  incision  in  the  perineum  in  the  middle 
line,  carried  inward  until  the  urethra  is  exposed,  and  then  the  point  of  a 
narrow-bladed  knife  should  be  thrust  directly  upward  between  the  rectum 
and  the  urethra,  under  the  guidance  of  the  finger  in  the  rectum,  until  the 
pus  is  reached.  The  oiiening  is  enlarged  by  dilating  it  with  forceps,  and 
the  cavity  is  irrigated  and  drained.  Alexander  advocates  doing  a  perineal 
urethrotomy,  inserting  the  finger  and  opening  the  abscess  into  the' urethra, 
as  in  his  method  of  prostatectomy.  But  if  suppuration  has  taken  place 
around  the  prostate,  it  is  best  to  expose  the  prostate  by  the  horseshoe-shaped 
flap  described  above  and  open  the  abscess  under  the  guidance  of  the  eye. 
If  properly  treated,  these  cases  usually  recover,  but  fistuke  are  apt  to  follow 
if  they  are  neglected,  and  if  they  open  spontaneously  into  the  rectum  sepsis 
may  take  place  from  infection  of  the  abscess  by  the  freces. 


INFLAMMATION  OF  COWPER'S   GLANDS.  1093 

Tumors. — Hypertrophy  of  the  prostate  (fibromyo-adenoma),  has 
ah-eady  been  considered  in  connection  with  the  diseases  of  the  bladder  on 
account  of  its  intimate  relation  to  urinary  diseases  and  the  sliglit  effect 
which  it  has  upon  the  sexual  function.  Other  neoplasms  are  found  in  the 
prostate,  such  as  lipoma,  but  they  are  all  very  rare,  and  only  the  malignant 
tumors  require  description.  Sarcoma  is  found  at  all  ages,  and  several  cases 
have  been  observed  in  infancy.  Carcinoma  is  more  frequent  in  advanced 
adult  life,  but  has  also  been  noted  at  a  very  early  age.  In  both  varieties  of 
tumor  no  symptoms  are  evident  until  the  mass  has  attained  a  considerable 
size  and  interferes  with  urination  or  ulcerates  on  the  vesical  or  urethral 
surface  and  produces  hematuria  and  cystitis.  At  this  stage  rectal  examina- 
tion will  reveal  the  prostate  enlarged,  stony  hard  to  the  touch,  with  indis- 
tinct outlines,  and  firmly  fixed  by  the  infiltration  of  the  surrounding  parts. 
Occasionally  the  glaud  is  soft  instead  of  hard.  Oijeration  is  out  of  the 
question,  and  palliative  measures,  similar  to  those  for  advanced  cancer  of 
the  base  of  the  bladder,  afford  the  only  possible  treatment. 

Seminal  Vesicles. — The  seminal  vesicles  are  generally  associated  with 
the  prostate  in  its  inflammations,  any  form  of  prostatitis  being  liable  to 
be  accompanied  by  swelling  of  the  seminal  vesicles  from  retention  or 
inflammation.  In  catarrhal  prostatitis  the  condition  of  the  seminal  vesicles 
should  always  be  ascertained  by  careful  rectal  examination,  for  the  ejacula- 
tory  ducts  are  often  obstructed  and  the  vesicles  suffer  from  over-distention. 
In  such  cases  relief  can  be  obtained  by  i-egular  evacuation  or  stripping  of  the 
vesicles,  which  is  executed  by  the  pressure  of  the  finger,  or  of  a  blunt, 
rounded  instrument  shaped  somewhat  like  the  curved  finger,  which  is  passed 
into  the  rectum  above  the  organ  and  made  to  press  forward  upon  each 
vesicle  in  turn  so  as  to  empty  its  contents.  Tuberculosis  invades  the 
seminal  vesicles  from  the  prostate  or  the  testicle.  In  the  early  stages  indu- 
rated nodules  can  be  felt,  but  later  the  vesicles  feel  soft  from  the  breaking 
down  of  the  tuberculous  exudate.  It  should  be  treated  similarly  to  tuber- 
culosis of  the  prostate,  and  the  organs  can  be  reached  by  the  perineal  incision 
already  described  for  that  gland.  The  seminal  vesicles  have  been  success- 
fully removed  through  a  similar  incision  in  cases  of  castration  for  tubercu- 
losis when  the  vesicles  were  secondarily  diseased  but  the  prostrate  was 
healthy.  When  the  prostate  is  exposed  the  rectum  is  separated  from  it,  and 
the  finger  can  enucleate  the  seminal  vesicles,  a  large  steel  sound  being  passed 
into  the  bladder  to  aid  in  protecting  that  organ.  The  final  result  of  these 
operations  is  still  uncertain.  Tumors  of  the  seminal  vesicles  are  so  rare  as 
not  to  require  description. 

Cowper's  Glands. — Inflammation. — Cowper's  glands  ai-e  some- 
times, although  seldom,  subject  to  inflammation  as  a  consequence  of  acute 
gonorrhoea.  The  development  of  this  complication  can  be  recognized  by 
deep-seated  lateral  pain  and  tenderness  in  the  perineum,  sometimes  asso- 
ciated with  retention  of  urine.  Examination  by  the  rectum  will  serve  to 
exclude  acute  prostatitis,  and  also  ischio-rectal  abscess,  which  would  lie 
nearer  the  anus.  Treatment. — Cold  applications  should  be  made  to  the 
Ijerineum,  laxatives  given,  and  the  patient  confined  to  bed  in  the  hope  that  the 
inflammation  may  be  dissipated.     If  suppuration  takes  place,  as  shown  by 

70 


1094  IMPOTENCE. 

the  occurrence  of  chills  or  an  irregular  hectic  curve  in  the  temperature,  an 
incision  should  be  made  as  early  as  possible.  The  abscesses  are  not  so  deep 
as  those  of  the  prostate,  and  the  incision  should  be  a  lateral  one  just 
external  to  the  bulb  of  the  urethra. 

Tumors. — Tumors  also  develop  in  Co^vper's  glands,  but  they  are  very 
rare.  They  can  be  distinguished  from  tumors  of  the  urethra  by  the  symp- 
toms, which  are  referred  rather  to  the  region  of  the  rectum  than  to  the 
urethra,  rectal  tenesmus  or  pain  in  defecation  being  present,  while  there  is 
no  retention  of  urine  until  the  tumor  reaches  a  lai'ge  size,  because  its  devel- 
opment takes  place  mainly  towards  the  rectum.  The  diagnosis  will  seldom 
be  made  early  enough  to  allow  of  successful  treatment,  as  the  tumors  are 
usually  malignant. 

i:mpotence,  sterility,  and  functional  diseases. 

Impotence. — By  impotence  is  meant  the  inability  to  indulge  in  coi- 
tion, which  may  be  the  result  of  congenital  or  acquired  defects  in  the  organs 
of  generation,  such  as  absence  of  the  penis  or  testicles,  or  of  loss  of  the 
power  of  erection.  The  latter  may  be  due  to  imperfect  circulation  in  the 
penis  owing  to  an  enlarged  dorsal  vein  or  damage  to  the  erectile  tissues,  or 
it  may  be  of  nervous  origin  from  exhaustion  of  the  lumbar  centres  or  weak- 
ness of  the  entire  system.  It  may  also  be  the  result  of  certain  mental  states, 
such  as  fright,  disgust,  or  exaggerated  self- consciousness. 

Treatment. — A  strong  mental  imxiression  will  often  overcome  impo- 
tence if  it  is  due  to  physical  causes,  although  some  of  these  cases  are  the 
most  difficult  to  cure.  The  use  of  electricity,  either  galvanic  or  faradic, 
applied  from  the  lumbar  region  obliquely  down  to  the  pubic  bone  and  in  the 
perineum,  or  with  one  electrode  in  the  rectum  and  the  other  at  the  peno- 
scrotal junction,  has  a  definite  value,  although  its  effect  is  probably  mainly 
a  psychical  one.  In  any  case  where  there  is  a  psychical  element,  as  well  as 
in  cases  of  sexual  neurasthenia  or  exhaustion,  and  of  incomj)lete  develop- 
ment, it  is  wise  to  prohibit  all  attempts  at  sexual  intercourse  during  the 
course  of  treatment,  or  to  allow  them  only  at  long  intervals  when  there 
seems  considerable  hope  of  their  successful  accomplishment,  as  every  failure 
increases  the  mental  depression  of  the  patient. 

Sterility. — Sterility  in  the  male  is  the  result  of  a  failure  to  fertilize  the 
ovum,  but  it  is  by  no  means  always  associated  with  impotence,  for  although 
impotence  is  one  cause  of  sterility,  the  latter  may  also  result  from  anj'  con- 
dition which  impairs  the  vitality  of  the  spermatozoa,  excludes  them  from 
the  seminal  fluids,  or  prevents  the  proper  ejaculation  of  the  latter.  Sterility 
may  be  due  to  functional  disturbances  of  the  testicle,  causing  imperfect 
production  of  spermatozoa,  to  a  chronic  epididymitis,  which  prevents  the 
spermatozoa  fi'om  entering  the  seminal  fluid,  to  a  tight  urethral  stricture, 
which  prevents  ejaculation  of  the  semen  during  the  act  of  coition,  or  to  any 
deformity,  such  as  hypospadias,  which  hinders  the  deposit  of  semen  in  the 
vagina.  Obstruction  of  the  ejaculatory  ducts  due  to  inflammation  or  to 
tumors  of  the  j)rostate  has  a  similar  effect.  In  some  cases  it  has  been  found 
that  spermatozoa  were  present  in  the  seminal  fluid  but  were  not  vigorous, 
and  in  others  the  fluid  has  been  found  entirely  destitute  of  these  organisms. 


MASTURBATION. 


1095 


Gonorrhoea  and  its  sequelfe  are  the  most  frequent  causes  of  steiility.     Treat- 
ment.— The  treatment  must  be  directed  to  the  removal  of  the  cause. 

Masturbation.  -  The  habit  of  masturbation  or  self-abuse  produces 
many  evil  effects  because  of  the  over-indulgence  in  the  sexual  act,  and  espe- 
cially because  it  is  usually  practised  at  an  early  age,  when  such  excess  is 
particularly  injurious.  It  also  has  disastrous  consequences  on  the  moral 
nature  of  the  individual.  But  its  local  effects  upon  the  organs  of  genera- 
tion, even  when  practised  to  excess,  are  not  very  serious.  Its  most  frequent 
evil  results  are  sexual  and  general  neurasthenia  and  hyperesthesia,  catar- 
rhal prostatitis,  and  sometimes  the  production  of  local  irritation  and  hyper- 
sesthesia  of  certain  parts  of  the  urethra.  Masturbation  is  sometimes  only  a 
symptom  of  stone  in  the  bladder  or  of  a  narrow  meatus  or  foreskin.  Mas- 
turbation is  much  less  common  in  the  female,  and  its  effects  are  less  serious. 
It  may  be  due  to  similar  causes,  or  to  irritation  of  the  vulva  by  adhesions, 
retained  secretions,  or  parasitic  worms  from  the  rectum.  Treatment. — 
Any  local  cause  of  irritation  must  be  removed.  In  some  cases  the  habit  can 
be  broken  by  friendly  advice,  or  in  very  young  children  by  restraint.  In 
older  persons  the  regular  passage  of  a  large  cold  urethral  sound  will  often 
quiet  the  sexual  hyperesthesia,  and  lead  to  a  cure  if  the  individual  is 
making  an  earnest  effort  to  stop  the  habit.  Many  of  the  measures  of  treat- 
ment described  in  the  next  section  will  be  found  useful  adjuvants. 

Sperraatorrhcea. — Spermatorrhoea  is  a  name  given  to  the  discharge 
of  a  mucous  fluid  from  the  genitals,  which  rarely  contains  spermatozoa, 
being  generally  the  secretion  of  the  prostate  or  of  the  deep  urethra  under 
sexual  excitement.  It  is  a  symj)tom  of  slight  catarrh  or  mere  hypersemia 
of  the  prostate  of  veiy  little  importance,  which  is  often  exaggerated  by 
neurasthenic  individuals  who  are  sexually  irritable.  If  the  seminal  vesicles 
are  distended,  the  discharge  of  their  contents  during  defecation  when  hard 
masses  press  upon  them  would  be  a  very  natural  consequence,  and  of  no 
pathological  significance,  even  if  the  discharge  contained  true  semen.  The 
ordinary  discharge  under  these  circumstances  is  merely  that  of  the  prostate. 
S^octurnal  emissions  are  also  perfectly  natural  modes  of  expelling  the  sur- 
plus semen,  and  should  not  be  considered  symptoms  of  a  diseased  condition 
unless  they  occur  too  frequently  for  the  strength  of  the  individual  con- 
cerned, as  shown  by  lassitude,  nervous  exhaustion,  or  irritability  and 
lumbar  jjain.  Too  frequent  emissions  can  be  avoided  by  strict  abstinence 
from  any  sexual  thoughts,  by  a  plain  light  diet,  regulation  of  the  bowels, 
out-of-door  exercise,  a  cool  bedroom,  and  light  bedclothes.  The  patient 
should  not  eat  or  drink  anything  for  some  hours  before  bedtime,  and  should 
sleep  on  his  side,  a  towel  tied  around  the  body  with  a  hard  knot  in  the 
lumbar  region  being  useful  to  prevent  rolling  over  on  the  back.  Erections 
are  frequently  due  to  a  full  bladder,  and  the  patient  should  cultivate  the 
habit  of  waking  once  during  the  night  to  evacuate  it.  In  bad  cases  a  regu- 
lar course  of  athletic  physical  training  should  be  instituted,  as  it  is  well 
known  that  this  not  only  improves  the  general  health,  but  lessens  sexual 
hyperiesthesia.  Above  all  things  sexual  intercourse  is  to  be  avoided  until  a 
cure  is  obtained,  for  nothing  is  more  likely  to  increase  the  sexual  hyperes- 
thesia, especially  if  it  be  practised  in  an  irregular  manner. 


CHAPTEK  XLI. 


SURGERY  OF  THE  FEMALE  GENITALS. 


By  B.  Faequhae  Cuetis,  M.D. 


3IETH0DS  or  EXAMINATION. 

Inspection. — The  external  genitals,  and,  by  the  aid  of  the  speculum, 
the  vagina  and  cervix  uteri  also,  are  accessible  to  inspection.     The  best 

specula  for  general  use  are  the  Sims  and 
the  bivalve  speculum.  The  Sims  in- 
strument (Fig.  834)  is  used  iu  the  left 
latero-prone  position.  (Fig.  835.)  The 
patient  should  lie  upon  her  left  side, 
with  the  legs  and  thighs  flexed,  the 
upper  thigh  being  flexed  a  little  more 
than  the  lower,  so  that  the  heel  of  the 
right  foot  shall  rest  upon  the  ankle  of 
the  left.  The  table  should  be  flat  and 
elevated  a  little  at  the  foot.  The  patient  lies  with  the  under  arm  behind 
her,  and  with  the  uj)per  shoulder  tui-ned  forward  and  depressed  as  much 
as  possible  towards  the  table,  so  that  the  thorax  is  partially  rotated  in 


The  Sims  speculum. 


The  left  latero-prone  or  the  Sims  position.     (Potter. ) 


that  direction.  In  this  position  all  strain  is  taken  off  the  diaphragm 
and  the  abdominal  muscles,  and  the  abdomen  and  its  contents  tend  to  fall 
towards  the  table.  When  the  speculum  is  inserted,  air  enters  and  distends 
the  vagina,  and  very  slight  pressure  with  an  instrument  called  a  depressor 
(Fig.  836)  on  the  anterior  wall  allows  free  inspection  of  the  parts.  The 
1096 


EXAMINATION   OF  THE  FEMALE   GENITALS. 


1097 


speculum  should  be  held  as  shown  in  Pig.  837,  the  nurse's  free  hand  draw- 
the  upper  buttock  and  labium  out  of  the  way.      The  bivalve  speculum 

Fig. 


Depressor. 

(Pig.  838)  may  be  used  in  this  position  or  with  the  patient  on  the  back  in 
the  lithotomy  position,  as  may  also  the  hollow  cylindrical  speculum.     (Pig. 


Fig.  837. 


Method  of  holding  the  Sims  speculum. 

839.)     Each  of  the  latter  has  its  uses,  and  they  are  more  convenient  than 
the  Sims  when  no  assistant  is  to  be  had.     In  some  cases  a  tenaculum  (Pig. 

840)  or  a  volsellum  (Pig.  841) 
hooked  into  the  anterior  lip  of 
the  cervix  will  assist  in  bringing 
it  into  the  field  of  view.  The 
uterine  probe  or  sound  is  made 

Fjg.  839. 


Fig.  838. 


Bivalve  speculum 


Cylindrical  speculu 


of  soft  metal,  such  as  copper  (nickel-plated),  so  that  it  can  be  bent  into 
a  curve  similar  to  that  of  the  uterus.     (Pig.  842.)    It  is  employed  to 


1098 


EXAMINATION  OF  THE  FEMALE   GENITALS. 


ascertain  the  patency,  length,  and  direction  of  the  uterine  canal,  and  must 
be  introduced  with  great  gentleness,  as  it  might  perforate  the  wall  of  a 

Fig.  840. 


-£ 


Uterine  tenaculum. 

diseased  uterus.     It  should  always  be  sterilized,  lest  an  infectious  endome- 
tritis or  salpingitis  follow  its  use,  and  for  the  same  reason  it  should  be  passed 

Fig.  841. 


with  the  aid  of  a  speculum  after  cleansing  the  cervix,  so  as  to  avoid  con- 
tamination by  the  vaginal  secretions.     When  there  is  marked  flexion  the 

Fig.  842. 


Fig.  843. 


uterine  sound  with  normal  curve. 

passage  of  the  sound  may  be  facilitated  by  drawing  down  the  cervix  with  a 
tenaculum  or  pushing  up  the  fundus  with  the  finger,  so  as  to  straighten  the 
uterine  canal. 

Digital  Examination. — The  best  position  for  a  thorough  pelvic 
examination  with  the  finger  is  with  the  patient  lying  on  her  back  on  a  table 
with  the  knees  drawn  uji.  In  some  cases  general 
anaesthesia  is  necessary  for  satisfactory  palj)ation. 
The  examining  finger  should  be  well  lubricated. 
The  index  fiuger  is  then  introduced  into  the 
vagina  while  the  fingers  of  the  other  hand  press 
upon  the  abdominal  wall  just  above  the  pubes,  and 
between  the  two  all  the  pelvic  organs  may  be 
distinctly  palpated.  (Fig.  843.)  When  the  hy- 
men is  intact  a  rectal  examination  will  often 
supj)ly  all  necessary  information.  In  women  who 
have  borne  children  a  little  higher  reach  can  be 
obtained  by  introducing  two  fingers  into  the 
vagina,  and  a  still  more  thorough  examination 
may  be  made  by  introducing  the  middle  finger  into 
the  rectum  and  the  index  finger  into  the  vagina,  the  perineum  being  pressed 
far  upward.      The  condition  of  the  cervix,  the  position  and  size  of  the 


Bimanual  palpation.     (MundC'.) 


DIAGNOSIS   OF   PELVIC  TUMORS. 


1099 


uterus,  the  ovaries,  and  the  tubes  can  be  studied.  By  drawing  down  the 
uterus  with  a  volsellum  fixed  in  the  cervix  the  posterior  and  anterior  walls 
can  often  be  exaiained  up  to  the  fundus  by  tlie  finger  passed  into  the  rectum 
or  the  bladder.  The  uterine  canal  may  also  be  dilated  so  as  to  admit  the 
finger  for  examination.  This  may  be  done  by  tents,  the  tissues  being  ren- 
dered very  soft  and  pliable  by  their  action.  Tents  are  made  of  tupelo 
(Pig.  844)  or  laminaria  or  sponge,  and  expand  under  the  influence  of  the 

Fig.  844. 


heat  and  moisture  of  the  body.  They  are,  however,  difficult  to  use  in  an 
aseptic  manner,  and  it  is  safer  to  emj)loy  instrumental  dilatation  by  passing 
a  series  of  sound-like  instruments,  or  by  dilating  forceps,  the  blades  of  which 


Goodell-EUinger  uterine  dilator. 

are  separated  by  comj)ressing  the  handle  by  the  hand  or  a  screw.  Of  the 
latter  we  prefer  the  Goodell-Bllinger  instrument.     (Fig.  845.) 

General  Facts  in  Diagnosis. — In  making  the  diagnosis  of  pelvic 
tumors  the  possibility  of  pregnancy  is  always  to  be  borne  in  mind,  the 
signs  indicating  that  condition  being  the  enlargement  of  the  uterus,  the 
softening  of  the  uterine  wall  at  the  level  of  the  internal  os  in  the  early  stages, 
the  patulous  cervix  later,  the  rhythmic  contractions  of  the  organ,  the  foetal 
movements  and  heart-sounds,  ballotement  of  the  foetus,  and  the  changes  in 
the  mammEe.  Palpation  may  reveal  the  ovaries  and  tubes  on  the  sides  and 
the  round  ligaments  passing  to  the  summit  of  the  tumor.  If  there  is  any 
suspicion  of  pregnancy,  the  sound  should  not  be  passed  into  the  uterus, 
except  in  urgent  cases,  as  miscarriage  will  follow.  Errors  are  most  likely  to 
occur  in  cases  of  hydramnios. 

If  a  mass  is  felt  in  the  pelvis,  its  attachment  to  the  uterus  is  ascertained 
by  moving  the  tumor  with  the  hand  outside,  the  finger  in  the  vagina 
observing  if  the  cervix  moves  in  a  corresponding  way.  If  the  fundus  can- 
not be  felt  separate  from  the  tumor,  a  sound  introduced  into  the  uterine 
canal  will  determine  the  direction  of  the  fundus  and  whether  the  mass  uni- 


1100 


DIAGNOSIS   OF  PELVIC  TIMOES. 


formlj'  surrouuds  it  or  lies  upon  one  side.  If  the  mass  is  upon  one  side  and 
distinct  from  the  uterus,  it  may  be  an  inflammatory  mass  formed  by  the 
tubes  and  ovaries,  a  distended  tube,  or  a  tumor  of  the  ovary.  In  the 
first  case  there  will  be  a  history  of  an  inflammatory  trouble,  such  as  pain 
and  uterine  discharge,  the  mass  will  be  uneven  on  the  surface,  fixed  in  the 
pelvis,  and  very  commonly  a  similar  condition  will  be  found  on  the  other 
side.  A  distended  tube  may  contain  blood,  serum,  or  pus  ;  it  may  or  may 
not  be  tender  to  pressure,  and  if  it  contains  pus  it  will  usually  be  fixed  by- 
adhesions.  A  tumor  of  the  ovary  will  be  globular  in  shape  ;  it  is  generally 
movable,  and  the  uterus  will  not  move  with  it.  The  pedicle  can  often  be 
felt  attached  to  one  horn  of  the  uterus.  A  cyst  of  the  broad  ligament, 
whether  parovarian  or  ovarian,  growing  downward  in  the  pelvis,  will  tend 
to  displace  the  uterus  towards  the  other  side  and  more  or  less  fix  it  in  its 
position.  A  fibroid  of  the  uterus  developing  ui^on  one  side,  even  if  it 
has  a  narrow  pedicle,  will  promptly  move  the  uterus  with  it.  Intraperi- 
toneal fibroids  are  usually  movable,  although  the  extraperitoneal  tumors 
may  be  fixed  by  folds  of  the  broad  ligament.  An  extraperitoneal  haema- 
tocele  will  form  a  rather  doughy  tumor,  surrounding  the  uterus  so  as  to 
fix  it  completely,  usually  being  more  marked  on  one  side  of  the  pelvis  than 
on  the  other.  An  intraperitoneal  hsematocele  "nill  be  bilateral,  will  fill 
Douglas's  cul-de-sac,  and  may  extend  high  enough  to  be  felt  by  the  baud  on 
the  abdomen.  The  tumor  will  give  one  the  impression  of  something  poured 
into  the  pelvis  and  solidified  there,  rather  than  of  a  distinct  mass.  Similar 
masses,  however,  are  produced  by  the  exudate  of  local  peritonitis.  When 
a  tumor  lies  in  Douglas's  cul-de-sac  the  fingers  can  often  be  passed  between 
it  and  the  uterus,  but  when  the  mass  has  developed  in  the  broad  ligament 
and  extended  behind  the  uterus  by  detaching  the  peritoneum,  this  will  be 
impossible. 

Displacements  of  the  uterus  are  readily  recognized,  and  the  position 
of  the  fundus  located  :  but  if  thei'e  is  any  doubt,  as  is  often  the  case  when  a 
tumor  of  about  the  same  size  lies  close  to  the 
uterus  (Fig.  846),  the  passage  of  the  uterine 
probe  will  i^oint  out  the  position  of  the  fundus. 
The  mobility  of  the  uterus  must  be  carefully 
studied  in  each  case,  and  if  it  is  fixed  the  fixa- 
tion may  be  due  to  adhesions,  the  result  of 
recent  or  former  inflammation,  or  to  the  pres- 
ence of  a  tumor  or  of  blood-clot.  When 
malignant  disease  attacks  the  uterus  that 
organ  is  usually  enlarged,  and  in  the  latter 
stages  becomes  fixed  in  the  pelvis  by  the  spread 
of  the  disease  through  the  cellular  tissue  about 
the  organ.  Tumors  of  the  uterus  and  ovary  will 
be  considered  later.  Tumors  of  the  vagina  are  readily  felt  by  the  finger, 
and  it  can  be  ascertained  whether  they  grow  from  the  vaginal  wall  or  from 
the  cervix,  or  protrude  through  the  cervical  canal  into  the  vagina  as  a  poly- 
poid growth.  When  abscesses  form  in  the  neighborhood  of  the  vagina, 
fluctuation  can   sometimes  be  made  out   distinctly  with   the  finger.      A 


Fig.  846. 


I  posterior  wall  of  uterus, 
(llunde.) 


CONGENITAL  DEFORMITIES   OF  THE   GENITALS.  ]]0l 

floating  kidney  or  spleen  may  lie  iu  Douglas's  cnl-cle-sac,  but  can  usually 
be  returned  to  Its  place  and  its  true  uature  recognized. 

MENSTEUAL   DISTURBANCES. 

Amenorrhoea. — In  the  symptomatology  of  the  diseases  of  the  female 
genitals  disturbances  of  the  menstrual  function  are  very  common.  Absence 
of  the  menses  may  be  due  to  malformation  of  the  organs,  but  is  most  fre- 
quently the  result  of  antemia,  especiallj'  in  tuberculosis.  In  the  latter  case 
it  is  to  be  considered  as  a  conservative  symptom,  and  attention  should  be 
directed  to  the  general  condition,  without  making  any  attempt  to  bring  on 
the  interrupted  function,  which  will  be  re-established  if  the  patient's  health 
is  sufficiently  restored  to  provide  the  necessary  blood. 

Dysmenorrhoea. — Painful  menstruation  may  be  due  to  mechanical 
causes,  such  as  an  obstruction  in  the  iiterine  canal  by  stricture,  an  abnor- 
mally small  OS,  acute  flexion,  or  merely  the  swelling  of  inflammation.  In 
such  cases  the  pain  is  usually  most  intense  at  the  beginning  of  menstrua- 
tion, is  colicky  in  character,  and  may  be  extremely  severe,  being  relieved 
only  by  very  large  doses  of  morphine,  but  it  generally  subsides  as  the  func- 
tion becomes  established.  In  other  cases,  however,  the  pain  is  throbbing, 
with  a  feeling  of  fulness  in  the  pelvis  and  aching  in  the  back  and  loins, 
which  may  be  felt  only  at  the  beginning  of  menstruation  or  may  persist 
throughout.  Such  symptoms  are  common  in  cases  of  malposition  of  the 
uterus  without  acute  obstruction  or  inflammation,  being  due  to  the  venous 
congestion  and  the  dragging  of  the  heavy  organ.  Obstructive  and  con- 
gestive dysmenorrhoea  must  be  treated  by  removing  the  cause.  Dysmenor- 
rhoea of  neuralgic  or  ovarian  origin  belongs  to  medicine  rather  than  to 
surgery. 

Menorrhagia  and  Metrorrhagia, — Too  profuse  menstruation  is  called 
menorrhagia,  and  a  flow  occurring  between  the  regular  periods  is  termed 
metrorrhagia.  The  former  may  be  a  symi^tom  of  fibroids,  of  endometritis, 
especially  of  the  fungoid  form,  and  of  malposition  of  the  uterus.  Metror- 
rhagia usually  indicates  the  presence  of  a  fibromyoma,  especially  one  within 
the  cavity  of  the  uterus.  It  may  be  a  symptom  of  malignant  disease  in  the 
first  stages.  Both  symptoms  may  be  caused  by  retained  portions  of  placenta. 
Whatever  cause  is  found  for  these  conditions  must  be  removed.  The  admin- 
istration of  gallic  acid  or  ergot  will  control  a  moderate  flow,  but  in  sevei'e 
cases  packing  of  the  uterus  and  vagina  will  be  necessary,  sometimes  pre- 
ceded by  curetting  the  uterus. 

CONGENITAL  DEFORMITIES. 

Absence  of  the  Genitals.— Complete  absence  of  the  genitals  is  rarely 
found,  but  absence  of  the  vagina  is  not  uncommon.  In  such  cases  the  vulva 
is  usually  well  formed,  but  no  opening  exists  between  the  labia  minora 
except  the  irrinary  meatus.  Occasionally  only  part  of  the  vagina  is  absent, 
either  the  upper  or  the  lower  part  being  naturally  formed.  This  atresia 
may  be  a  congenital  defect  or  may  be  the  result  of  cicatricial  contraction 
following  destructive  inflamxnation  in  infancy.  The  uterus  may  be  absent, 
and  if  no  uterus  can  be  found  on  rectal  examination,  no  attempt  should  be 


1102  CONGENITAL   DEFOEMITIES  OF  THE   GENITALS. 

made  to  rectify  the  deformity.  If,  however,  a  uterus  of  fair  size  is  found, 
an  artificial  vagina  can  be  made  by  blunt  dissection  in  the  vesicorectal 
space,  between  the  urethra  and  the  rectum,  up  to  the  uterus.  This  can  be 
kept  ox^en  by  dilatation  with  glass  plugs,  by  lining  it  with  Thiersch  skin- 
grafts,  or  by  the  transplantation  of  a  flap  of  skin  from  the  vulva  or  from  the 
thighs  into  the  wound,  suturing  it  to  the  cervix  if  possible.  If  no  uterus  is 
present  or  the  organ  is  undeveloped,  it  will  be  difficult  or  impossible  to  keep 
the  new  canal  patent.  In  some  cases  of  absence  of  the  vagina  sexual  Inter- 
course takes  place  through  the  dilated  urethra,  and  if  the  uterus  is  present 
the  cervical  canal  sometimes  connects  with  the  bladder,  and  menstrual 
blood  may  escape  through  that  organ.  No  operation  should  be  undertaken 
before  puberty.  If  the  condition  is  hopeless,  the  removal  of  the  ovaries, 
which  are  usually  fairly  well  develojied,  will  often  prevent  unpleasant 
nervous  symptoms.  Women  with  these  congenital  deficiencies  are  not 
infrequently  of  fine  physique,  with  the  ordinary  feminine  characteristics. 

Reduplication. — Double  genital  organs  are  not  uncommon.  There  may 
be  a  sex)tum  dividing  the  vagina  entirely  or  in  part,  or  extending  up  through 
the  cavitj'  of  the  uterus.  The  latter  is  sometimes  divided  by  a  septum  when 
the  vagina  is  normal,  and  in  other  cases  the  entire  fundus  of  the  uterus  is 
double,  with  two  cavities,  resembling  the  uterus  bicornis  of  the  lower  animals, 
the  cervix  being  single.  Very  rarely  a  double  uterus  is  found  with  two  sep- 
arate vaginjE.  Eeduplication  of  the  ovaries  and  tubes  is  one  of  the  rarest 
of  these  deformities,  and  a  supernumerary  ovary  is  also  very  rare.  These 
conditions  usually  need  no  treatment,  except  that  division  of  the  vaginal 
septum  may  be  necessary  to  facilitate  sexual  intercourse  or  parturition. 

Hermaphroditism. — True  hermaphroditism  is  rare,  the  great  majority 
of  these  cases  being,  as  already  mentioned,  instances  of  hypospadias  in  the 
male. 

Cervical  Deformities. — Atresia  or  stricture  of  the  cervix  occasions 
menstrual  retention  like  imperforate  vagina  or  hymen,  and  requires  incision 
for  its  relief.  Stenosis  of  the  cervical  canal  is  apt  to  be  a  cause  of  endome- 
tritis and  serious  complications  if  infection  occurs,  as  it  prevents  free  drain- 
age of  the  secretions.  It  should  be  treated  by  dilatation,  aided,  if  necessary, 
by  superficial  incisions  of  the  wall  of  tlie  canal.  The  dilatation  may  be 
accomplished  by  repeated  introductions  of  dilating  sounds,  or  may  be  made 
in  one  sitting  by  means  of  the  Goodell-Ellinger  dilator.  The  same  treat- 
ment is  indicated  in  cases  of  obstruction  due  to  sharp  congenital  flexions, 
and  a  stem  jpessary  should  be  worn  afterwards.  Hypertrophic  elongation 
of  the  cervix  may  be  so  extreme  that  the  cervix  protrudes  from  the  vulva. 
It  may  prevent  conception  and  should  be  treated  by  amputation  of  the 
redundant  j)art,  the  canal  being  slit  open  to  insure  an  os  of  sufficient  size. 

Adherent  Labia. — The  labia  are  often  adherent  in  the  infant,  simulating 
atresia  of  the  vulva,  but  can  usually  be  separated  by  a  blunt  instrument  like 
a  director,  although  the  use  of  the  knife  is  occasionallj'  uecessaiy. 

Atresia  of  the  Hymen. — The  most  common  malformation  is  atresia  of 
the  hymen.  (Fig.  847.)  The  opening  in  the  hymen  should  normally  be  of 
considerable  size.  In  some  cases  it  is  very  narrow,  reduced  to  the  size  of 
a  pin-head,  or  even  absent.    When  the  hymen  is  imperforate  and  menstrua- 


INJURIES  OF  THE  FEMALE  GENITALS. 


1103 


tion  begins  at  puberty,  the  discharge  collects  behind  it,  distends  the  vagina, 
carries  the  uterus  up,  and  even  distends  that  organ,  pi'oduciug  large  tumors 
which  reach  half-way  to  the  umbilicus  (hwmatometra).  (Fig.  848.)  The 
symptoms  of  this  condition  are  absence  of  the  menses,  occasional  attacks  of 
cramp-like  pains  especially  at  the  men- 
strual   epoch,    signs   of    pressure    by   the  Fig  s4s 


Imperforate  hymen.    (Hirst.) 


Vagina  and  uterus  distended  with  blood 
from  imperforate  hymen ;  T',  vagina ;  U, 
uterus.    (Hirst.) 


large  tumor  (such  as  constipation  and  frequent  micturition),  and  the  pro- 
trusion at  the  vulva  of  the  distended  hymen.  The  contents  of  these  tumors 
are  blood  in  a  more  or  less  clotted  condition.  If  left  unrelieved,  infection 
is  certain  to  take  place  sooner  or  later,  and  fatal  sepsis  usually  results. 
The  treatment  consists  in  freely  incising  the  hymen,  clearing  out  the  clots 
completely,  irrigating  the  large  cavity  with  sterilized  water,  and  packing 
the  vagina  with  sterilized  gauze,  the  irrigation  and  packing  to  be  renewed  if 
the  temperature  rises.  The  j^rincipal  danger  in  the  operation  is  the  risk  of 
infection,  and  every  precaution  to  maintain  asepsis  must  be  taken. 


IN.JUEIES   OP   THE   FEMALE   GENITALS. 

The  female  genitals  are  but  little  exposed  to  injury,  and  yet  falls  upon 
the  buttocks  may  produce  contusions  of  the  vulva,  an  immense  hsematoma 
often  forming  in  the  labia.  Palls  iipon  sharp  objects  may  produce  lacerated 
wounds  of  the  parts,  or  a  stake  may  enter  the  vagina  and  open  the  perito- 
neal cavity  or  wound  the  rectum  or  bladder.  Gunshot  wounds  are  occa- 
sionally, but  rarely,  met  with.  The  pregnant  uterus  may  be  injured  by 
penetrating  wounds  of  the  abdomen,  and  has  most  commonly  been  wounded 
in  the  accident  of  goring  by  cattle.  "Wounds  of  the  uterus  are  most  fre- 
quently the  result  of  attempts  at  abortion,  but  may  follow  incautious  use  of 
the  uterine  sound.  Rupture  of  the  Uterus. — The  most  common  injury, 
however,  is  the  rupture  of  the  uterus  during  labor.  The  rent  usually  begins 
in  the  lower  third,  where  the  tissues  are  stretched  over  the  presenting  part 
of  the  child,  but  it  may  extend  upward  to  the  fundus.  The  laceration  may 
be  incomplete,  either  the  mucous  membrane  or  the  peritoneum  remaining 
intact.    It  may  also  be  entirely  extraperitoneal,  but  more  frequently  it  opens 


1104  LACERATION   OF  THE  PEEINEUM  AND  VAGINA. 

the  peritoneal  cavity.  The  diagnosis  of  complete  ruptoi-e  is  easy  ;  the  child 
recedes,  and  may  escajpe  into  the  peritoneal  cavity,  and  there  is  great  shock 
and  cessation  of  the  labor- pains.  In  the  incomplete  form  there  will  be  an 
arrest  of  the  descent  of  the  presenting  part  of  the  child,  or  even  recession, 
unusual  hemorrhage,  loss  of  the  symmetrical  shape  of  the  uterus,  and  thin- 
ning of  its  lower  segment,  which  can  be  felt  through  the  abdominal  wall. 
Treatment. — Immediate  laparotomy  is  necessary  with  removal  of  the  child 
and  placenta,  and  hysterectomy  should  generally  follow.  If  the  mother 
were  in  good  condition,  suture  of  the  rent  would  be  preferable,  but  she  is 
generally  so  feeble  that  the  operation  must  be  rapidly  completed  by  trans- 
fixing the  cervix  with  pins,  surrounding  it  with  a  ligature,  and  cutting  away 
the  uterus.  The  pedicle  is  secured  in  the  abdominal  wound.  A  vaginal 
drain  should  be  inserted  in  Douglas's  cul-de-sac  and  the  abdominal  wound 
should  also  be  drained.  The  abdomen  should  be  thoroughly  washed  out 
and  the  wound  closed.  Eecovery  is  rare,  for  even  if  the  patient  survives 
the  shock,  peritonitis  is  very  apt  to  follow. 

Injuries  to  the  Vagina. — The  vagina  may  be  injured  in  coitus  owing  to 
a  disproportion  of  the  parts  or  to  violent  efforts  in  intoxication.  The  j)enis 
has  been  forced  through  the  recto- vaginal  septum  or  into  Douglas's  cul-de-sac. 
These  injuries  are  apt  to  be  followed  by  profuse  hemorrhage,  on  account  of 
the  great  vascularity  of  the  parts,  but  their  principal  danger  is  the  injury 
to  the  neighboring  organs  or  subsequent  infection.  Infection  in  this  region 
may  produce  extensive  suppuration  within  the  pelvis  or  result  in  perito- 
nitis. Self-inflicted  injuries  to  the  parts  are  occasionally  seen  in  demented 
persons.  Treatment. — The  hemorrhage  should  be  arrested  by  ligature  or 
by  packing  the  vagina,  after  thorough  cleansing  and  removal  of  torn  and 
gangrenous  tissues.  Extensive  wounds  may  be  sutured,  but  this  will  seldom 
be  necessary.  Thorough  asepsis  and  drainage  must  be  provided,  and  a 
beginning  cellulitis  or  an  infected  hnematoma  treated  by  early  incision. 

Foreign  Bodies. — Foreign  bodies  are  sometimes  introduced  into  the 
genital  passages  by  accident,  but  more  frequently  with  intention.  If 
allowed  to  remain  long  in  place,  as  is  sometimes  the  case  with  neglected 
pessaries,  they  may  become  iucrusted  with  lime  salts  and  produce  deep 
ulcers  penetrating  the  rectum  or  bladder.  When  an  obstinate  vaginitis 
exists  in  children  a  careful  search  should  always  be  made  for  a  foreign  body. 

Laceration  of  the  Perineum  and  Vagina.— As  the  result  of  par- 
turition, tears  are  often  found  in  the  vagina  and  perineum,  either  lateral  or 
directly  backward.  The  perineal  laceration  may  be  slight,  involving  only 
the  vaginal  mucous  membrane  and  the  commissure,  it  may  divide  all  the 
tissues  down  to  the  sphincter  aui,  or  it  may  be  complete  and  extend  into 
the  rectum.  The  principal  factor  in  these  injuries  is  not  the  laceration  of 
the  skin  and  mucous  membrane,  but  the  damage  to  the  pelvic  fascia  and 
levator  ani.  The  loss  of  the  support  leads  to  eversion  of  the  vaginal  mucous 
membrane,  especially  on  the  posterior  wall.  This  eversion  is  aided  by  the 
falling  forward  of  the  lower  part  of  the  rectum,  and  the  pouching  of  the 
latter  produces  an  obstruction  to  defecation  and  is  constantly  increased  by 
the  straining  dming  that  act.  As  the  posterior  vaginal  wall  descends  it 
drags  the  cervix  of  the  uterus  forward  and  downward,  and  that  organ  takes 


OPERATIONS   FOE  LACERATED  PERINEUM. 


1105 


Fig.  849. 


the  first  step  towards  retroversion  and  prolapse.  The  bladder  also  jjrolapses 
quite  frequently.  The  prolapsed  vaginal  wall  is  called  a  rectocele  or  a 
cystocele  (Fig.  849),  according  to  the 
organ  affected.  In  some  cases  the  extent 
of  the  laceration  is  not  evident  until  the 
fingers  are  passed  into  the  vagina  and 
pressure  made  towards  the  rectum,  when 
it  will  be  discovered  that  the  entire  fas- 
cial support  of  the  perineum  has  been 
torn  away,  leaving  it  lax  and  non-resist- 
ant, although  the  vulvovaginal  opening- 
may  not  appear  much  larger  than  normal. 
The  sphincter  ani  may  be  divided  by 
these  subcutaneous  lacerations.  If  this 
muscle  is  weakened  or  destroyed,  the 
woman's  condition  is  pitiable  from  the 
loss  of  control  over  the  fecal  movements, 
or  at  least  over  flatus. 

Treatment. — Primary  sutures  should 
be  introduced  as  soon  as  the  injury  is 
received,  unless  the  sphincter  ani  is  in- 
volved, a  few  stitches  being  placed  so  as 
to  bring  the  raw  surfaces  together.  Many 
secondary  plastic  operations  have  been 
devised,  but  we  can  mention  only  a  few. 
In  all  cases  the  hair  sh'^uld  be  cut  close  or  shaved  and  the  vagina  thoroughly 
washed  with  soap  and  water  before  the  operation.  The  patient  should  be 
in  the  lithotomy  position. 

A.  Perineorraphy  for  Partial  Laceration. — 1.  In  the  simplest  method 
the  cicatricial  skin  and  mucous  membrane  are  pared  from  a  triangular 
surface  on  each  side  of  the  vulva,  the  two  being  con- 
tinuous in  the  middle  line  behind.  (Fig.  850.)  In 
some  cases  the  injury  is  unilateral  and  the  paring 
should  be  correspondingly  asymmetrical.  The  freshen- 
ing can  usually  be  limited  to  the  part  about  the  hymen, 
and  the  normal  skin  should  never  be  encroached  upon. 
If  a  rectocele  is  present,  the  freshening  must  extend 
up  to  its  crest.  A  deep  suture  is  then  passed  near  the 
anterior  border,  the  needle  entering  the  skin  one- 
quarter  of  an  inch  away  from  the  edge  of  the  wound, 
ti'aversing  the  lateral  tissues  very  deeply  to  pick  up 
the  torn  fascia,  and  being  carried  backward  and  inward 
towards  the  median  angle  of  the  wound.  It  passes 
beneath  the  latter  and  retiu-ns  in  a  similar  course  on 
the  other  side.  Other  sutures  are  passed  jjarallel  to 
this  first  one,  about  one-quarter  of  an  inch  apart.  When  the  denudation 
extends  forward  along  the  sides  of  the  vulva,  as  in  Fig.  850,  the  two  anterior 
sutures  simply  take  up  these  prolongations  and  do  not  pass  through  the  recto- 


Cyatocele  and  rectocele.    (Mund^. 


Fig.  850. 


Operation  for  partial 
laceration  of  the  perineum, 
surfaces  freshened,  and  su- 
tures placed  ready  for  tying. 


1106 


OPERATIONS  rbR  LACERATED  PERINEUM. 


cele.  In  passing  these  sutures,  one  finger  of  the  left  hand  should  be  kept 
in  the  rectum,  in  order  to  avoid  perforation  of  its  mucous  membrane,  as  the 
needle  must  sometimes  pass  very  close  to  it  in  order  to  pick  uj)  the  submu- 
cous rectal  tissues.  The  sutures  should  not  be  drawn  too  tight,  for  fear  of 
strangulation,  as  oedema  is  the  rule  after  these  operations. 

2.  A  second  form  of  ojieration,  suggested  by  Emmet,  makes  a  butterfly 
or  clover-leaf  denudation  of  the  part,  one  part  of  the  trefoU  being  on  each 
side  of  the  perineum,  and  the  central  one  being  formed  on  the  prolapsing 
posterior  vaginal  wall.  The  sutures  are  passed  in  this  operation  so  as  to 
draw  the  three  leaf-shaped  denudations  into  a  bunch,  the  two  sides  of  the 
vulva  being  brought  together  and  the  rectocele  drawn  down  against  them  so 
as  to  form  a  solid  mass.  This  operation  may  be  performed  internally,  as 
suggested  by  Emmet,  by  limiting  the  denudation  to  the  membrane  within 
the  introitus. 

3.  The  perineum  may  be  repaired  by  a  split-flap  method,  similar  to 
that  suggested  by  Jenks  and  Tait.  The  parts  are  put  upon  the  stretch  by  a 
finger  in  the  anus,  and  tenacula  hooked  in  each  side  of  the  labia  so  as  to 
pull  the  edge  of  the  perineum  out  in  a  horizontal  line.  A  sharp-pointed 
pair  of  scissors  is  introduced  at  the  posterior  edge  of  the  vaginal  mucous 
membrane  and  horizontal  cuts  made,  so  as  to  split  the  septum  into  two  fiaps. 
(Pig.  851.)     In  deep  lacerations  the  vaginal  flap  is  very  thin,  and  consists  of 

Fig.  851.  Fig.  852. 


Incision  for  split-flap  method. 


Split-flap  method 


the  vaginal  mucous  membrane  only.  This  splitting  of  the  perineum  is 
carried  to  the  depth  necessary  to  reach  the  crest  of  the  rectocele,  and  well 
out  on  the  sides,  arching  slightly  forward  at  each  end.  The  middle  point 
of  the  vaginal  flap  is  then  picked  up  with  toothed  forceps  or  a  tenaculum 
and  drawn  directly  forward,  while  a  similar  instrument  pulls  the  centre  of 
the  rectal  flap  directly  backward,  converting  the  transverse  diamond-shaped 
opening  to  a  median  diamond.  Sutures  are  then  introduced  trans\-ersely 
(Fig.  852),  the  first  suture  being  placed  in  the  middle  of  the  wound  at  the 
angles  of  the  former  horizontal  incision.     Working   backward  from  this 


OPERATIONS   FOE  LACERATED  PERINEUM.  HOT 

point,  parallel  stitclies  are  passed  until  the  posterior  angle  is  closed.     A 
continuous  suture  is  passed  anteriorly,  bunching  uj)  the  vaginal  flap,  and 


the  originally  horizontal  incision  is  converted  into  a  vertical  one.  When  a 
large  rectocele  is  present  it  is  well  to  cut  away  a  V-shaped  segment  fi-om  the 
vaginal  flap  and  unite  the  edges  of  this  last  incision. 

Sutures. — Either  silk,  silkworm-gut,  or  catgut  may  be  employed  for 
sutures.  Silver  wire  is  not  much  used  now.  The  needles  may  be  straight, 
but  a  curved  Hagedorn  is  much  easier  to  use,  and  a  needle  on  a  handle 
(Fig.  853)  may  be  employed  with  advantage  by  the  novice.  In  all  these 
oijerations  a  continuous  buried  suture  may  be  introduced.  The  wound  is 
spread  widely  open,  a  curved  needle  threaded  with  fine  chromicized  catgut 
is  introduced  at  the  bottom  of  the  wound,  picking  up  a  little  of  the  raw 
surface  on  each  side,  and  the  thread  is  tied.  A  continuous  suture  is  then 
passed,  running  along  the  deepest  i^art  of  the  wound,  picking  up  only  a 
little  tissue  on  each  side.  Having  made  this  first  tier,  a  second  tier  is 
introduced,  and  so  on  in  successive  steps  until  the  entire  wound  is  closed. 
It  is  well  to  interrux^t  the  suture  by  a  knot  at  intervals.  The  edges  of  the 
mucous  membrane  may  be  united  by  buried  sutures  also,  or  ordinary 
stitches  can  be  employed.  When  this  buried  suture  is  employed  in  cases 
in  which  there  has  been  much  lateral  injury  of  the  fascia,  it  is  wise  to  add 
a  couple  of  deep  external  sutures  to  draw  the  torn  edges  of  the  latter 
together.  The  advantages  of  the  buried  suture  are  that  there  are  no  sutures 
to  be  removed,  no  stitch-holes  to  carry  infection  to  deeper  parts,  and  no 
spaces  left  where  possible  blood-clot  can  collect.  The  disadvantages  are  the 
possibility  of  strangulation  if  the  sutures  are  drawn  too  tight,  and  the  fact 
that  if  infection  should  take  place  the  entire  wound  must  be  opened  in  order 
to  relieve  the  suppurating  point.  We  ijrefer  two  or  three  deep  sutures  of 
chromicized  catgut  or  silkworm-gut  introduced  deeply  on  each  side  so  as  to 
pick  up  the  torn  pelvic  fascia,  left  untied  until  a  buried  continuous  suture  of 
ordinary  catgut  has  been  applied,  and  then  loosely  tied  across  the  wound. 

The  rectocele  is  sufficiently  closed  in  by  the  perineal  operation,  but  if  a 
marked  cystocele  is  present  it  will  require  a  separate  denudation  aud 
suture.  An  oval  space  should  be  pared  on  the  most  prominent  pai't  of  the 
prolapse,  and  its  edges  united  in  the  median  liue  in  the  long  axis  of  the 
vagina  by  buried  catgut  or  ordinary  sutures.  More  durable  results  can  be 
obtained  if  the  vaginal  wall  is  resected  in  its  entire  thickness,  and  the  edges 
united,  than  if  the  raw  surface  is  made  by  paring  in  the  ordinary  manner. 
Even  more  can  be  gained  by  detaching  the  bladder  from  the  cervix  without 
opening  the  peritoneal  cavity  and  ijushing  the  bladder  well  upward  before 
closing  the  wound.  Or  a  circular  denudation  may  be  made  (Fig.  Soi),  as 
suggested  by  Stoltz,  and  then  folded  in  by  a  purse-string  suture  passed 
around  its  edges.  A  continuous  suture  is  made  in  the  mucous  membrane 
just  beyond  the  denuded  area,  and  when  the  two  ends  of  the  thread  are 


1108 


OPERATIONS   FOE  LACERATED  PERINEUM. 

Fig.  S54. 


Stoltz's  operation  for  cystocele,  with  circular  suture  inserted  ;  below  is  seen  tiie  denudation 
in  Hegar's  operation  tor  rectocele  and  lacerated  perineum.    (Mund^.) 


Thie  same,  with  the  cystocele  suture  tied  and  the  rectocele  stitches  partly  introduced.     (Munde.) 


OPERATIONS  FOR  LACERATED  PERINEUM.  1109 

drawn  iipon  and  the  raw  surface  is  pushed  inward,  the  latter  forms  a 
pouch,  and  the  cut  edges  of  the  mucous  membrane  are  brought  together 
across  the  neck  of  this  pouch.  (Fig.  855.)  In  this  operation  it  is  necessary 
to  avoid  drawing  the  cervix  so  far  forward  a.s  to  facilitate  prolapse  of  the 
uterus,  and  if  this  cannot  be  done,  the  wound  should  be  united  in  the  long 
axis  of  the  vagina  and  not  circularly. 

In  the  after-treatment  of  these  cases  the  vagina  is  kept  loosely  packed 
with  gauze,  and  the  urine  should  be  drawn  regularly  by  catheter,  or,  if  this 
is  considered  unwise  for  any  reason,  the  urine  should  be  passed  in  the  bed- 
pan while  a  stream  of  irrigating  fluid  from  a  fountain  syringe  is  allowed  to 
run  over  the  vulva.  If  the  urine  is  drawn,  the  gauze  in  the  vagina  can  be 
left  for  several  days,  unless  there  is  much  utei'ine  discharge,  when  a  simple 
strij)  of  gauze  should  be  jilaced  in  the  vagina  daily  for  drainage.  Vaginal 
irrigation  will  be  unnecessary  unless  voluntary  micturition  is  permitted. 
The  patient  should  be  kept  in  the  recumbent  position  for  at  least  two  weeks, 
and  preferably  three,  until  union  has  become  perfect.  The  bowel  contents 
should  be  kept  soft  and  moved  every  day. 

B.  Operations  for  Complete  Laceration. — Complete  lacerations  of 
the  perineum  are  those  which  extend  through  the  rectal  septum  and  the 
sphincter  ani.  In  rare  cases  the  sphincter  ani  or  the  greater  portion  of  it 
will  be  found  torn  but  the  rectal  mucous  membrane  left  intact.  In  com- 
plete lacerations  we  have  two  difficulties  to  deal  with, — the  restoration  of  the 
muscular  action  of  the  sphincter  ani  and  the  avoidance  of  infection  from 
the  rectum.  The  split-flap  method  is  the  best  for  closing  these  lacerations. 
If  the  septum  is  torn  high  up,  it  is  well  to  do  the  operation  in  two  sittings, 
first  closing  the  rent  in  the  septum  down  to  the  sphincter.  To  unite  the 
sphincter,  the  parts  are  put  upon  the  stretch  by  sharp  hooks,  and  with  knife 
or  scissors  the  sej)tum  between  the  rectum  and  the  vagina  is  split  into  two 
layers  for  a  depth  of  about  half  an  inch,  the  incisions  running  laterally  into 
the  remains  of  the  septum  as  far  as  they  can  be  recognized.  On  the  sides  of 
the  gap  all  traces  of  a  septum  may  have  disappeared,  leaving  a  smooth  sur- 
face passing  from  one  labium  majus  around  the  posterior  border  of  the  anus 
to  the  opposite  side.  The  divided  sphincter 
lies  like  a  transverse  band  along  the  poste-  ^^^'-  ®^''- 

rior  margin  of  the  anus,  and  can  often  be 
felt  as  a  soft,  rounded  border  under  the 
skin.  The  ends  are  usually  marked  by  a 
dimple  in  the  skin.  If  the  muscle  is  stimu- 
lated by  the  sudden  application  of  heat  or 

cold-,    or   by    electricity,    the   fibres   will   be  Diagram  of  suture  of  to™  sphincter  ani : 

seen  to   contract  and   draw  upon   the    skin     ed,  the  sphincter;  ah,  suture  in  place,  its 

.   , ,  -,         -,x7i         ii  ■    J-    1  1  course  shown  bv  dotted  lines ;  a'6',  the  suture 

at  the  ends.  When  these  points  have  been  ,,h3„  yghtened,  drawing  orf  into  the  ring  .-d'. 
located,  the  incision  through  the  recto- 
vaginal septum  is  to  be  continued  down  on  each  side  until  the  ends  of  the 
muscular  flljres  are  freely  exposed,  and  here  the  ends  of  the  V-shaped  incision 
terminate.  A  couple  of  heavy  sutures  are  introduced  an  eighth  of  an  inch 
away  from  the  edge  of  the  wound  at  this  point,  in  order  to  pick  up  the 
ends  of  the  torn  muscle  on  each  side,  but  are  left  untied.     (Fig.  856,  ab.) 

71 


1110 


LACERATION   OF  THE  CERVIX. 


Interrupted  sutures  of  fine  silk  are  tlien  ajiplied  to  the  two  edges  of  tlie 
flap  of  rectal  mucous  membrane,  beginning  at  the  apex  of  the  V,  and  these 
edges  are  united  down  to  the  mucocutaneous  juncture  of  the  anus.  The 
heavy  sutures  through  the  muscular  fibres  are  tied  (Fig.  856,  a'b'),  bringing 
the  divided  muscle  together.  Sutures  are  then  applied  to  the  vaginal  part 
of  the  wound  as  in  the  usual  perineorrhaphy. 

The  bowels  are  kept  closed  by  small  doses  of  opium  for  three  or  four 
days,  constipation  being  aided  by  strict  limitation  of  food,  but  a  milk  diet 
should  be  avoided  because  of  its  tendency  to  form  hard  masses  of  fteces. 
Before  the  first  movement  of  the  bowels  an  injection  of  a  large  quantity  of 
warm  water  should  be  given,  and  retained  long  enough  to  soften  the  fseces 
as  far  as  possible,  or,  if  they  are  hard,  an  injection  of  ox-gall  may  be  used, 
or  the  mass  may  be  broken  up  by  the  little  finger  introduced  into  the  anus. 
An  ounce  or  more  of  olive  oil  is  to  be  thrown  into  the  rectum  so  as  to 
lubricate  the  lower  part  just  before  the  bowels  move,  and  during  their 
action  it  is  well  to  have  lateral  pressure  made  by  the  fingers  of  the  nurse,  so 
as  to  prevent  gaping,  the  forefinger  and  thumb  being  placed  on  each  side 
of  the  labia  majora.  The  patient  must  on  no  account  be  allowed  to  strain. 
If  gas  collects  in  the  rectum  and  causes  pain  during  the  j)eriod  of  constipa- 
tion, it  may  be  allowed  to  escape  by  the  introduction  of  a  catheter. 

Fig.  857. 


Normal  (nullii>aroiisj  cervix  uteri.     (Madden.) 


Unilateral  laceration  of  cervix.    (Emmet.) 


Fig  859 


Laceration  of  the  Cervix.— The  cervix  (Fig.  857)  is  always  torn 
slightly  in  parturition,  and  often  to  such  an  extent  as  to  produce  a  positive 
deformity.  The  small  lacerations  require  no 
attention,  but  severe  tears  may  extend  to  the 
vaginal  junction,  and  may  involve  the  base 
of  the  bladder  or  the  ureters  and  form  urinary 
fistulte.  They  may  be  single  (Fig.  858)  or 
multiple,  a  bilateral  tear  being  especially 
common.  They  usually  lie  at  the  side,  as  if 
that  were  the  weakest  point,  but  may  have  a 
stellate  arrangement  when  multiple.  (Fig. 
859.)  As  a  result  of  the  laceration  the  cer- 
vical mucous  membrane  is  everted  and  be- 
comes the  seat  of  a  chronic  inflammation  with 
cystic  hypertrophy  of  the  Nabothian  glands.  The  wounds  are  generally 
infected  from  the  first,  and  consequently  heal  with  the  production  of  much 
cicatricial  tissue,  which  may  extend  into  the  surrounding  cellular  tissue. 


stellate  laceration  of  cervix.     (Emmet.) 


TREATMENT  OF  LACERATION  OF  THE  CERVIX.        HH 

These  masses  of  cicatricial  tissue  may  compress  the  nerves  and  cause 
severe  symptoms  which  may  demand  ti-eatment  by  comj)lete  excision  of 
the  scar-tissue,  even  when  the  laceration  itself  is  trifling.  Subinvolution, 
endometritis,  and  salpingitis  are  frequent  consequences  of  the  infection  of 
these  wounds.  The  large  and  heavy  uterus  is  often  retroverted  or  prolapsed, 
especially  when  a  laceration  of  the  perineum  occurs  at  the  same  time,  as  is 
the  rule.  Malignant  disease  probably  often  results  from  the  inflammation 
and  chronic  irritation  of  a  lacerated  cervix. 

Symptoms. — The  symptoms  of  a  laceration  of  the  cervix  which  has 
existed  for  some  time  are  pain  in  the  back  and  pelvis,  leucorrhoea,  menor- 
rhagia,  and  other  disturbances  from  the  accompanying  uterine  displacement 
and  inflammation.  They  are  by  no  means  proportional  to  the  degree  of  the 
tear,  as  a  small  fissure  or  nodule  of  cicati'icial  tissue  may  cause  quite  severe 
symptoms.  All  lacerations  which  extend  to  the  vaginal  junction  or  which 
cause  eversion  of  the  cervical  mucous  membrane  demand  operation,  and 
also  slight  tears  which  cause  severe  symj)toms.  The  diagnosis  is  sometimes 
easier  to  the  touch  than  to  the  sight,  superficial  union  having  occurred 
across  the  tear,  and  it  may  be  difficult  to  determine  the  situation  of  a 
unilateral  laceration,  as  the  uterus  inclines  towards  the  injured  side.  The 
patient  should  be  examined  with  a  Sims  speculum,  the  uterus  drawn  down 
by  a  tenaculum,  and  the  sound  introduced,  which  will  give  the  true  direc- 
tion of  the  uterine  canal  and  render  evident  the  extent  and  exact  situation 
of  the  laceration. 

Treatment. — It  is  well  to  repair  these  injuries  by  suture  (trachelor- 
rhaphy) inimediately  after  their  occurrence,  but  the  precise  shape  and 
relations  of  the  cervix  are  not  always  evident  at  that  time  and  the  ex- 
haustion of  the  patient  from  shock  or  loss  of  blood,  or  some  external 
circumstance,  may  make  the  operation  impossible.  Subinvolution,  endome- 
tritis, and  other  inflammatory  conditions  are  to  be  reduced  as  far  as  possible 
by  rest,  hot  douches,  and  local  applications  before  a  secondary  plastic 
operation  is  undertaken. 

The  operation  should  be  preceded  by  a  thorough  curetting  of  the  uterine 
canal,  which  can  be  done  at  the  same  sitting  unless  the  discharge  from  the 
endometritis  is  very  purulent,  in  which  case  the  curetting  should  be  done 
several  days  beforehand.  In  many  of  these  cases  there  is  great  hypertrophy 
of  the  vaginal  portion  of  the  uterus,  and  amputation  is  to  be  preferred  to 
any  plastic  operation.  The  plastic  operation  is  done  by  fixing  the  uterus 
with  a  tenaculum  and  drawing  it  well  down,  the  patient  being  either  in  the 
dorsal  or  in  the  lateral  position  as  preferred.  The  surfaces  of  the  angular 
cleft  in  the  cervix  are  freshened  and  all  cicatricial  tissue  at  the  angle  excised, 
preferably  with  the  scissors.  The  wound  is  closed  by  sutures  of  chromicized 
catgut,  silkworm-gut,  or  silver  wire.  A  straight,  short,  round  needle,  or  a 
Hagedorn  needle  of  suitable  curve,  may  be  used,  and  should  be  passed 
towards  the  cervical  canal  parallel  with  the  angle  of  the  wound  (Fig.  860), 
and  returned  by  a  reverse  course  on  the  other  side.  If  wire  is  used  it  is 
bent  and  hooked  into  a  "carrying  loop"  of  thread  on  the  needle,  biit  fine 
wire  can  be  threaded  directly  into  a  Hagedorn  needle.  Two  or  three  sutures 
are  introduced  parallel  to  the  first.   The  sutures,  when  tied  or  twisted,  draw 


1112 


VAGINAL  FISTUL.E. 


the  edges  of  the  wound  together,  and  convert  it  into  a  linear  incision  on  the 
outer  side  of  the  vaginal  portion.  (Fig.  861.)  The  sutures  must  not  be 
drawn  so  tight  as  to  i^roduce  strangulation  of  the  tissues.      A  bilateral 

laceration  is  treated  in  a  similar  manner, 
Fig.  860.  both  sides  being  jjared  and  all  the  su- 

tures inserted  before  any  are  tied.     It 


Operation  for  double  laceration  of  the  cervix  Operation    for    double    laceration    of   the 

uteri,  showing  the  denuded  surfaces,   the  sutures  cervix  uteri,  showing  the  wound  closed  and 

placed  ready  for  tying  on  one  side,  the  needle  pass-  the  last  wire  suture  being  twisted.    (Mann;) 

ing  on  the  other  side,  the  wire  suture,   and  the 
"  carrying  loop"  of  thread.     (Mann.) 

is  seldom  necessary  to  employ  a  ligatm-e,  as  the  introduction  of  the  sutures 
usually  controls  the  hemorrhage  perfectly.  If  the  cervix  is  very  hypertrophic,  ■ 
a  large  amount  of  tissue  may  be  cut  away,  so  as  to  result  in  a  wedge-shaped 
partial  excision  of  the  cervix.  If  the  cervical  mucous  membrane  is  greatly 
degenerated,  containing  many  cysts  of  the  Nabothian  glands,  it  may  also  be 
extirpated  in  part,  only  a  narrow  strip  being  left  to  preserve  the  site  of  the 
uterine  canal.  In  operating  upon  very  deep  fissures,  injury  to  the  ureters 
must  be  avoided,  and  the  cellular  spaces  at  the  sides  of  the  uterus  should 
not  be  opened  too  freely.  All  aseptic  precautions  must  be  taken,  and  after 
the  operation  the  vagina  should  be  lightly  packed  with  gauze.  In  the 
majority  of  cases  some  plastic  oijeration  upon  the  perineum  will  be  necessary 
at  the  same  time.  The  after-treatment  of  these  cases  is  similar  to  that  of 
laceration  of  the  perineum.  The  sutures  should  be  removed  at  the  end  of  a 
fortnight  or  three  weeks. 

Vaginal  FistulSB. — Fistulse  between  the  A^agina  and  the  rectum,  or 
between  the  vagina  and  the  bladder,  are  very  frequent  as  the  result  of  diffi- 
cult parturition.  The  openings  may  be  so  large  that  three  or  foui-  fingers 
can  be  passed  through,  and  the  uterus  may  be  implicated  in  them,  especially 
if  the  opening  extends  up  into  the  cervix  as  a  consequence  of  laceration  of 
that  part.  Small  fistulte  often  close  spoutaneously,  especially  those  made 
for  drainage  of  the  bladder  in  cystitis.  Fistulse  between  the  vagina  and  the 
urethra,  or  one  of  the  ureters,  also  occur.  Plastic  operations  for  the  repair 
of  these  fistulse  are  among  the  most  difficult  in  surgery. 

Treatment. — The  methods  which  we  have  employed  with  the  best  suc- 
cess for  both  vesical  and  rectal  fistulfe  are  the  following :  The  border  of 


TREATMENT  OF  VAGINAL  FISTULA. 


1113 


the  fistula  is  freshened  by  cutting  away  the  edges  obliquely,  paring  o£f  more 
from  the  vaginal  side  than  from  the  other  (Fig.  862),  and  sutures  of  silk- 
worm-gut or  of  silver  wire  are  then  passed  through  in  such  a  manner  as  to 

Fig.  862. 


Fig  663 


Operation  for  vesico-vasinal  li&tula     The  mid-.  ~i_eeulum  m  j.^ilc   iln. ,  ci  - 1\  appearing  just  below  it     The 
tenaculum  and  scissors  are  employed  in  paring  the  edges  of  the  fistula.    (Jewett  and  Polak  ) 

embrace  the  vaginal  mucous  membrane  and  the  submucous  tissue  on  the 

other  side  and  to  avoid  entering  the  bladder  or  rectum.    (Figs.  863  and  864.) 

The  sutures  must  be  placed  very  close 

together,  not  over  an  eighth  of  au  inch 

apart.     The  stiffness  of  the  gut  or  wire  is 

an  advantage,  as  it  acts  like  a  splint :  we 

prefer  the  former  because  it  is  easier  to 

introduce.     The  needles  may  be  round  and 

straight  or  Hagedorn  curved  needles,  but 

the  latter  require  some  experience,  as  they 

are   apt  to   make   too    large    a   puncture 

unless  carefully  handled. 

The  Split-Flap  Method.— Instead  of 
paring  the  borders  of  the  fistula,  a  sharp 
knife  is  made  to  incise  the  border  between 
the  vaginal  and  the  -rectal  or  vesical  mucous  membrane  to  the  depth  of  a 
quarter  of  an  inch  or  more  on  all  sides.  This  can  be  facilitated  by  jilacing 
forceps  or  sutures  on  the  edge  of  the  fistula  and  pulling  it  towards  the  vagina, 
putting  its  walls  on  the  stretch  in  a  cone-like  form.  The  vesical  or  rectal 
mucous  membrane  is  then  turned  into  the  corresponding  organ,  and  fine  catgut 
or  silk  sutures  are  inserted  on  the  raw  surface  of  this  flap  and  tied  so  as  closely 
to  approximate  the  edges.  The  needle  should  be  very  small,  and  in  passing 
these  stitches  it  must  not  perforate  the  mucous  membrane  of  the  rectum  or 
bladder,  but  should  take  up  only  the  submucous  tissues.  The  edges  of  the 
vaginal  flap  are  then  turned  into  the  vagina  and  united  by  silkworm-gut  or 
silver  wire  sutures  passed  in  the  ordinary  way.  The  sutures  in  the  first  flap 
are  thus  buried  and  protected  from  infection,  because  they  do  not  penetrate 


The  course  of  the  needle  in  passing  sutures . 
B,  bladder  surface ;  F,  vaginal  surface. 


1114 


OPERATIOKS  FOR   VAGINAX  FISTULA. 


the  mucous  membrane  on  either  side,  while  the  stitches  in  the  vaginal  flap 
take  the  strain  and  remove  all  tension  from  the  first.  Tait  used  a  single 
submucous  suture  in  operating  upon  small  fistulse  by  the  split-flai)  method, 

Fig.  864. 


( Jew  ett  and  Polak. ) 


passing  it  around  the  opening  between  the  two  flaps  and  puckering  them  up 
like  a  purse-string  by  tying  it.  We  have  also  employed  the  Szymanowsky 
double-flap  principle  of  turning  a  flap  of  vaginal  mucous  membrane  into  the 
bladder  and  reinforcing  it  by  another  flajj  from  the  same  source.  (See  page 
1000.) 

The  line  of  union  in  either  of  these  methods  must  be  in  the  direction  of 
the  least  tension,  and  it  is  a  matter  of  indifference  whether  it  lies  parallel 
to  the  long  axis  of  the  vagina  or  crosses  it  transversely  or  obliquely.  If 
there  is  much  cicatricial  tissue  surrounding  the  fistula  it  must  be  freely 
divided  by  separate  incisions  (made  openly  or  submucous)  before  the  sutures  ' 
are  tied,  so  that  the  edges  shall  come  together  without  tension.  Cicatricial 
bands  passing  to  the  pubic  bones  especially  will  require  division. 

In  large  vesico-vaginal  fistulse  situated  high  up  the  bladder  may  be  dis- 
sected up  from  the  uterus  and  from  the  vagina  through  an  incision  along 
the  posterior  margin  and  the  base  of  the  bladder  drawn  downward  and  for- 
ward and  sutured  to  the  freshened  anterior  margin  of  the  fistula  so  as  to 
close  the  latter  (Kelly).  In  very  severe  cases  the  bladder  may  be  exposed 
by  a  suprapubic  incision,  the  peritoneum  drawn  uj),  and  the  fistula  reached 
in  this  manner,  or  the  bladder  may  be  opened  as  in  ordinary  suprapubic 
cystotomy  and  the  fistulous  opening  sutured  from  within.  Sometimes  the 
vaginal  portion  of  the  uterus  may  be  freed  by  incisions,  its  surface  denuded 
and  united  to  freshened  surfaces  around  the  fistula  in  order  to  close  the 
opening.  In  operating  upon  fistulfe  involving  the  uterine  cervical  canal, 
wounds  of  the  ureter  must  be  avoided.  The  most  difficult  of  all  cases  are 
those  in  which  the  ureter  itself  is  involved  in  the  fistula.  In  cases  of  a 
lateral  opening  in  the  ureter  near  its  orifice  the  remaining  part  of  the  canal 


VULVITIS  AND  VAGINITIS.  1115 

should  be  laid  widely  open  down  to  the  base  of  the  bladder.  The  large 
opening  thus  created  may  be  closed  by  one  of  the  methods  already  described. 
Or  the  ureter  can  be  dissected  out,  divided  above  the  fistula,  and  the  renal 
end  implanted  in  the  bladder.  Fistula  which  do  not  admit  of  cure  by  other 
operations  have  been  treated  by  closing  the  iutroitus  of  the  vagina  and 
making  the  vaginal  cavity  practically  a  part  of  the  bladder.  This  operation 
is  suitable  only  for  women  of  advanced  life  who  have  ceased  to  menstruate, 
as  the  admixture  of  the  menstrual  blood  with  the  urine  would  be  apt  to 
result  in  a  severe  cystitis.  A  preliminary  vaginal  hysterectomy  would 
remove  this  objection. 

After-Treatment. — After  operations  upon  vesical  fistulfe  the  bladder 
should  be  drained  by  a  permanent  catheter,  or  the  water  drawn  off  every 
two  hours.  In  operations  for  rectal  flstul£e  the  sphincter  should  be 
thoroughly  dilated,  the  bowel  contents  kept  very  soft  with  laxatives,  and 
the  diet  limited  to  articles  which  will  give  the  least  amount  of  fecal  residue. 
The  plan  of  confining  the  boMels  by  opiates,  formerly  in  use,  is  not  so  sat- 
isfactory. In  recto-vaginal  fistulte  which  extend  very  low  down,  the  sphinc- 
ter and  the  narrow  band  of  tissue  between  the  vagina  and  the  anus  should 
be  divided  and  the  fistula  converted  into  a  complete  perineal  laceration, 
which  can  then  be  closed  in  the  usual  way.  The  vagiua  needs  very  little 
attention  after  these  operations,  a  light  i^acking  of  iodoform  gauze  being 
the  best  dressing,  but  this  should  be  changed  daily.  Irrigation  of  the  vagina 
is  not  employed  unless  there  is  some  discharge  from  the  uterus.  The  patient 
must  not  be  allowed  to  sit  up  in  bed  for  at  least  a  fortnight,  and  then  the 
stitches  may  be  removed.  Very  frequently  partial  union  only  is  obtained, 
and  several  operations  are  necessary  to  close  the  fistula. 

Cicatrices. — As  the  result  of  extensive  inflammation  or  of  sloughing 
fi-om  parturition,  cicatrices  are  often  seen  in  the  vulva  or  the  vagina,  par- 
ticularly in  the  latter,  and  they  may  com]3letely  occlude  the  passage  and 
cause  hnematometra.  Strictures  are  also  seen  in  elderly  women  as  the  result 
of  senile  vaginitis.  The  atresia  may  be  limited  or  may  involve  the  entire 
vagina.  These  conditions  usually  need  no  treatment,  but  the  cicatricial 
bands  may  be  treated  by  free  incision,  with  care  not  to  injure  the  surround- 
ing parts.  If  extensive  raw  surfaces  are  left  by  the  operation,  an  attempt 
should  be  made  to  cover  them  by  sliding  flajjs  of  mucous  membrane  or  by 
suturing  the  wounds  ;  extensive  bands  can  thus  be  disposed  of  and  primary 
union  obtained.     Hfematometra  should  be  treated  as  described  on  page  1103. 

INFLAMMATION. 

Vulvitis  and  Vaginitis. — Inflammation  of  the  vulva  and  of  the 
vagina  is  very  frequent,  the  former  usually  being  secondary  to  the  latter. 
K'on-specific  forms  occur,  especially  in  children  and  in  old  age,  but  the 
commonest  of  these  affections  are  the  venereal.  Vaginitis  is  excited  by 
the  irritation  of  a  gonoi-rhoeal  cervical  discharge,  but  it  is  claimed  the  adult 
vaginal  mucous  membrane  resists  the  gonococcus.  A  vulvitis,  however, 
may  be  the  result  of  any  irritating  discharge  from  the  vagiua,  the  leakage 
of  urine  from  the  bladder  in  cases  of  incontinence,  or  mere  neglect  of  clean- 
liness.    In  the  majority  of  such  cases  it  can  be  subdued  by  thorough  clean- 


1116  ENDOMETRITIS. 

liness.  Bartholin's  vulvo-vaginal  glands  may  become  inflamed  and 
form  labial  abscesses,  wliich  require  treatment  by  incision  and  thorough 
extirpation  of  the  lining  membrane,  or  a  recurrence  is  certain  to  take  place. 
(See  page  1121.) 

Tuberculosis. — Tuberculosis  more  commonly  attacks  the  vagina  than 
the  vulva,  being  generally  secondary  to  uterine  infection.  It  appears  in 
two  varieties.  The  first  is  more  or  less  extensive  ulceration  with  blue  un- 
dermined edges,  a  pale  base  covered  with  flabby  granulations,  and  a  slight, 
thin  discharge.  The  second  form  is  the  nodular  or  lupous  variety,  resem- 
bling very  much  lupus  of  the  mucous  membranes  elsewhere.  It  can  be  dis- 
tinguished from  epithelioma  by  the  lesser  induration  and  by  the  presence 
of  dark  bluish  nodules  at  a  little  distance  from  the  ulceration.  The  treat- 
ment of  these  lesions  consists  in  their  thorough  excision  or  destruction  by 
the  cautery.  Plastic  operations  may  be  necessary  afterwards,  to  obviate 
the  contractions  and  other  deformities  which  ensue.  The  results  of  treat- 
ment are  not  satisfactory,  for  recurrences  are  very  frecxuent  and  the  patient 
is  generally  tuberculous  otherwise.  If  the  cases  are  neglected,  however, 
very  extensive  destruction  of  the  parts  may  be  produced  by  ulceration,  and 
vesical  or  rectal  fistulfe  may  form.  The  ingninal  glands  will  usually  be 
found  affected. 

Endometritis. — Inflammation  of  the  lining  membrane  of  the  uterus  is 
termed  endometritis,  and  may  affect  either  the  body  or  the  cervix,  or  both. 
Endometritis  may  be  the  result  of  gonorrhoeal  or  tubercular  infection,  but 
is  most  commonly  due  to  septic  inoculation  by  instruments  used  in  uterine 
examinations  or  for  the  production  of  abortion,  or  to  sepsis  from  careless 
midwifery.  Tuberculous  endometritis  is  usuallj^  secondai-y  to  tuberculous 
salpingitis.  The  predisposing  causes  of  endometritis  are  subinvolution  of 
the  uterus  following  childbirth,  malpositions  of  the  organ,  and  antemia. 

With  the  acute  infections,  excluding  the  gonorrhoeal,  the  surgeon  is 
seldom  brought  in  contact,  although  hysterectomy  has  lately  been  recom- 
mended for  acute  septic  endometritis  after  labor.  The  chronic  form  results 
in  certain  changes  in  the  uterine  mucous  membrane,  irritation  and  ulcera- 
tion of  that  membrane  in  the  vaginal  portion,  painful  obstruction  to  the 
menstrual  flow  from  the  swelling  of  the  uterine  lining,  and  menorrhagia. 
The  changes  in  the  uterine  mucous  membrane  may  be  simply  catarrhal  or 
a  fungoid  degeneration  may  take  place.  In  the  latter  the  endometrium  is 
thickened,  forming  an  adenomatous  growth  full  of  tortuous  cystic  irregular 
glands.  There  is  an  increase  in  the  connective  tissue,  a  formation  of  thin- 
walled  new  vessels,  and  myxomatous  degeneration.  These  changes  may  be 
localized  to  a  small  part  or  affect  the  entire  uterine  lining.  If  localized 
they  may  form  true  tumors  of  polypoid  shape.  The  tendency  of  these  changes 
is  to  greater  irregularity  of  cell-growth  and  the  final  development  of  carci- 
noma or  sarcoma.  This  fungoid  degeneration  of  the  endometrium  gives  rise 
to  metrorrhagia  because  of  the  new  vessels.  There  is  also  an  exfoliative 
endometritis  in  which  the  membrane  is  detached  in  sheets.  Tuberculous  endo- 
metritis may  be  miliary,  or  a  general  cheesy  degeneration.  It  is  usually 
found  at  the  fundus.  Cicatricial  contraction  of  the  ulcers  may  result  in 
stenosis  of  the  canal  and  the  distention  of  the  uterus  with  purulent  tuber- 


ENDOMETRITIS.  III7 

cular  material.  The  symptoms  of  endometritis  are  a  profuse  discharge  of 
clear  mucus  or  a  muco-purnlent  fluid,  menorrhagia,  metrorrhagia,  dysmen- 
orrhagia,  dysmeuorrhcea,  sterility,  various  nervous  symptoms,  pain  in  the 
back,  and  tenderness  in  the  uterus.  The  uterus  is  often  enlai-ged  from  sub- 
involution, but  in  nullipara  any  enlargement  should  awaken  suspicion  of 
malignant  disease.  In  the  acute  septic  cases  there  is  a  rise  of  temperature. 
Treatment. — It  is  very  difdcult  to  treat  endometritis  effectively.  The 
patient  shoxild  be  kept  in  bed  for  a  week  or  a  fortnight  at  the  beginning  of 
treatment.  Any  malposition  of  the  uterus  must  be  corrected,  and  any  ste- 
nosis of  the  canal  dilated.  Meanwhile,  every  care  must  be  taken  to  improve 
the  general  health  of  the  iDatieut  by  proper  diet,  abundant  rest,  and  perhaps 
a  change  of  scene.  Abstention  from  sexual  intercourse  is  absolutely  neces- 
sary. Hot  vaginal  douches,  with  a  temperature  of  110°  F.  (43°  C.)  or 
higher,  if  the  patient  can  endure  it,  will  contract  the  vessels  and  diminish 
the  congestion.  In  ordinary  cases  the  application  of  pure  carbolic  acid, 
strong  tincture  of  iodine,  ten  per  cent,  solution  of  protargol,  or  a  strong 
solution  of  methylene  blue  to  the  uterine  canal  will  bring  about  an  alteration 
of  the  mucous  membrane  for  the  better.  In  severe  cases  the  cervix  must  be 
dilated,  and  the  uterine  mucous  membrane  entirely  removed  with  a  sharp 
curette.    (Fig.  865.)   In  cases  of  fungoid  degeneration  this  treatment  is  espe- 


Sliarp  uterine  curette. 

cially  indicated.  After  the  curetting,  hemorrhage  is  controlled  by  tinctiire 
of  iodine  applied  with  cotton  on  an  applicator,  and  the  cavity  of  the  uterus 
is  thoroughly  packed  with  iodoform  gauze,  which  is  allowed  to  remain  in 
place  for  several  days.  The  dilatation  and  curetting  must  be  doue  with 
full  antiseptic  precautions,  for  fear  of  causing  salpingitis  or  peritonitis,  and 
also  to  gain  the  full  advantage  of  the  treatment.  After  the  removal  of  the 
gauze  an  Outerbridge  wire  intra-uterine  stem  is  to  be  inserted  and  worn  for 
some  weeks  in  order  to  secure  good  drainage,  and  the  intia-uterine  applica- 
tions are  to  be  made  at  gradually  lengthening  intervals.  Ap])lications  of 
live  steam  to  the  uterine  canal  by  a  special  apparatus  (Pinkus)  have  been 
recommended  for  endometritis  and  hemorrhage.  They  are  sometimes  made 
vigorously  enough  to  cause  destruction  of  the  mucous  membrane  and  to  pro- 
duce intentional  obliteration  of  the  uterine  cavity  by  cicatricial  contraction 
afterwards.  If  a  cure  is  not  obtained,  the  possibility  of  a  chronic  salpingitis 
discharging  through  the  uterus  is  to  be  borne  in  mind.  Eecurrence  of  the 
fungoid  form  should  excite  suspicion  of  cancer. 

Inflammation  of  the  Cervical  Mucous  Membrane.— Cysts  in 
the  ISfabothian  glands  and  erosions  of  the  os  result  from  cervical  endome- 
trititis.  The  term  erosion  (Fig.  866)  is  given  to  a  bright-red  papillomatous 
condition  of  the  mucous  membrane  resembling  an  ulcer  covered  by  small 
velvet-like  granulations,  but  there  is  no  true  ulceration  here,  the  epithelial 
layer  being  intact.     An  eversion  of  the  cervical- mucous  membrane  due  to  a 


1118 


PELVIC  PERITONITIS. 


laceration  has  a  somewhat  similar  appearance  at  times,  and  may  be  mistaken 
for  it.     The  treatment  of  this  inflammation  is  similar  to  that  for  endome- 
tritis of  the  fundus,  but  the  cysts  should  be  punc- 
FiG.  866.  tured  as  soon  as  they  form.     In  obstinate  cases  the 

vaginal  ijortion  may  be  split  laterally  (Schroeder's 
operation.  Fig.  867),  the  internal  cervical  mucous 
membrane  extirpated,  and  the  mucous  membrane 
of  the  vaginal  surface  turned  in  and  secured  by 
sutures  so  as  to  co^'er  the  raw  surface.  The  use  of 
caustics  for  erosions  is  dangerous,  from  the  possi- 
bility of  setting  up  malignant  disease. 

The  diagnosis  of  tubercular  endometritis  is  un- 
certain and  its  treatment  unsatisfactory.  Gonor- 
rhoeal  endometritis  is  discussed  in  the  chapter  on 
Venereal  Diseases. 

Metritis. — Metritis,  or  inflammation  of  the  ute- 
rine tissue,  is  not  likely  to  come  under  the  surgeon's  care,  except  that  hyste- 
rectomy may  be  required  for  a  septic  metritis  after  labor. 

Fig.  867. 


Erosion  of  cervix      (Ruge  and 
Veit  ) 


Schroeder's  excision  of  cervical  mucous  membrane :  A,  sutures  introduced  in  the  upper  flap,  the  lower 
flap  having  been  sutured  ;  B,  the  shaded  portion  shows  the  extent  of  excision,  and  he  shows  the  course  of 
the  suture :  C  shows  a  suture  tightened  and  the  flap  inverted.     (Pozzi.) 

Pelvic  Peritonitis. — Pelvic  peritonitis  is  the  result  of  septic  infection 
in  j)arturition,  or  occurs  as  the  consequence  of  pyosalpinx  and  salpingitis. 
It  may  be  tuberculous,  following  tuberculosis  of  the  genitals.  In  the  very 
acute  cases  the  patient  has  intense  pain,  a  high  temi^erature,  and  chills,  and 
the  case  may  terminate  rapidly  in  septicEemia  or  a  general  peritonitis.  Or 
the  disease  may  be  subacute,  with  less  marked  but  similar  symptoms,  which 
may  be  so  slight  that  the  patient  will  be  uj)  and  about,  the  irregular  slight 
fever  not  being  noticed.  In  still  other  cases  the  disease  runs  almost  a  latent 
course,  slowly  progressing  from  the  infected  tubes.  The  acute  form  is  usu- 
ally seen  as  the  result  of  infection  in  parturition,  in  criminal  abortions,  or 
in  severe  ffonorrhceal  infection. 


PEL^'IC  CELLULITIS.  1119 

Treatment. — For  the  acute  variety  but  little  can  be  done  beyond  the 
application  of  a  cold  coil  to  the  abdomen  and  the  administration  of  mori^hine. 
In  tlie  subacute  form  the  use  of  hot  vaginal  douches,  rest  in  bed,  laxatives, 
and  tonics  are  indicated.  Thorough  treatment  may  prevent  the  formation 
of  adhesions,  and  the  exudate  may  become  absorbed,  leaving  the  parts  in  a 
fairly  healthy  condition.  In  the  latent  variety  the  diagnosis  will  usually  not 
be  made  until  it  is  too  late  to  accomplish  much  by  these  means.  The  per- 
sistent use  of  hot  douches,  however,  with  the  ai^plication  of  iodine  to  the 
vault  of  the  vagina,  and  packing  the  vagina  with  tampons  wet  with  boro- 
glyceride,  will  often  ameliorate  the  symijtoms.  Very  frequently,  however, 
a  chronic  salpingitis  is  the  cause  of  the  peritonitis,  and  a  cure  can  be 
obtained  only  by  an  operation  with  removal  of  the  tubes. 

Pelvic  Cellulitis. — Inflammation  of  the  cellular  tissue  of  the  pelvis, 
especially  that  of  the  broad  ligament,  is  usually  secondary  to  some  inflam- 
mation of  the  genitals,  but  is  not  a  very  common  complication,  the  majoritj' 
of  cases  formerly  thought  to  represent  this  disease  being  instances  of  peri- 
tonitis. In  most  cases,  also,  the  ijeritoneum  is  involved  as  well  as  the 
cellular  tissue,  and  it  is  impossible  to  distinguish  between  the  two.  Cellu- 
litis, however,  does  occasionally  accompany  a  septic  inflammation  of  the 
uterus  or  of  the  vagina,  and  sometimes  results  in  abscess  of  the  broad  liga- 
ment. This  is  especially  likely  to  take  place  during  pregnancy  and  parturi- 
tion, because  the  uterus  lifts  up  the  pelvic  peritoneum,  causing  an  increase 
of  the  connective  tissue  beneath  it.  These  abscesses  are  to  be  distinguished 
from  intraijeritoneal  masses  of  adhesions  and  pus  collected  about  the  inflamed 
tubes  and  ovaries  by  the  fact  that  they  lie  rather  low  down  in  dose  contact 
with  the  upper  part  of  the  vagina,  especially  on  the  side  of  the  latter  (Fig. 
868),  whereas  tumors  formed  by  inflamed  tubes  are  generally  higher  ui> 


Relations  of  parametric  exudate  (a)  to  Relations  of  pyosalpinx  (a)  to  the 

the  uterus.    (Byford.)  uterus.    (Byford.) 

(Fig.  869),  or  occupy  Douglas's  cul-de-sac.  The  symptoms  of  cellulitis  are 
pelvic  pain  and  tenderness,  with  the  constitutional  indications  of  infection 
occurring  during  the  course  of  septic  disease  of  the  genitals.  Examination 
will  reveal  tenderness  on  one  or  both  sides  of  the  uterus,  which  will  be 
somewhat  fixed  by  the  exudate.  The  inflammatory  mass  may  attaiu  consid- 
erable size,  and  as  the  pelvic  connective  tissue  is  continuous  with  that  above 
and  below,  the  inflammation  maj'  extend  upward  towards  the  kidneys  or 


1120 


TUMORS  OF  THE  VAGINA  AND  VLXVA. 


downward  to  the  thigh  or  buttock  along  the  vessels  and  nerves.  When  pus 
forms  fluctuation  may  be  absent,  but  there  will  usually  be  some  oedema  or 
boggy  feeling  of  the  upper  vaginal  wall.  If  left  untreated  these  abscesses 
may  burst  into  the  vagina,  rectum,  or  bladder,  or  externally  along  Poupart's 
ligament.  In  the  jjueri^eral  cases  the  abscess  often  opens  high  up  on  the 
abdominal  wall.  If  an  abscess  of  considerable  size  has  formed  it  is  gener- 
ally difBcult,  if  not  impossible,  to  determine  whether  it  is  in  the  cellular  tissue 
or  whether  there  is  an  intraperitoneal  collection  of  pus  around  the  tube. 

Treatment. — The  treatment  of  abscesses  in  this  situation  is  prompt 
evacuation  as  soon  as  the  pus  can  be  recognized,  an  exploratory  puncture 
being  made  in  doubtful  cases  by  the  aspirating  needle  introdiiced  into  the 
uijper  part  of  the  vagina,  one  finger  being  placed  in  the  rectum  as  a  guide. 
If  pus  is  reached  the  needle  should  be  left  in  jilace  and  a  shar]3-pointed  pair 
of  scissors  thrust  along  it  through  the  vaginal  mucous  membrane  to  the 
cavity.  A  dressing-forceps  will  easily  follow  this  instrument,  and  the 
opening  should  be  dilated  by  spreading  the  branches.  A  drainage-tube  is 
introduced  and  secured  in  j)lace  by  a  stitch  through  the  vaginal  mucous 
membrane,  and  should  be  kept  in  place  until  the  discharge  ceases. 

TUMOES  or  THE  VAGINA  AND  VULVA. 

The  clitoris  is  liable  to  hypertrophy,  but  tumors  of  the  organ  are  rare. 
Many  varieties  of  neoplasm  have  been  observed,  the  most  common  being 

fibroma,  angioma,  and  epithelioma. 
They  are  treated  by  extirpation,  for 
complete  removal  of  the  organ  does 
not  disturb  the  sexual  functions. 
Clitoridectomy  was  once  advised  as  a 
cure  for  masturbation,  but  has  been 
found  useless.  The  separation  of  ad- 
hesions about  the  organ  may,  how- 
ever, allay  sexual  irritation.  Fibrous 
and  fatty  tumors  and  angiomata,  cysts 
and  papillomata,  form  the  great  major- 
itj^  of  the  benign  tumors  of  the  vulva 
and  vagina.  Angioma  is  usually 
external,  and  occurs  in  infants. 
Fatty  tumors  develop  in  the  labia, 
being  formed  of  a  soft,  almost  myx- 
omatous, tissue,  and  sometimes  attain 
an  enormous  size,  being  more  or  less 
Ijedunculated.  (Fig.  870.)  Sebaceous  cysts  are  found  on  the  outer  surface 
of  the  labia. 

Cysts  of  Bartholin. — Eetention  cysts  develop  in  Bartholin's  glands, 
and  also  in  the  mucous  glands  (Fig.  871)  in  the  vulva  and  vagina.  The 
latter  seldom  attain  a  size  large  enough  to  be  of  clinical  importance.  Cysts 
of  the  vulvo-vaginal  glands  are  situated  in  the  substance  of  the  labium  majus 
near  its  posterior  border,  and  even  when  large  retain  more  or  less  of  its 
shape.     They  are  generally  ca.used  by  infection  of  the  ducts,  especially  by 


(Case  of  Dr.  J.  B. 


TUMORS  OF  THE  VAGINA  AjS^D   VULVA. 


1121 


gonorrhoea,  and  the  duct  is  not  alwaj^s  completely  obstructed,  so  that  under 
strong  pressure  part  of  the  contents  of  the  sac  may  be  evacuated.  Those 
cysts  cause  slight  symptoms  unless  they  are  large  or  unless  they  suppurate 

Fro.  871.  Fig.  872. 


Mucous  cyst  of  labium.    (After  Agnew.) 


Suppurating 


vaginal  gland. 


Fig.  873. 


A 


(Fig.  872),  when  there  is  great  pain  and  swelling,  motion  of  the  thigh 
becoming  ]Dainful  and  adduction  impossible,  while  micturition  may  be 
impeded  by  the  oedema. 

Treatment. — The  mucous  membrane  covering  these  cysts  should  be 
incised  and  the  capsule  dissected  out.  When  suppuration  has  occurred, 
forming  a  vulvo-vaginal  abscess,  the  same  method 
should  be  adopted  if  possible  ;  but  if  the  parts  are 
too  adherent  to  the  capsule,  the  cavity  should  be 
thoroughly  laid  open,  as  much  as  possible  of  the 
caijsule  removed,  and  the  wound  packed  with  gauze 
and  made  to  heal  from  the  bottom.  The  small 
mucous  cysts  seldom  require  treatment  other  than 
incision  and  the  application  of  strong  carbolic  acid 
or  some  other  mild  caustic  to  the  interior  of  the 
sac.     Larger  mucous  cysts  should  be  enucleated. 

Papillomata  of  the  Vulva. — Warts  of  the 
vulva  (Fig.  S73j  are  at  first  soft,  moist  growths, 
covered  with  a  cheesy  discharge,  but  when  exposed 
to  the  air  they  become  hard.  Thej'  are  usually 
multiijle,  and  result  from  the  discharges  of  venereal 
disease.  Treatment. — The  cure  of  the  discharge 
usually  causes  the  disappearance  of  the  papilloma. 
Thorough  cleansing  of  the  parts,  with  the  applica- 
tion of  a  dry  dusting  i^owder,  such  as  calomel,  will  often  effect  a  cure  of  the 
soft  variety.  The  mild  caustics,  such  as  alum  or  acetic  acid,  will  destroy 
all  except  the  hard  growths.  If  thej^  recur,  fuming  nitric  acid  should  be 
applied  and  their  bases  thoroughly  destroyed.  In  very  dense,  fibrous  warts 
excision  may  be  necessary. 

Congenital  Cysts. — Cysts  which  originate  from  Gartner's  ducts  are 
occasionally  found  in  the  vagina,  but  are  so  rare  as  to  be  of  little  clinical 
consequence. 


< 


V 


Papilloma  of  rulva. 


1122  MALIGNANT  TUMOES  OF  THE  VAGINA  AND  VULVA. 

Fibromyomata. — Pibromyomata  may  grow  from  the  vaginal  wall,  usu- 
ally becoming  pedunculated,  and  sometimes  protruding  from  the  vulva. 
The  vagina  may  also  be  occupied  by  pedunculated  tumors  of  the  uterus, 
and  in  any  case  of  vaginal  polypus  the  attachments  of  the  tumor  should  be 
carefully  examined. 

Malignant  Tumors. — Primary  malignant  tumors  of  the  vulva  and 
vagina  may  be  either  sai'coma  or  epithelioma.  Secondary  tumors  of  the 
vagina  are  common,  often  involving  the  latter  by  direct  extension  from  the 
cervix  uteri  or  the  rectum.  Sarcoma. — Primary  sarcoma  is  rare,  but  when 
it  occurs  it  develojjs  in  the  deeijer  parts  of  the  mucous  membrane  of  the 
vagina  or  in  the  connective  tissue  of  the  labia,  although  in  the  latter  it  is 
even  rarer  than  in  the  vagina.  It  forms  small  ovoid  tumors,  at  first  covered 
with  mucous  membrane,  but  soon  ulcerating,  and  then  often  vegetating  and 
filling  the  vagina  with  cauliflower  masses  like  papillomata.  In  the  later 
stages  hemorrhages  are  common,  and  the  discharge  is  very  offensive.  The 
diagnosis  from  epithelioma  can  seldom  be  made,  as  the  tumors  are  rarely 
seen  before  the  advanced  stages,  when  the  resemblance  is  very  close.  Epi- 
thelioma.— Epithelioma  of  the  vulva  and  vagina  is  not  common.  It  forms 
hard,  flat  nodules,  which  ulcerate  early,  or  it  may  begin  as  an  ulcer.  It 
resembles  very  much  in  its  physical  characteristics  the  epithelioma  of  the 
lips.  The  course  is  usually  a  chronic  one,  the  induration  preceding  the 
ulceration  as  it  extends.  Epitheliomata  tend  at  first  to  spread  superficially, 
but  when  they  attack  the  septum  between  the  vagina  and  the  bladder  or 
rectum  they  may  produce  flstulte  into  either  of  these  organs.  Occasionally 
they  assume  a  iiapillomatous  growth  and  produce  large  cauliflower  masses, 
which  are  very  friable  and  bleed  very  easily.  More  rarely  a  carcinoma  may 
develop  from  Bartholin's  glands,  in  which  case  it  may  reach  a  considerable 
size  before  ulceration  takes  place.  The  inguinal  glands  are  involved  very 
early  when  the  tumor  is  situated  at  the  vulva,  and  sometimes  in  vaginal 
cancer.  The  latter  infects  the  pelvic  glands.  There  ai-e,  as  a  rule,  no  symp- 
toms in  the  early  stages,  not  even  pain.  In  the  later  stages  there  may 
be  a  vaginal  discharge  of  blood,  pus,  and  foul  serum,  severe  pain,  and  the 
symptoms  of  fecal  or  urinary  fistula. 

Syphilitic  disease  of  the  vulva  and  vagina  frequently  simulates  malig- 
nant tumors,  but  in  the  former  case  there  are  syphilitic  lesions  elsewhere, 
the  induration  and  fixation  of  the  parts  are  less,  the  ulcers  have  not  the 
characteristic,  brittle,  readily  bleeding  granulation,  and  the  tendency  is 
towards  destruction  rather  than  jjroduction  of  new  tissue.  A  short  and 
determined  course  of  antisyphilitic  treatment  should  be  tried  in  doubtful 
cases,  and  a  portion  removed  for  microscopic  examination. 

Treatment. — Complete  extirpation  of  these  growths  is  rarely  feasible, 
on  account  of  the  great  extent  of  the  disease  when  first  seen.  Extirj)ation 
should  be  limited  to  movable  tumors,  as  there  is  no  hope  of  a  radical  cure 
after  they  have  become  fixed  to  the  deeper  j)arts,  and  decided  enlargement 
of  the  inguinal  glands  also  contraindicates  operation.  Vaginal  cancer 
should  be  thoroughly  examined  with  the  finger  in  the  rectum  and  a  sound 
or  a  finger  in  the  bladder.  Involvement  of  these  organs  need  not  prevent 
an  attempt  at  extirpation,  as  the  openings  which  may  be  made  in  them  can 


VAGINISMUS.  1123 

be  closed  afterwards.  But  any  extension  of  the  disease  into  tlie  cellular 
tissue  around  the  vagina  or  in  the  broad  ligament,  as  shown  by  adhesions  or 
thickening  of  the  parts,  would  coutraindicate  operation,  because  a  radical 
cure  woiild  be  impossible.  In  tumors  limited  to  the  vaginal  mucous  mem- 
brane, the  latter  and  the  submucous  tissue  should  be  thoroughly  and  widely 
cut  awaj-.  Diseased  portions  of  the  bladder  and  rectum  are  to  be  removed. 
The  hemorrhage  is  usually  free,  but  can  be  conti'olled  by  mass  ligatures  or 
by  clamps  and  pressure.  In  operating  for  epithelioma  of  the  vulva,  a  thor- 
ough extirpation  of  the  inguinal  glands  on  both  sides  is  also  necessary,  even 
if  they  are  not  perceptibly  enlarged,  as  the  glandular  tumors  are  more  fre- 
quently the  cause  of  death  than  a  local  recurrence.  Various  plastic  opera- 
tions may  be  required  to  cover  the  defects  made  by  the  excision.  Excision 
is  to  be  preferred  to  the  use  of  the  cautery,  on  account  of  the  thoroughness 
and  the  greater  exactness  with  which  the  work  can  be  done.  In  inoperable 
cases  improvement  can  sometimes  be  obtained  by  thorough  cauterization  of 
the  ulcerating  surface  after  removing  the  softer  tissues  with  the  curette, 
which  lessens  the  hemorrhage  and  discharge,  and  sometimes  even  the  pain. 

Elephantiasis  of  the  Vulva. — Elephantiasis  is  due  to  filaria-infection, 
lymphatic  obstruction,  or  the  solidification  of  a  chronic  oedematous  swelling 
caused  by  the  inflammation  of  the  parts.  In  the  tropics  immense  tumors 
are  found,  and  even  in  this  country  the  swelling  may  be  sufiicient  to  require 
operation.  The  skin  and  subcutaneous  tissues  are  thickened  and  oedema- 
tons,  and  the  surface  is  usually  papillomatous,  with  hypertrophy  of  all  the 
constituents  of  the  skin.  The  tumors  are  not  so  hard  as  epithelioma,  and 
the  structure  of  the  altered  skin  is  different.  The  swollen  parts  may  be 
excised,  hemorrhage  being  arrested  by  clamps  and  pressure,  and  the  edges 
of  the  wound  brought  together  with  sutures. 

Hydrocele  in  the  Female. — Occasionally  a  process  of  peritoneum 
accompanies  the  round  ligament  down  through  the  canal  of  Nuck  into  the 
labium  majus,  and  it  may  become  shut  oif  from  the  general  jperitoneal  cavity 
and  fill  up  with  serous  fluid,  forming  a  cyst  to  which  the  name  hydrocele  is 
given  on  account  of  its  analogy  to  scrotal  hydrocele.  These  cysts  are  usually 
pear-shaped,  having  a  neck  running  up  towards  the  inguinal  ring,  which 
distinguishes  them  from  cysts  of  Bartholin's  glands.  The  diagnosis  from 
hernia  is  made  by  the  irreducibility  of  the  tumor,  by  the  absence  of  impulse 
on  coughing,  and  in  some  cases  by  its  trauslucency.  These  cysts  may  be 
treated  by  aspiration  and  injection  with  carbolic  acid,  as  in  the  male,  or  by 
extirpation.  Occasionally  the  cysts  communicate  with  the  peritoneal  cavity, 
and  in  such  cases  the  fluid  can  be  pressed  back  into  the  abdomen. 

Varicose  Veins. — Varicose  veins  occur  in  the  vulva,  but  only  the 
superficial  veins  are  affected.  They  can  be  cured  by  multiple  ligation  or 
partial  extirpation. 

Vaginismus. — Vaginismus  is  a  spasmodic  contraction  of  the  sphincter 
and  even  of  the  muscular  fibres  of  the  vagina.  It  is  common  in  newly 
married  women  as  the  result  of  the  traumatism  of  beginning  intercourse, 
especially  if  they  are  of  a  neurotic  temperament.  The  spasm  in  some  cases 
is  very  violent  and  painful,  affecting  the  levator  ani,  and  the  sphincters  of 
the  bladder  and  rectum,  so  that  evacuation  of  either  organ  is  accompanied 


1124 


DISPLACEMENTS  OF  THE   UTERUS. 


witli  inteuse  ijain.  In  such  cases  the  slightest  touch  upon  the  vulva  may 
initiate  the  spasm.  The  spasm  is  often  due  to  a  small  ulcer  or  fissure 
between  the  fragments  of  the  hymen,  or  to  hj-pertesthesia  of  some  of  the 
fragments  or  carunculge  ;  in  other  cases  the  cause  appears  to  he  a  neuralgic 
condition  of  the  nerves  of  the  vestibule  or  a  pure  neurosis.  Treatment. — 
The  treatment  consists  iu  abstention  from  sexual  intercourse,  rest  in  bed, 
and  then  slow  and  cautious  dilatation,  beginning  with  glass  plugs  small 
enough  to  be  introduced  without  paiu,  for  if  the  stretching  be  carried  so  far 
as  to  cause  pain  a  relapse  will  be  produced.  Or  an  emj^ty  rubber  bag  dilator 
may  be  introduced  and  distended  with  air,  water,  or  mercury.  Any  local 
lesion  which  may  be  found  must  be  treated.  In  the  worst  cases  excision  of 
the  carunculge  should  be  tried,  and  in  some  cases  the  pudic  nerve  has  been 
divided  with  success. 


DISPLACEMENTS  OF  THE  UTEPvUS. 

The  uterus  normally  lies  in  a  position  of  slight  anteversion,  its  axis  being- 
straight  and  about  at  right  angles  with  the  axis  of  the  vagina  and  the  fundus 
just  below  the  upper  border  of  the  j)ubic  bone,  and  separated  from  it  by  a 
slight  interval.  A  full  bladder  throws  it  backward,  and  a  distended  rectum 
pushes  it  forward.  The  normal  uterus  is  quite  movable,  and  in  some  per- 
sons extremely  so,  and  displacements  should  be  considered  pathological  only 
when  they  are  extreme  or  when  they  produce  symptoms.  (Fig-  874.) 
Fig.  874.  Fig.  875. 


Normal  mobility  of  the  uterus.    (Munde. ) 


Eetroversion  of  uterus,     (llunde.) 


The  rotation  of  the  uterus  about  a  transverse  axis  is  called  version. 
The  uterus  may  remain  at  a  projjer  level,  but  rotated  about  a  transverse 
axis  so  that  the  fundus  will  be  thrown  backward  (Fig.  875)  or  forward.  The 
uterus  may  be  displaced  from  its  normal  position  iu  the  pelvis  by  simple 
descent,  and,  as  it  must  follow  the  natural  curve  of  the  axis  of  the  pelvis  in 
descending,  the  fundus  must  be  thrown  backward,  making  a  retroversion. 
A  bending  of  the  organ  is  termed  a  flexion.  A  bending  backward  is  a 
retroflexion,  and  the  fundus  passes  into  Douglas's  cul-de-sac.  In  ante- 
flexion the  fundus  turns  forward  so  that  it  presses  upon  the  bladder  (Fig. 
876),  or  even  becomes  prominent  in  the  vagina  anterior  to  the  cervix. 
Lateral  flexions  of  the  organ  are  also  seen,  but  they  are  less  common. 
Flexion  and  version  may  be  combined,  as  when  a  uterus  which  is  anteflexed 
is  then  rotated  backward  on  a  transverse  axis  so  as  to  become  retroverted. 


DISPLACEMENTS   OF  THE   UTERUS. 


1125 


Anteflexion  of  uterus.    (Muude.) 


or  when  it  is  retroflexed  and  at  the  same  time  retroverted.     The  uterus  may 
also  be  displaced  as  a  whole,  without  version  or  flexion,  by  the  pressure  of 
tumors,  the  traction  of  adhesions,  or  the  yielding 
of  its  ligaments. 

In  elderly  womeu  displacements,  especially 
prolapse,  are  veiy  frequent  because  of  the  ab- 
sorption of  fat  from  the  pelvis  and  perineum, 
and  the  consequent  loss  of  support  to  the  organs, 
as  well  as  the  atrophy  of  the  fibrous  tissues  and 
the  ligaments.  Versions  of  the  uterus  are  due 
to  laxity  of  the  ligaments  which  should  keep  it 
in  position,  to  the  j)ressiu-e  of  a  tumor  which 
pushes  the  organ  out  of  place,  or  to  adhesions 
which  draw  it  to  one  side,  and  in  rare  cases  a 
congenital  shortening  of  the  anterior  vaginal  wall 
holds  the  cervix  forward  and  causes  a  retroversion.  Flexions,  on  the  other 
hand,  are  often  congenital,  being  due  to  insufficient  development  of  the 
anterior  or  posterior  wall  or  of  one  lateral  half,  the  undeveloped  portion 
forming  the  concave  side  of  the  curve.  Flexion  can  be  produced  or  exag- 
gerated by  the  same  causes  that  produce  version,  and  also  by  an  unnatural 
softening  of  the  uterine  tissue,  especially  in  cases  of  subinvolution,  where 
the  large  size  of  the  uterus  is  an  additional  cause  of  the  displacement.  The 
effect  of  version  upon  the  uterus  is  to  obstruct  its  venous  circulation,  and 
thus  increase  its  liability  to  inflammation. 

Prolapsus. — Descent  of  the  uterus,  or  falling  of  the  womb,  is  called 
prolapse,  or  procidentia.  It  may  be  due  to  laxity  of  the  ligaments  and 
absorption  of  the  fat  in  the  pelvis,  esj)ecially  if  the  uterus  is  hea^'j  from 
subinvolution  or  the  presence  of  a  tumor.  Laceration  of  the  perineum  is 
the  most  common  cause.  The  displacement  is  therefore  most  common  in 
women  who  have  borne  children,  and  in  advanced  life,  but  it  may  be  seen 


Fig.  877. 


Fig  878 


Extreme  prolapsus  uteri.    (Case  of  Dr.  R.  Abbe.) 


Prolapsus  uteri.    (Munde.) 


in  virgins  even  before  the  thirtieth  year,  as  the  result  of  falls  upon  the 
buttocks  or  straining  in  lifting  heavy  weights.  The  uterus  maj^  be  only 
slightly  below  its  normal  j)osition  or  may  pass  entirely  out  of  the  body  and 
hang  between  the  thighs,  covered  with  everted  vagina.     (Pig.  877.)    In 

72 


1126 


TREATMENT  OF  DISPLACEMENTS   OF  THE  UTERUS. 


such  cases  the  mucous  membrane  becomes  greatly  thickened  and  hardened, 
resembling  skin,  and  it  is  often  ulcerated.  The  principal  complaint  of  the 
patient  even  in  these  severe  cases  may  be  the  disturbance  of  function  of  the 
bladder,  which  is  rolled  out  with  the  anterior  vaginal  wall  so  as  to  form  a 
pouch  and  render  it  liable  to  cystitis.  As  the  uterus  descends  it  follows  the 
curve  of  the  pelvis  and  is  somewhat  retro  verted.  (Fig  878.)  A  careful 
examination  is  needed  to  distinguish  between  these  cases  and  simple  retro- 
version, especially  as  the  mere  turning  back  of  the  fundus  in  retroversion 
carries  the  cervix  forward  and  nearer  the  introitus,  so  that  it  is  easier  to 
reach  it  with  the  finger,  and  it  seems  to  have  pi'olapsed.  In  the  slighter 
grades  of  descent  it  may  be  necessary  to  examine  the  patient  in  the  standing 
position  in  order  to  appi-eciate  the  amount  of  prolapse.  The  cervix  is  often 
elongated  to  twice  its  natural  length  in  cases  of  prolapse,  and  the  exact 
position  of  the  fundus  must  be  determined  in  order  to  ascertain  how  much 
of  the  apparent  displacement  is  due  to  a  real  descent  of  the  entire  organ 
and  how  much  to  the  elongation  of  the  cervix. 

Symptoms. — The  general  symptoms  produced  by  displacements  of  the 
uterus  are  pain  in  the  back,  caused  by  the  dragging  on  the  various  ligaments 
or  merely  by  the  congestion  of  the  organ,  and  pains  are  occasionallj'  felt 
running  down  the  legs,  owing  to  pressure  on  the  sacral  plexus.  Consti- 
pation and  vesical  irritation  may  be  caused  if  the  uterus  presses  upon  the 
rectum  or  bladder.  Menstruation  may  be  very  painful,  but  very  seldom  is 
the  exit  of  the  flow  really  obstructed  by  the  malposition  of  the  uterus. 
Mechanical  dysnienorrhcea  is  more  frequent  in  flexion  than  in  version,  but 
the  congestion  of  the  uterus  in  extreme  version  results  in  menstrual  dis- 
turbances, such  as  too  frequent  menstruation,  too  j)rolonged  and  too  abun- 
dant flow,  and  an  increase  in  the  various  general  symptoms  of  menstruation. 
Endometritis  is  usually  present,  and  adds  its  symptoms  to  those  mentioned. 

Many  of  the  symptoms  of  displace- 
ment are  really  due  to  the  inflam- 
mation or  the  adhesions  which  ac- 
company or  cause  the  malposition, 
and  may  sometimes  be  relieved  by 
treatment  directed  to  these  condi- 
tions even  without  correction  of  the 
displacement. 

Treatment.— Replacement. 
— The  'malposition  of  the  uterus 
may  be  reducible  by  pressure  with 
the  finger  in  the  vagina  or  rectum, 
di-awing  downward  on  the  cervix 
with  a  tenaculum  at  the  same  tiime, 
the  patient  being  placed  in  a  posi- 
tion to  facilitate  the  movements. 
Thus,  in  a  retroflexion  or  retroversion  the  patient  is  to  be  placed  in  the  knee- 
chest  position  with  the  hips  elevated.  (Pig.  879.)  Instruments  have  been 
invented  for  this  purpose,  but  they  are  not  considered  safe.  The  uterine  sound 
may  be  used  during  reduction,  but  only  to  hold  the  organ  in  position  after  it 


Fig.  879. 


Reduction  of  retroversion  witti  patient  in  knee-cliest 
position.    (Madden.) 


TREATMENT  OF  DISPLACEMENTS   OF  THE  UTERUS. 


1127 


has  been  replaced  as  far  as  possible  by  the  finger,  for  iierforation  of  the  uterine 
wall  might  easily  occur  if  the  pressure  necessary  to  move  the  organ  were  to 
be  exercised  with  that  instrument.  When  the  abdominal  wall  is  lax  the 
fundus  of  the  uterus  can  often  be  reached  by  the  palpating  hand  outside  and 
carried  into  its  proper  position.  If  pregnancy  takes  place  in  an  organ  out 
of  position  very  severe  symptoms  may  result,  and  miscarriages  from  this 
cause  are  frequent,  but  this  may  be  prevented  if  the  condition  is  recognized 
early  enough  to  allow  of  replacement  of  the  organ  before  its  large  size  has 
fixed  it  in  its  faulty  position.  If  adhesions  prevent  the  reposition  of  the 
uterus,  they  may  be  stretched  by  constant  and  persistent  attempts  at  replace- 
ment carried  out  daily  or  weekly  for  a  long  period,  their  absorption  being 
hastened  by  the  daily  use  of  the  hot  douche  and  other  medical  measures. 
What  is  gained  each  day  may  be  maintained  by  packing  the  vagina  with 
cotton  balls  so  jilaced  as  to  hold  the  uterus  in  position. 

Pessaries. — When  the  uterus  has  been  replaced  and  shows  a  tendency 
to  return  to  its  malposition,  an  instrument  known  as  a  pessary  may  be 
inserted  in  the  vagina  in  order  to  retain  the  organ  in  its  proper  place.  In 
cases  of  anteversion  or  anteflexion  a  pessary  can  accomplish  but  little,  as  it 
must  then  take  its  bearings  upon  the  soft  part  of  the  vaginal  wall,  but  in 
backward  displacements  a  properly  placed  pessary  curves  forward  and  the 
lower  end  rests  against  the  pubic  arch  in  such  a  way  as  to  give  a  toler- 
ably firm  supjjort.  Some  pessaries  act  only  by  their  size,  forming  a  large 
mass  on  which  the  uterus  rests  with- 
out giving  definite  supjjort  in  any  pj^  ^gQ 
one  direction.  The  Hodge  pessary 
of  hard  rubber  is  the  most  generally 
useful,  and  when  heated  can  be  bent 
to  any  required  shape.  Pessaries 
must  be  made  to  fit  the  parts  exactly. 
They  should  not  cause  pain  when  in- 
troduced, and  there  should  be  enough 
space  around  them  to  permit  the 
finger  to  be  passed  between  the  pes- 
sary and  the  vaginal  wall  on  all  sides. 
A  daily  vaginal  douche  is  necessary 
when  a  pessary  is  worn,  and  the  pa- 
tient should  always  be  instructed 
how  to  remove  it  in  case  of  accident. 
The  introduction  of  the  instrument, 
however,  should  always  be  made  by 
the  physician.  To  introduce  the 
Hodge  pessary,  place  the  patient 
upon  the  side,  insert  the  broad  end 
of  the  instrument  in  the  introitus, 
and  press  back  the  perineum  with  it 

until  it  enters  without  ijressure  upon  the  urethra.  (Fig.  880,  A.)  The  pes- 
sary then  readily  slips  into  the  vagina,  where  it  must  be  turned  around  into 
proper  position.     The  index  finger  is  introduced,   and  the  upper  bar  is 


Introduction  of  Hodge  pessary.     (Madden.) 


1128  OPERATIONS   FOE   RETROVERSION   AND   RETROFLEXION. 

placed  behind  the  cervix.  (Pig.  880,  B.)  The  use  of  pessaries  must  be 
discontinued  if  it  is  found  that  in  spite  of  careful  adjustment  ulceration  is 
caused  by  their  pressure,  as  there  is  then  danger  of  septic  infection  and  of 
malignant  disease.  Pessaries  which  are  supported  by  a  band  passing  up  to  a 
waistband  are  uncomfortable  to  wear,  and  when  they  are  ef&cient  in  holding 
the  uterus  in  position  the  pressure  is  usually  so  great  that  ulceration  is 
almost  certain  to  occur,  so  that  their  use  cannot  be  recommended.  A  pes- 
sary is  only  palliative ;  it  does  not  cure.  In  the  majority  of  cases  of  dis- 
placement of  the  uterus  severe  enough  to  warrant  the  use  of  a  pessary  a 
cure  can  be  obtained  by  an  operation,  but  in  some  cases  it  is  necessary  to 
postpone  the  operation  on  account  of  the  patient's  health  or  for  other  rea- 
sons, and  then  pessaries  are  a  useful  temporary  expedient.  Sometimes  a 
retroversion  pessary  will  relieve  the  symptoms  of  anteversion  or  anteflexion, 
by  lifting  the  uterus  and  lessening  the  pressure  upon  the  bladder,  which  is 
the  most  urgent  symptom  of  this  condition. 

Operations  for  Retroversion  and  RetroiQexion. — Vaginal  Fixa- 
tion.— An  incision  is  made  along  the  cervix  at  the  vaginal  junction,  the 
bladder  stripped  up  from  the  anterior  wall  of  the  organ,  and  the  fundus 
then  thrown  forward  with  a  sound  or  by  a  blunt  hook,  or  the  finger  intro- 
duced into  the  j)eritoneal  cavity  through  a  small  wound  in  the  peritoneum. 
The  fundus  is  caught  by  a  curved  needle,  and  deep  sutm-es  passed  through 
it,  securing  it  firmly  to  the  anterior  vaginal  wall.  This  operation  is  not 
devoid  of  danger,  on  account  of  the  proximity  of  the  bladder  and  ureters, 
and  it  is  very  dangerous  to  perform  it,  as  has  been  recommended  by  some, 
without  first  incising  the  mucous  membrane  and  detaching  the  bladder.  It 
places  the  uterus  in  the  worst  possible  position  in  case  of  pregnancy,  and 
many  instances  of  abortion  and  rui^ture  of  the  uterus  have  followed  it.  It 
should,  therefore,  be  strictly  limited  to  women  in  whom  pregnancy  is  impos- 
sible. 

Ventrosuspension. — Ventrofixation. — The  uterus  may  be  secured 
by  sutures  to  the  anterior  abdominal  wall  by  making  a  small  laparotomy 
wound.  The  original  idea  was  to  attach  the  uterus  as  firmly  as  possible, 
but  it  was  found  that  a  close  attachment  was  liable  to  cause  abortion  or  rup- 
ture of  the  uterus  in  case  of  pregnancy,  and  we  now  limit  the  operation  to 
patients  in  whom  pregnancy  is  impossible,  or  try  to  get  an  elongated  liga- 
mentous attachment  which  will  not  interfere  with  the  growth  of  the  uterus. 
Kelly  draws  the  uterus  forward  into  extreme  anteversion  and  passes  two 
sutures  through  the  posterior  wall  of  the  fundus  and  the  parietal  ijeritoneum, 
bringing  them  into  contact  for  an  area  about  one-half  an  inch  square.  Per- 
sonally we  do  not  perform  the  operation  so  long  as  pregnancy  is  possible,  and 
then  using  it  chiefly  for  complete  prolapse  we  make  as  firm  an  attachment 
as  can  be  formed,  sometimes  turning  back  the  parietal  peritoneum  at  the 
edge  of  the  abdominal  wound  and  bringing  the  fundus  closely  in  apposition 
with  that  point  by  chromic  gut  sutures  passed  through  the  muscular  layer 
of  the  abdominal  wall  and  the  anterior  wall  of  the  fundus.  The  uterus  is 
secured  as  high  up  as  possible.  The  wound  is  closed  by  separate  sutures,  so 
that  too  great  a  strain  shall  not  come  on  the  fixation  sutures.  Another 
objection  to  the  method  is  the  possibility  of  a  loop  of  bowel  slipping  under 


OPERATIONS   FOR  PROLAPSE   OF  THE  UTERUS.  1129 

the  uew  ligament  between  the  uterus  and  bladder  and  becomiug  strangulated. 
When  laparotomy  is  done  for  ventrosuspension  an  excellent  cosmetic  result 
can  be  obtained  by  making  the  cutaneous  incision  transverse  in  the  region 
of  the  suprapubic  hair.  The  skin  and  subcutaneous  tissue  are  detached 
uj)ward  in  a  flap  until  three  or  four  inches  of  the  linea  alba  have  been 
exposed  and  the  latter  is  divided  and  the  peritoneum  opened  as  usual. 

Shortening  the  Round  Ligaments. — Alexander^ s  operation  for  shovten- 
ing  the  round  ligaments  may  also  be  employed  for  these  conditions,  as  fol- 
lows. The  ligaments  are  exposed  by  a  dissection  at  the  external  inguinal 
ring,  and  are  drawn  out  of  the  ring,  the  uterus  being  lifted  up  at  the  same 
time  by  an  assistant's  finger  in  the  vagina,  as  the  round  ligaments  may  not 
be  strong  enough  to  bear  the  strain  of  the  organ  by  themselves.  It  is 
generally  advisable  to  incise  the  inguinal  canal  somewhat  in  order  to  draw 
the  ligaments  well  down.  The  sheath  of  j)eritoneum  which  accompanies  the 
ligament  into  the  canal  is  fi^equently  opened  in  the  dissection.  The  serous 
membrane  should  be  stripi^ed  back  with  forceps,  and  it  usually  peels  off 
readily.  If  a  large  opening  is  made  in  the  peritoneum,  it  should  be  closed 
by  a  catgut  suture.  The  round  ligaments  may  be  stitched  to  the  edges  of 
the  ring,  but  the  best  method  of  securing  them  is  that  suggested  by  Abbe. 
He  uses  the  ligament  itself  as  a  suture  material,  and  draws  it  back  and  forth 
through  the  pillars  of  the  ring  by  a  special  instrument  shaped  like  Cleve- 
land's ligature-passer,  or  by  a  loop  of  stout  silk  used  as  a  carrying-thread 
on  a  needle.  We  pass  these  ligament-sutures  through  the  conjoined  tendon 
and  Poupart's  ligament  as  in  the  Bassini  operation  for  the  radical  cure  of 
hernia.  When  the  uterus  is  adherent  we  sometimes  free  it  through  a  pos- 
terior vaginal  incision  before  proceeding  to  the  Alexander  operation.  The 
latter  fails  occasionally  because  the  round  ligament  cannot  be  found  or  is  so 
weak  that  it  cannot  be  effectively  used. 

The  round  ligaments  may  also  be  shortened  by  an  intraperitoneal  operation. 
A  laparotomy  is  done,  the  ligaments  are  drawn  up,  and  a  looiJ  is  made  in 
each  at  the  centre  and  the  loops  are  secured  by  sutures  passed  through  the 
overlapping  parts.  Webster  detaches  the  round  ligament  from  the  uterus, 
passes  the  distal  part  through  the  broad  ligament  just  below  the  uterine 
attachment  of  the  Fallopian  tubes  and  sutures  the  ends  to  the  posterior  wall 
of  the  fundus.  The  intraperitoneal  methods  are  suitable  for  cases  in  which 
strong  adhesions  are  present  or  when  a  laparotomy  is  done  for  some  other 
purpose,  such  as  the  removal  of  a  tumor.  Goife  shortens  the  ligaments 
through  a  vaginal  incision  in  front  of  the  cervix.  The  round  ligaments  are 
drawn-forward  in  turn  by  a  blunt  hook,  and  the  two  limbs  of  the  loop  thus 
made  are  sutured  together  as  far  back  as  can  be  reached,  the  shortening  usu- 
ally amounting  to  two  inches.  The  loops  can  also  be  sutured  to  the  fundus, 
which  is  thus  firmly  held  in  place.     The  wound  is  closed  by  sutures. 

Operations  for  Prolapse. — -The  slighter  grades  of  prolapse  can  be  pre- 
vented from  growing  worse  by  plastic  operations  upon  the  vagina  and  vulva. 
The  severer  forms  require  some  operation  upon  the  uterus  itself. 

Colporrhaphy. — When  the  vagina  has  been  everted  with  a  prolapsed 
uterus  the  canal  becomes  very  greatly  stretched,  and  it  is  necessary  to 
reduce  its  caliber  by  colporrhaphy.      This  is  done  by  making  an   oval 


1130  INVERSION   OF  THE   UTERUS. 

deniidatiou  on  the  anterior  or  posterior  wall  or  both,  each  denuded  area 
being  closed  for  itself,  its  edges  being  united  by  sutures  across  the  raw  sur- 
face. The  posterior  operation  should  be  combined  with  the  ordinary  perine- 
orrhaphy. Some  perform  this  operation  by  cutting  out  a  segment  including 
the  entire  thickness  of  the  vaginal  wall  at  these  points.  Some  have  sug- 
gested denuding  a  portion  of  the  vaginal  wall  anteriorly  and  posteriorly  and 
bringing  the  raw  surfaces  together  across  the  vagina  by  a  series  of  sutures, 
forming  a  sort  of  pillar  in  the  centre  of  the  vagina.  The  uterus  has  also 
been  utilized  to  fill  the  vagina,  being  secured  anteriorly  as  in  vagino-flxation, 
then  the  surface  and  the  posterior  vaginal  wall  both  freshened  and  united 
together  by  sutures.  The  results  obtained  by  these  methods  are  fair,  but  in 
both  there  is  a  tendency  to  yield  to  the  pressure  in  time.  Another  method 
consists  in  passing  a  series  of  buried  sutures  circularlj^  around  the  vagina 
just  under  the  mucous  membrane,  and  thus  constricting  the  canal  so  that 
the  uterus  cannot  descend,  but  the  sutures  soon  cut  through  and  the  result 
is  temporary. 

Hysterectomy. — In  vei'y  severe  cases  of  prolapse  of  the  uterus  removal 
of  the  organ  at  the  vulva  may  be  undertaken  as  a  last  resort.  The  operation 
is  not  easy,  in  spite  of  the  low  position  of  the  uterus,  on  account  of  the 
great  extent  to  which  the  bladder  covers  the  uterus  in  the  anterior  wall  of 
the  prolapse.  Hysterectomy,  however,  does  not  entirely  correct  the  condi- 
tion found,  and  leaves  the  iielvic  floor  very  weak,  and  the  recent  suggestion 
to  extirpate  the  vagina  as  well  does  not  seem  to  promise  better  results. 

Complete  Prolapse. — When  the  displacement  is  extreme  the  best  treat- 
ment consists  in  :  (1)  amputation  of  the  hypertrophied  cervix,  in  order  to 
reduce  the  weight  of  the  organ  ;  (2)  ventrosuspension  or  fixation  ;  (3)  col- 
porrhaphy  and  xjerineorrhaphy.  In  these  cases,  in  addition  to  ventrosuspen- 
sion, it  is  well  to  try  to  form  a  diaphragm  across  the  pelvis  by  suturing  the 
appendices  epiploicie  to  the  back  of  the  uterus  or  broad  ligament,  or  by 
drawing  together  the  edges  of  the  broad  ligament. 

Operations  for  Anteversion  and  Anteflexion. — No  really  successful 
method  of  operative  treatment  for  anteversion  has  yet  been  devised.  As 
anteflexion  is  almost  invariably  due  to  a  lack  of  tissue  in  the  anterior  wall 
of  the  uterus,  little  or  nothiug  can  be  done  to  correct  the  malposition.  But 
if  sterility  or  dysmenorrhcea  is  present  owing  to  the  acute  flexion  of  the 
canal,  these  conditions  may  be  relieved  by  incising  the  canal  of  the  cervix 
backward,  so  as  to  split  the  vaginal  portion.  Another  method  of  treatment 
consists  in  small  multiple  incisions  of  the  os,  with  systematic  dilatation  of 
the  caual  and  the  wearing  of  an  iutra-uterine  stem  pessary.  Pregnancy  has 
been  known  to  follow  these  measures. 

Inversion. — Inversion  of  the  uterus  takes  place  as  an  accident  in  partu- 
rition, and  it  is  also  gradually  produced  by  the  traction  of  polypoid  tumors 
attached  near  the  fundus  and  exj)elled  into  the  vagina  by  uterine  contrac- 
tions. The  symj)toms  of  inversion  are  profuse  vaginal  discharge  and  dis- 
comfort owing  to  the  presence  of  the  tumor  in  the  vagina,  and  sometimes 
hemorrhage  from  the  surface  of  the  inverted  womb.  The  diagnosis  is  made 
by  a  jjhysical  examination.  If  the  inversion  is  complete,  the  tumor  will  be 
continuous  with  the  vault  of  the  vagina  on  all  sides,  and  the  edge  of  the 


TREATMENT  OF  INVERSION  OF  THE  UTERUS. 


1131 


cervix  can  be  felt  high  up  and  reversed, — that  is,  directed  upward  instead  of 
downward.  If  the  cervix  is  not  inverted  but  the  fundus  has  descended 
through  it,  a  finger  or  a  sound  can  be  passed  into  it  along  the  sides  of  the 
tumor,  but  will  be  arrested  just  within  at  the  point  where  the  inversion 
occurs.     (Fig.  881.)     Bimanual  examination  will  show  an  absence  of  the 


Differential  diagnosis  of  inveisio  uteri :  A,  prolapse  ;  B,  polypus ;  C,  inversion.    (Madden.) 


fundus  in  the  pelvis,  and  the  central  depression  produced  by  its  inversion 
can  sometimes  be  felt  either  through  the  abdominal  wall  or  by  the  finger  in 
the  rectum.  The  possibility  of  j)artial  inversion  should  be  remembered  in 
removing  all  polyiioid  tumors  from  the  vagina.  We  have  seen  one  horn  of 
the  uterus  drawn  down  through  the  fundus  so  that  it  appeared  to  be  part  of 
the  pedicle  of  the  tumor  and  was  cut  off  by  a.  careless  operator.  If  the 
inversion  is  not  reduced  at  once,  adhesions  form  and  reposition  may  be 
exceedingly  difficult. 

Treatment. — Eeposition  has  been  effected  by  means  of  a  cup-shaped 
instrument  secured  to  a  long  stem  with  a  spiral  spring.  The  patient  is  put 
in  the  lithotomy  position,  the  fundus  of  the  uterus  is  placed  in  the  cup  and 
the  base  of  the  stem  and  spring  rests  against  the  chest  of  the  operator  seated 
in  the  usual  manner.  Gradual  pressure  is  made  upward,  while  the  parts 
are  steadied  by  one  hand  on  the  abdomen  sunk  well  into  the  pelvis,  where 
the  depression  in  the  ujiper  surface  of  the  uterus  can  sometimes  be  felt.  It 
is  wise  to  make  a  small  laparotomy  wound  in  order  to  break  up  adhesions 
and  control  the  action  of  the  instrument.  The  narrow  ring  found  on  the 
abdominal  surface  of  the  uterus,  where  the  fundus  has  been  turned  in,  can 
be  exposed  in  the  wound  and  dilated  with  strong  forcejjs,  or  incised  in  the 
median  line  posteriorly,  the  incision  being  gradually  ]3rolonged  towards  the 
cervix  as  the  uterus  is  forced  back  into  the  peritoneal  cavity  from  below.. 
The  utei-ine  incision  is  to  be  sutured  after  reduction  is  complete,  and  the 
laparotomy  wound  closed  as  usual.  If  all  attempts  at  reduction  fail,  hyste- 
rectomy may  be  done,  or  (by  way  of  the  vagina)  the  cervix  can  be  dilated 
and  the  inverted  fundus  amputated  above  the  level  of  the  internal  os. 
Heavy  sutures  should  be  passed  through  the  inverted  portion  before  the 


1132 


TUMORS   OF  THE  UTERUS. 


fundus  is  cut  away,  for  the  thick  iiterine  wall  will  spring  up  out  of  reacli  as 
soon  as  it  is  divided.  If  the  fundus  can  be  partly  reduced,  Emmet  suggests 
fresheniug  the  lips  of  the  cervix  and  uniting  them  with  sutui*es  over  the 
prolapsing  fundus,  to  prevent  any  increase  of  the  inversion. 

TUMORS   OP   THE   UTERUS. 

Adenoma. — While  adenoma  is  rarely  found  in  the  uterus  as  a  large 
tumor,  fungoid  endometritis  and  the  cysts  of  the  Nabothian  glands  are 
microscopically  adenomata. 

Myxoma. — Large  polypi  are  sometimes  found  hanging  in  the  vagina 
which  originate  in  the  endometrium,  especially  that  of  the  cervix,  and 
resemble  the  nasal  polypi.  But  the  onlj^  benign  tumor  of  the  uterus  of 
clinical  importance  is  the  fibromyoma. 

Pibromyoma. — A  fibroid  tumor  begins  as  an  encapsulated  growth  in 

the  wall  of  the  uterus,  and  as  it  enlarges  works  its  way  either  towards  the 

cavity  of  the  organ  or  to  its  external  surface.     When  the  tumor  projects 

into  the  cavity  of  the  organ  it  is  called  a  submucous  fibroid  (Fig.  882),  and 

it  may  have  a  broad  base  or  form  a  polypoid  growth 

^"-''  ^^^'  with  a  narrow  pedicle.     This  is  the  least  frequent 

variety.     In  over  one-half  of  the  cases  it  lies  in  the 


Subperitoneal  and  submu-  Interstitial  fibroids.    (Agnew.) 

ecus  fibroids ;  uterus  laid  open. 
(Madden.) 

substance  of  the  wall  of  the  organ,  and  is  called  an  interstitial  or  mural 
fibroid.  (Fig.  883.)  When  situated  upon  the  external  surface  of  the  uterus 
it  may  be  a  subperitoneal  growth  (Fig.  882),  or  may  make  its  way  outward 
at  a  part  not  covered  with  peritoneum.  These  tumors  may  be  multiple,  and 
they  may  acquire  an  immense  size,  especially  when  they  undergo  cystic  de- 
generation. Their  relations  to  the  uterus  are  various.  They  may  grow  in 
the  wall  and  expand  the  entire  uterus  as  if  it  were  enlarged  by  pregnancy. 
In  other  cases  the  uterus  and  the  tumor  are  connected  only  by  a  long  and 
narrow  pedicle.  The  intraperitoneal  tumors  may  be  pedunculated  or  sessile, 
but  the  larger  ones  are,  as  a  rule,  attached  to  a  considerable  part  of  the  sur- 
face of  the  organ.  These  tumors  often  reach  a  weight  of  thirty  or  forty 
pounds,  and  one  has  been  reported  of  one  hundred  and  forty  pounds.    They 


SYMPTOMS   OF  FIBROID  TUMORS   OF  THE  UTERUS.  1133 

may  extend  up  into  the  abdomen  as  high  as  the  ensiform  cartilage.  We 
have  I'emoved  a  tumor  which  extended  up  to  this  point,  filling  the  entire 
abdomen,  and  j'et  was  connected  with  the  uterus,  which  was  of  normal  size, 
by  a  pedicle  not  thicker  than  a  man's  thumb.  Fibroids  sometimes  vary  in 
size,  enlarging  during  the  menstrual  epoch  or  in  pregnancy,  and  undergoing 
partial  involution  afterwards.  Polypi  have  been  known  to  enlarge  and 
descend  iuto  the  vagina  during  the  menses,  and  to  retreat  up  into  the  uterine 
cavity  between  the  periods.  A  uterus  containing  fibroid  tumors  is  usually 
so  heavy  that  there  is  a  tendency  to  retroversion  and  prolapse,  but  when  the 
mass  has  attained  a  certain  size  it  gains  support  from  the  pelvic  walls,  and 
then  it  begins  to  ascend  into  the  abdomen,  drawing  the  uterus  up  with  it,  as 
in  the  enlargement  of  a  normal  pregnancy.  The  extraperitoneal  fibroids 
have  more  or  less  tendency  to  grow  downward  into  the  pelvis,  and  even 
when  small  they  may  cause  much  distress  by  pressure  uf>on  the  rectum 
or  bladder,  or  by  compressing  the  nerves  and  blood-vessels  against  the 
pelvic  walls. 

Fibromyoma  is  liable  to  myxomatous  changes  or  to  mucoid  degeneration 
producing  large  cystic  cavities.  Softening  also  occurs  from  telangiectasis 
of  the  blood-vessels  or  lymphatics.  The  tumor  may  become  infected  through 
uterine  ulceration,  and  then  rapidly  breaks  down  and  sloughs,  causing  sepsis. 
Sloughing  may  also  result  from  a  twist  in  the  pedicle  of  the  tumor,  and  in 
some  cases  tumor  and  uterus  may  become  twisted  upon  the  elongated  cervix. 
In  rare  instances  these  tumoi'S  undergo  a  sarcomatous  or  carcinomatous 
change,  or  are  associated  with  malignant  tumors,  and  a  rapid  spread  of  the 
malignant  disease  is  the  rule  in  such  cases. 

The  causes  of  these  tumors  are  obscure.  They  are  usually  found  asso- 
ciated with  sterility,  but  whether  as  cause  or  as  effect  is  uncertain.  They 
are  most  frequent  between  twenty-five  and  thirty-five  years  of  age,  and  the 
negro  race  is  especially  liable  to  them. 

Symptoms. — The  presence  of  a  uterine  fibroid  does  not  affect  the  gen- 
eral health  directly,  but  it  may  interfere  mechanically  with  the  bladder, 
rectum,  or  other  abdominal  organs,  especially  when  the  tumor  is  large  or 
becomes  impacted  in  the  pelvis.  Fibroids  may  give  rise  to  neuralgia,  espe- 
cially sciatica,  by  pressure  on  the  nerves,  and  the  interstitial  or  submucous 
tumors  may  cause  backache  and  colickj^  uterine  pains,  especially  at  the 
menstrual  periods.  They  also  occasion  hemorrhages  from  the  uterus,  at 
first  a  mere  menorrhagia,  but  afterwards  metrorrhagia  as  well.  If  they 
become  inflamed  or  slough,  a  septic  condition  may  be  produced.  The 
submucous  fibroids  cause  more  abundant  hemorrhage  than  the  subperitoneal. 
Quite  common  is  the  discharge  of  a  serous  fluid  from  the  uterus,  which 
may  be  very  abundant  and  may  be  evacuated  in  gushes.  It  may  be  odorless 
or  offensive.  While  a  subperitoneal  fibroid,  or  even  an  internal  tumor,  is 
no  impediment  to  conceiDtion,  the  majority  of  women  with  fibroids  are 
sterile,  and  when  conception  takes  place  miscarriage  is  very  frec]uent. 

Diagnosis. — Examination  reveals  a  rather  globular  tumor,  more  or  less 
firmly  attached  to  the  uterus,  following  the  movements  of  the  latter  and 
drawing  the  organ  with  it  when  it  moves,  usually  freely  movable  in  the  ab- 
domen, often  lobular  or  multiple,  hard  to  the  touch,  and  prominent  below 


1134  DIAGNOSIS  OF  FIBEOID  TUMORS  OF  THE  UTERUS. 

in  the  pelvis  or  above  in  tlie  abdomen,  according  to  the  direction  of  its 
growtli.  When  cystic  degeneration  takes  place  the  tumor  usually  reaches 
the  largest  size  and  grows  more  rapidly  than  otherwise.  Examination 
of  the  uterus  with  the  sound  will  usually  show  that  the  canal  is  longer 
than  it  should  be,  the  uterus  having  taken  on  a  certain  amount  of  growth 
or  else  having  been  elongated  by  the  growth  of  the  tumor  to  which  it  is 
adherent.  The  intra-uterine  tumors  may  be  felt  by  the  finger  if  the  cervix 
is  dilated,  and  sometimes  they  protrude  into  the  vagina,  hanging  by  a  long 
pedicle  from  the  interior  of  the  uterus.  Examination  of  the  interior  of  the 
uterus  with  the  sound  will  sometimes  give  a  clue,  for  the  point  where  the 
pedicle  is  attached  to  the  outer  wall  may  be  distinctly  felt  with  the  instru- 
ment. Palpation  of  the  round  ligaments,  the  tubes,  and  the  ovaries  is 
sometimes  possible,  and  enables  one  to  determine  the  side  from  which  the 
tumor  has  develoj)ed  and  its  relations  to  the  fundus. 

In  the  ordinary  cases  the  diagnosis  is  easy,  on  account  of  the  large  size, 
free  mobility,  and  hardness  of  the  tumor,  the  hemorrhages,  and  the  dis- 
placement of  the  uterus.  The  origin  of  the  tumor  in  the  pelvis  and  its 
attachments  indicate  its  connection  with  the  genitals.  Percussion  reveals  a 
central  area  of  dulness  extending  from  the  pubes  uj)  towards  the  umbili- 
cus, and  the  sides  of  the  abdomen  are  resonant  unless  ascites  is  ijresent.  It 
is  distinguished  from  solid  tumors  of  the  ovary  by  its  attachment  to  the 
uterus,  but  a  fibrocystic  tumor  may  not  be  easy  to  differentiate  from  a 
large  ovarian  cyst,  although  it  is  usually  of  rather  unequal  consistency, 
some  parts  still  remaining  firm  and  hard.  The  shape  of  the  abdomen  is 
also  diiferent,  being  more  pointed  (see  Figs.  776,  777,  and  892),  and  the 
projection  of  more  than  one  nodule  of  the  tumor  may  be  evident  instead  of 
an  even,  globular  extension.  The  uterus  rises  into  the  abdomen  only  in  dis- 
tention from  retained  menses,  in  fibroids,  and  in  pregnancy.  The  first  is 
seen  only  before  puberty,  but  particular  pains  must  be  taken  to  exclude  the 
possibility  of  pregnancy.  Fibroid  tumors  are  hard  if  solid,  and  tense  if 
cystic.  If  single,  they  present  a  globular  or  pear-shaped  mass,  usually 
movable,  the  uterus  moving  with  them,  but  they  may  become  fixed  by 
adhesions  or  by  growing  between  the  layers  of  the  broad  ligament.  Tlie 
uterine  sound  generally  shows  a  considerable  increase  in  the  depth  of  the 
uterine  canal.  The  bladder  may  extend  upward  upon  the  surface  of  the 
tumor,  as  shown  by  examination  with  the  sound.  The  uterus  is  usually 
displaced  upward.  A  subperitoneal  fibroid  tumor  may  be  connected  with 
the  uterus  by  only  a  narrow  pedicle,  and  may  be  quite  freely  movable  inde- 
pendently of  that  organ  even  when  the  tumor  is  of  large  size.  These  tumors 
are  often  multiple,  and  then  several  hard  masses  may  be  felt  connected 
together  bu.t  independently  movable. 

Treatment. — A  small  fibroid  which  gives  no  symistoms  i-equires  no 
treatment,  as  the  growth  of  the  tumor  is  slow,  and  until  it  reaches  at  least 
the  size  of  a  man's  fist,  or  causes  decided  symptoms,  it  should  not  be  oper- 
ated upon.  Fibroids  cease  to  bleed  and  become  atrophied  when  the  meno- 
pause arrives.  When,  therefore,  a  fibroid  is  first  discovered  at  this  time, 
and  is  troublesome  only  on  account  of  hemorrhage,  it  does  not  require 
operation  even  if  it  is  of  considerable  size,  provided  the  hemorrhage  can 


TREATMENT  OF  FIBROID  TUMORS  OF  THE  UTERUS!  1135 

be  checked  by  the  administration  of  gallic  acid  or  ergot,  by  a  thorough 
curetting  of  the  uterine  canal,  or  bj'  electrolysis.  The  presence  of  the 
tumor,  however,  may  delay  the  menopause  for  several  years,  and  this  fact 
must  be  given  due  weight  in  the  selection  of  treatment.  Electricity  has 
been  recommended  for  the  treatment  of  iibroids,  and  some  remarkable  cures 
have  been  claimed.  Experience  has  shown  that  this  troublesome  treatment 
merely  lessens  the  hemorrhage.  The  method  most  in  use  is  known  as 
Apostolus,  and  consists  in  the  introduction  into  the  uterine  canal  of  an 
electrode  connected  with  the  negative  pole,  the  positive  pole  being  attached 
to  a  large  flat  electrode  of  metal,  covered  with  cotton,  gauze,  sponge,  or 
clay,  and  placed  upon  the  abdomen.  A  strong  current  of  from  1.50  to  300 
milliamperes  is  used,  aj)plications  being  made  at  intervals  of  a  week.  If 
used  to  check  hemorrhage,  the  intra-uterine  electrode  is  connected  with  the 
positive  pole.  If  a  good  result  is  not  obtained  in  a  few  sittings,  the  method 
should  be  abandoned. 

Oophorectomy. — When  the  tumor  itself  is  not  troublesome,  or  when 
the  condition  of  the  i^atient  forbids  more  extensive  operations,  removal  of 
the  ovaries  and  tubes  has  been  suggested,  in  order  to  control  the  hemorrhage 
by  bringing  on  an  artificial  menopause.  Theoretically  the  operation  prom- 
ised well,  but  practically  it  has  been  found  that  its  execution  is  exceedingly 
difficult  in  some  cases,  and  may  require  a  very  large  incision  on  account  of 
the  unusual  position  of  the  ovaries  and  tubes,  which  may  be  carried  high 
uj)  into  the  abdomen  by  the  growth  of  the  tiamor.  The  removal  of  the 
ovaries,  moreover,  does  not  always  bring  about  the  menopause,  as  instances 
have  been  known  in  which  the  hemorrhages  from  the  uterus  have  continued 
for  months  or  years  after  the  operation.  There  can  be  no  doubt,  however, 
that  the  shock  of  oophorectomy  is  less  than  that  caused  by  the  removal  of  a 
large  fibroid.  The  operation  is  done  by  a  median  incision,  the  ovary  and 
Fallopian  tube  on  each  side  being  ligated  and  cut  away,  and  the  abdomen 
closed  as  usual.  Another  palliative  method  of  treatment  consists  in  the 
ligation  of  the  uterine  arteries  from  the  vagina,  but  it  is  not  suitable  for  large 
tumors  or  when  the  uterus  is  drawn  high  up  in  the  abdomen,  and  it  often 
fails  to  check  the  metrorrhagia. 

Myomectomy. — Myomectomy  is  the  name  given  to  the  removal  of  the 
tumors  without  ablation  of  the  uterus.  It  preserves  the  uterus,  and  preg- 
nancy may  occur  later.  It  has  been  frequently  performed  during  i^regnancy 
without  causing  abortion.  But  there  is  the  disadvantage  that  myomectomy 
may  leave  some  nodules  in  the  uterus  which  will  grow  and  necessitate  a 
second  operation.  It  may  be  performed  through  the  vagina  or  by  a  laparot- 
omy, the  former  being  suitable  for  submucous  and  the  latter  for  subperitoneal 
tumors,  while  the  interstitial  may  be  attacked  from  either  direction.  Sub- 
mucous fibroids  may  be  removed  by  the  vagina  if  the  cervical  canal  is  dilated 
or  distensible,  and  even  when  rigid  it  may  be  incised  so  as  to  give  access  to 
the  growth.  The  operation  consists  in  dilating  the  cervix  widely,  ligating 
the  tumor  at  its  base,  and  cutting  it  away.  If  the  point  of  attachment  cau 
be  clearly  seen,  the  pedicle  may  be  divided  without  ligation  and  a  deep 
stitch  taken  with  a  curved  needle  through  the  tissues  underneath  it,  in 
order  to  control  the  hemorrhage.     Mural  fibroids  have  also  been  removed 


1136  TREATMENT  OF  FIBROID  TUMOR,S   OF  THE  UTERUS. 

by  the  internal  route,  by  dilating  the  cervix,  splitting  the  mucous  membrane, 
and  shelling  out  the  tumor  with  the  finger  or  with  a  serrated  spoon.  The 
hemorrhage  is  apt  to  be  free,  but  can  usually  be  controlled  by  a  tampon. 
Tumors  of  considerable  size,  however,  have  been  removed  through  the 
vagina  by  morcellement,  cutting  away  small  ijieces  at  a  time,  controlling 
the  hemorrhage  meanwhile  by  the  j)ressure  of  sponges  on  handles,  or  by 
clamj)s.  It  is  necessary  to  detach  the  cervix  from  the  vagina  by  a  circular 
incision  and  then  split  it  on  both  sides  in  order  to  gain  access  to  the  cavity 
for  this  proceeding.  The  uterus  can  be  drawn  down  by  volsella  set  in  the 
lips  of  the  cervix,  and  tumors  removed  from  the  fundus  as  described.  The 
cavity  is  then  firmly  i^acked  and  the  cervix  restored  by  sutures.  Abdominal 
myomectomy  is  performed  by  laparotomy  through  a  median  incision,  the 
uterus  being  brought  outside  the  abdomen.  Some  have  advised  the  appli- 
cation of  an  elastic  band  around  the  uterine  pedicle,  but  this  is  dangerous, 
because  of  the  possibility  of  thrombosis  and  embolism.  Pedunculated 
tumors  are  treated  by  a  wedge-shaped  excision  of  the  base  of  the  pedicle, 
hemorrhage  being  controlled  by  ligatures  or  deep  sutures.  Interstitial 
tumors  require  an  incision  through  the  uterine  tissue  down  to  their 
capsule,  and  they  can  then  be  shelled  out.  Ligatures  and  deep  sutures 
arrest  the  bleeding.  Sometimes  the  uterine  canal  is  opened  during  the 
oiDcration,  therefore  it  should  always  be  given  a  preliminary  curetting,  but 
it  can  be  closed  by  sutures.  If  there  are  many  tumors,  a  number  of  incisions 
will  be  needed  for  their  removal.  After  the  myomectomy  the  uterus  is 
replaced  and  the  laparotomy  wound  closed  as  usual. 

Hysterectomy. —  Vaginal  hysterectomy  can  be  employed  for  fibroids,  and 
recently  even  large  tumors  have  been  removed  in  this  manner.  A  circular 
incision  detaches  the  cervix  from  the  vagina,  and  ttaction  with  strong- 
forceps  draws  the  uterus  downward.  The  bladder  is  detached  bluntly  and 
the  peritoneum  opened  in  front  and  posteriorly.  The  anterior  or  posterior 
wall  of  the  cervix  is  incised,  exposing  the  interior  of  the  uterus.  Small 
tumors  may  be  shelled  out  with  curette  or  finger.  Larger  ones  are  seized 
with  forceps  or  a  corkscrew-like  instrument  and  drawn  down,  and  then  they 
can  be  enucleated  with  scissors  or  knife.  Gradually  the  uterus  is  turned 
over  towards  the  part  laid  open  until  the  fundus  reaches  the  vagina.  The 
uterus  is  then  completely  split  in  two.  Up  to  this  time  the  bleeding  has 
been  controlled  by  traction  or  clamps,  but  now  the  broad  ligaments  can  be 
easily  secured  by  clamps  or  ligatures.  If  clamj^s  are  left  in  place  some 
gauze  should  be  placed  in  the  pelvis  above  their  j)oints  to  keep  them  from 
contact  with  the  bowel,  aiad  to  prevent  the  latter  from  entering  the  vagina. 
If  ligatures  are  employed  the  peritoneum  can  be  closed  as  in  ordinary 
vaginal  hysterectomy.  (See  page  1140. )  Abdominal  hysterectomy,  however, 
is  the  operation  most  frequently  performed.  The  usual  antiseptic  precau- 
tions are  to  be  taken,  and  the  uterus  should  be  thoroughly  curetted  before 
the  abdomen  is  opened,  and  gauze  packing  inserted  in  the  uterus  and 
vagina.  The  operation  may  be  done  by  a  long  median  incision,  the  length 
of  which  should  be  in  proportion  to  the  size  of  the  tumor.  The  patient  is 
put  in  the  Trendelenburg  position,  the  tumor  brought  into  the  incision,  and 
gauze  pads  packed  aroxind  it  to  hold  back  the  intestines.     The  operator 


TREATMENT  OF  FIBROID  TUMORS   OF  THE  UTERUS.  1137 

begins  at  one  side  by  tying  off  the  ovarian  artery  at  the  edge  of  the  broad 
ligament,  either  applying  double  ligatures,  or  applying  a  ligature  on  the 
proximal  side  and  a  forceps  ou  the  distal  or  tumor  side,  and  cutting  between 
them.  A  series  of  ligatures  is  thus  passed  down  to  the  base  of  the  broad 
ligament,  which  is  divided  step  by  step  as  the  ligatures  are  placed.  The 
proximal  ligatures  must  interlock  or  at  least  overlap  in  the  tissues  which 
they  include,  so  that  there  is  no  possibility  of  any  vessel  being  left  untied 
between  them.  The  vessels  of  these  large  fibroids  ai'e  very  large  and  the 
veins  very  thin-walled,  so  that  hemorrhage  is  apt  to  be  free,  and  the 
aneurism-needle  not  infrequently  passes  through  one  of  the  veins.  Having 
freed  the  tumor  upon  one  side,  the  operator  treats  the  other  in  a  similar 
way,  and  finally  reaches  and  secures  the  uterine  arteries.  In  this  last  liga- 
ture care  must  be  taken  not  to  include  the  ureter.  The  peritoneum  should 
then  be  divided  across  the  front  of  the  tumor,  and  the  bladder  dissected  off 
bluntly  and  pushed  downward  ;  the  peritoneum  is  also  incised  on  the  pos- 
terior surface  and  stripped  downward  to  separate  the  rectum.  In  this 
manner  the  upper  part  of  the  vagina  becomes  accessible  ;  the  vaginal  por- 
tion of  the  uterus  is  easily  recognized  by  the  touch,  and  the  vault  of  the 
vagina  can  be  opened  with  scissors  at  its  junction  with  the  cervix.  A  num- 
ber of  small  vessels  bleed  in  this  incision,  and  should  be  caught  with  clamps. 
The  tumor  and  uterus  are  then  taken  away.  The  vaginal  opening  is  closed 
by  sutures  ;  the  edges  of  the  divided  peritoneum  are  brought  together  and 
sutured,  all  ligatures  having  been  cut  close,  and  the  peritoneal  cavity  is 
thus  shut  off  from  the  raw  surfaces.  The  abdominal  wound  is  closed  in  the 
usual  way,  and  a  light  packing  put  in  the  vagina.  If  there  is  much  oozing, 
or  if  infection  is  feared,  the  vagina  is  not  closed,  but  the  subperitoneal  space 
is  drained  by  a  strip  of  gauze,  the  end  of  which  is  brought  out  of  the  vagina 
and  the  peritoneum  is  sutured  over  it.  The  after-treatment  of  these  cases  is 
that  of  the  ordinary  laparotomy.     (See  page  908. ) 

Formerly  a  portion  of  the  cervix  was  left,  being  secured  in  the  abdominal 
wound  by  clamps  or  needles  passed  through  it,  or  the  centre  being  excised 
in  a  wedge-shaped  manner,  and  the  two  flaps  of  the  uterine  tissue  brought 
together  and  sewed  in  place.  This  operation  is  now  seldom  used,  but  it  may 
be  employed  when  it  is  not  easy  to  reach  the  vagina,  and  differs  in  no  other 
respect  from  the  operation  described.  Kelly  has  suggested  enucleating  the 
fibroid  by  splitting  the  edge  of  the  broad  ligament,  detaching  the  peritoneum 
from  the  vessels,  and  ligating  them  in  the  loose  cellular  tissue  as  the  operator 
proceeds  downward  towards  the  cervix.  When  the  latter  has  been  reached 
it  is  divided,  the  tumor  and  the  uterus  are  rolled  upward  out  of  their  bed, 
and  the  uterine  artery  of  the  other  side  is  then  secured  with  its  branches, 
working  upward,  and  tying  the  ovarian  artery  of  that  side  last.  The  opera- 
tion should  be  begun  upon  the  side  where  the  cervix  is  most  accessible. 
This  method  is  the  easiest  one  by  which  to  attack  extraperitoneal  gro-ni;hs, 
and,  although  it  requires  more  skill,  it  undoubtedly  leaves  the  peritoneal 
surfaces  in  better  condition.  If  the  tumor  has  grown  extraperitoneally 
between  the  folds  of  the  broad  ligament  the  difficulties  of  removal  are  much 
greater.  The  large  vessels  run  irregularly  in  the  connective  tissue  to  the 
tumor,  and  there  is  more  danger  of  injuring  or  occluding  the  ureter  in  a 


1138 


MALIGNANT  TUMORS  OF  THE  UTERUS. 


ligature,  as  it  may  be  displaced  by  the  downward  growth  of  the  tumor.  lu 
such  cases  the  peritoneum  should  be  incised  high  up  near  the  fundus  of  the 
tumor,  the  latter  shelled  out,  and  the  operation  completed  extraperitoneally 
in  a  manner  similar  to  Kelly's.  In  anj^  case  it  is  of  great  assistance  to  have 
a  bougie  introduced  into  each  ureter  by  Kelly's  method  of  cystoscopy  before 
the  laparotomy  is  begun,  for  injury  to  these  ducts  is  one  of  the  chief  dangers 
of  the  operation. 

Malignant  Tumors. — Sarcoma. — Sarcoma  occurs  at  any  age,  but 
most  frequently  between  thirty  and  fifty  years  of  age,  developing  in  the 
submucous  tissue  or  in  the  uterine  wall  and  forming  tumors  of  considerable 
size,  often  pedunculated,  which  bleed  very  readily,  and  are  rather  soft  to 
the  touch,  although  some  of  these  tumors  originate  from  fibromyomata  and 
are  hard.  Sarcoma  is  more  frequent  in  the  body  than  in  the  cervix.  Car- 
cinoma is  forty  times  as  frequent  as  sarcoma.  The  first  symptom  is  profuse 
hemorrhage,  and  it  is  only  when  the  tumor  has  reached  a  considerable  size 
that  the  pain  is  troublesome.  The  diagnosis  can  seldom  be  made  sufficiently 
early  for  a  radical  cure,  but  the  uterus  should  be  extirpated  whenever  it  is 
movable  and  the  disease  appears  to  be  limited  to  the  organ.  It  is  impossible 
to  distinguish  between  sarcoma  and  carcinoma  except  by  the  microscope. 

Carcinoma.—  Carcinoma  is  found  most  commonly  in  the  cervix  as  an 
ordinary  tubular  carcinoma  originating  in  the  mucous  glands,  and  more 
rarely  as  an  epithelioma  from  the  flat  epithelium  on  the  surface  of  the 
vaginal  portion.     Scirrhus  is  very  rare  in  the  uterus. 

Symptoms. — Epithelioma  begins  as  a  superficial,  flat  induration,  which 
soon  forms  an  ulcer  and  spreads  over  the  cervix,  the  latter  often  being 

entirely  destroyed  before  its  presence  is 
appreciated.  The  surface  of  the  ulcer 
is  covered  with  brittle  granulations, 
which  break  down  easily  under  the 
finger  and  bleed  profusely.  The  ordi- 
nary carcinoma  develops  in  the  interior 
of  the  cervix  (Fig.  884)  or  at  the  fun- 
dus, and  forms  rather  large  tumors, 
often  protruding  from  the  cervix  in  a 
cauliflower  growth,  but  sometimes  re- 
maining entirely  within  the  organ  and 
simply  distending  it.  As  the  disease 
progresses  it  involves  the  entire  organ, 
attacks  the  vagina,  licnetrates  the  vesi- 
cal and  rectal  seftta,  and  sometimes 
attacks  adherent  coils  of  intestine. 
Glandular  infection  occurs  very  early.  Metastatic  deposits  are  rare,  but 
are  more  frequently  found  in  the  liver  and  lungs  than  elsewhere. 

The  first  symptom  of  carcinoma  of  the  uterus  may  be  a  more  or  less  con- 
stant discharge  of  a  foul-smelling  watery  fiuid  slightly  tinged  with  red,  or 
slight  hemorrhages  occurring  at  irregular  intervals  and  often  following- 
sexual  intercourse  or  the  use  of  a  vaginal  syringe.  The  hemorrhages  usually 
do  not  occur  until  late  in  cancer  of  the  cervix,  but  are  an  early  symptom  in 


Fig.  884. 


Cancer  of  cervix  uteri  beginning 
membrane.     (Boldt.) 


DIAGNOSIS  OF  MALIGNANT  TUMORS   OF  THE   UTERUS.  1139 

that  of  tlie  corpus.  Hemorrhages  after  the  menopause  has  been  duly  estab- 
lished are  almost  invariably  due  to  malignant  disease.  Women  should  be 
instructed  that  any  irregular  flow  or  excessive  menstruation  about  the  time 
of  the  menopause  is  a  suspicious  symptom,  and  not  "natural  to  the  change 
of  life."  Cancerous  ulcers  of  the  cervix  have  a  sharp  indurated  border,  the 
base  is  nodular  and  may  rise  above  the  surface.  When  ulceration  has  once 
set  in,  the  discharge  becomes  exceedingly  offensive,  with  a  peculiar  acrid 
odor.  In  the  later  stages  the  sufferings  of  the  patient  are  intense,  and  may 
be  uncontrollable  by  large  doses  of  morphine  ;  but  in  the  early  stages  pain 
is  usually  absent,  for  it  is  not  caused  by  the  disease  in  the  uterus,  but  by  the 
secondary  pelvic  deposits.  The  tumor  often  runs  an  extremely  latent  course, 
and  the  patient  is  iinaware  of  its  existence,  and  may  even  consider  herself 
in  perfect  health,  until  some  slight  discharge  attracts  her  attention  and  an 
examination  reveals  advanced  malignant  disease. 

Diagnosis. — Cystic  degeneration  of  Naboth's  glands  sometimes 
forms  a  hard  nodular  tumor  in  the  vaginal  portion,  but  the  mucous  mem- 
brane is  smooth,  the  translucent  cysts  appear  at  various  points,  and  ulcera- 
tion does  not  take  place.  Venereal  warts  may  make  a  considerable 
tumor,  but  their  base  is  not  indurated,  they  are  not  brittle,  and  there  is  no 
true  ulceration.  Erosions  often  surround  the  os  uteri,  but  they  have  a 
graduated  margin,  and  usually  a  soft  base,  without  true  ulceration. 
Tuberculous  ulcers  are  rare ;  they  are  not  so  indurated,  and  they  often 
have  undermined  edges,  and  bases  with  yellow  nodules.  Chancroids  should 
not  occasion  difficulty,  but  the  primary  lesion  of  syphilis  may  resemble 
malignant  disease.  Syphilis,  however,  will  usually  be  ibund  early  in  life, 
there  will  be  lesions  elsewhere,  the  induration  is  of  a  ditFerent  character, 
and  there  will  be  a  sloughing  base  instead  of  carcinomatous  granulations.  A 
carcinoma  may  distend  the  cervix  so  as  to  resemble  an  interstitial  fibroma 
when  no  external  ulceration  has  occurred.  Carcinoma  of  the  body  may 
closely  resemble  endometritis,  and  even  when  the  introduction  of  the 
sound  or  the  finger  detects  flattened  tumors  or  uneven  places  on  the  endo- 
metrium it  is  not  certain  that  they  may  not  be  iilacental  remains  after  abor- 
tion. Adenomatous  degeneration  of  the  endometrium  may  resemble  car- 
cinoma in  its  symiitoms  and  may  later  become  malignant.  On  the  other 
hand,  the  malignant  changes  in  the  endometrium  may  produce  such  slight 
alterations  that  they  cannot  be  recognized  by  the  finger.  As  a  rule,  the 
diagnosis  of  internal  carcinoma  of  the  uterus,  except  in  the  late  stages, 
requires  the  microscopic  examination  of  fragments  obtained  by  a  thorough 
curetting  of  the  entire  organ.  In  doubtful  tumors  or  ulcers  of  the  vaginal 
portion  a  piece  of  considerable  size  should  be  cut  out  of  the  suspected 
tissues  and  submitted  to  microscopic  study. 

Treatment. — Contraindications  to  Radical  Operation. — The  best 
treatment  for  cancer  is  extirpation  of  the  uterus,  although  some  believe  that 
high  amputation  of  the  cervix  is  sufficient  when  the  disease  is  limited  to 
that  ijortion  of  the  organ  and  is  not  extensive.  A  radical  care  can  be  hoped 
for  only  when  the  disease  is  entirely  limited  to  the  uterus,  as  proved  by  the 
absence  of  indurated  glands  or  cellular  tissue  in  the  pelvis,  and  by  the  fact 
that  the  uterus  is  freely  movable,  for  the  first  symptom  of  extension  of  the 


1140 


VAGINAL   HYSTERECTOMY. 


disease  is  apt  to  be  fixation  of  the  organ.  Immobility  of  tlie  uterus  caused 
by  adhesions  left  from  a  former  pelvic  peritonitis  should  not  be  confounded 
with  the  fixation  of  malignant  infiltration.  By  introducing  two  fingers  into 
the  rectum  and  the  thumb  into  the  vagina  under  anaesthesia  (Winter),  the 
very  first  signs  of  infiltration  of  the  parametrium  may  be  found  as  indura- 
tions close  to  the  cervix.  Inflammatory  masses  are  usually  larger  than  these 
indurations,  and  tumors  formed  by  inflamed  tubes  and  ovaries  lie  much 
higher  up,  with  the  soft  tissues  in  the  broad  ligament  between  them  and  the 
cervix  and  vagina.  If  the  bladder  appears  unusually  adherent,  or  the 
mucous  membrane  of  the  vagina  is  involved  near  it,  the  urethra  should  be 
dilated  and  the  interior  examined  with  the  little  finger.  Involvement  of 
the  vagina  is  less  important  than  that  of  the  parametrium,  as  the  former  can 
be  widely  extirpated  with  a  good  result. 

Vaginal  Hysterectomy. — The  usual  method  of  removing  a  uterus  for 
malignant  disease  is  by  the  vagina.  The  patient  is  placed  in  the  dorsal 
position,  and  a  perineal  retractor  is  inserted.  If  the  disease  is  within  the 
uterus  the  cavity  is  thoroughly  curetted  and  packed  with  gauze,  and  the 
cervix  may  be  closed  by  two  or  three  deep  sutures.  If  the  vaginal  portion 
is  involved  it  may  be  partly  removed,  or  covered  in  with  flaps  cut  from  the 
vaginal  wall  and  sutured  across  the  cervix.  The  operator  incises  the  vagina 
at  its  junction  with  the  anterior  surface  of  the  cervix  and  strips  the  bladder 
from  the  cervix  by  blunt  dissection,  inserting,  if  necessary,  a  sound  into  the 
bladder  in  order  to  determine  the  limits  of  the  latter.     The  posterior  fornix 

is  opened  in  the  same  way,  and  the  mucous 
Fig.  885.  membrane  is  incised  upon  the  side  of  the 

cervix.  "When  the  patient  is  antemic  some 
blood  may  be  saved  by  dividing  the  vaginal 
mucous  membrane  with  the  cautery,  or  by 
suturing  the  cut  edge  with  an  overhand 
suture  as  soon  as  it  is  divided.  (Fig.  885.) 
Douglas's  cul-de-sac  is  then  opened,  and 
under  guidance  of  the  finger  a  stout  liga- 
ture is  carried  by  a  curved  aneurism-needle 
or  ligature-passer  through  the  base  of  the 
broad  ligament  quite  close  to  the  uterus, 
and  tied.  This  is  repeated  on  the  other 
side,  and  the  tissues  between  the  ligatures 
and  the  uterus  are  then  cut  with  the  scis- 
sors and  the  organ  pulled  farther  down. 
By  a  series  of  three  or  foiu-  ligatures  on 
each  side  all  the  tissues  of  the  broad  liga^ 
The  bladder  has  ment  are  tied  o&,  the  ovaries  and  Fallo- 
pian tubes  being  drawn  into  the  wound  and 
their  vessels  included  in  the  final  ligature. 
Some  surgeons  prefer  to  invert  the  uterus  and  bring  the  fundus  out  into  the 
vagina  posteriorly,  the  cervix  then  passing  up  into  the  peritoneal  cavity,  after 
applying  the  lower  ligatures,  claiming  that  it  is  then  easier  to  secure  the 
upper  part  of  the  broad  ligament.    If  the  uterus  is  not  easily  drawn  down 


Vaginal  hystereetomj'. 
been  separated  from  the  uterus  and  the  vagi- 
nal mucous  membrane  sutured.    (Boldt.) 


ABDOMINAL  HYSTERECTOMY.  1141 

or  the  vagina  is  narrow,  a  deep  incision  should  be  made  on  each  side  of  the 
vagina,  beginning  above.  These  incisions  are  employed  by  some  in  every 
case  because  they  allow  much  better  access  to  the  parametric  tissues  and  freer 
removal  of  suspicious  parts.  That  side  of  the  uterus  which  can  be  most 
easily  reached  should  be  detached  first.  The  uterus  is  then  freed,  and  can  be 
removed.  The  wound  may  be  left  open  and  lightly  packed  with  gauze,  or 
the  peritoneal  surface  of  the  rectum  and  bladder  united  across  the  roof  of  the 
vagina,  all  stumps  being  turned  into  the  latter.  The  ligatures  are  left  long, 
and  drop  off  into  the  vagina  later.  Some  surgeons  use  clamps  instead  of 
ligatures,  those  on  the  proximal  side  being  left  in  situ  for  two  or  three  days, 
their  handles,  which  project  from  the  vagina,  being  wrapj)ed  in  gauze. 
Much  greater  speed  can  be  attained  by  the  use  of  clamps  than  by  the  use  of 
ligatures,  but  they  are  inconvenient.  All  danger  of  the  ureters  being 
included  in  the  ligatures  can  be  avoided  by  passing  catheters  into  them  by 
Kelly's  method,  in  order  to  show  their  course  and  allow  safe  dissection. 

Abdominal  Hysterectomy. — In  more  advanced  cases  the  uterus  may 
be  removed  by  an  abdominal  incision,  which  allows  more  extensive  removal 
of  the  disease,  but  the  operation  is  much  more  difficult.  An  abdominal 
incision  is  made  from  the  pubes  nearly  to  the  umbilicus,  the  patient  being 
in  the  Trendelenburg  position.  A  transverse  incision  just  above  the  pubes, 
curving  upward  parallel  to  Poupart's  ligaments,  is  more  convenient,  and  if 
properly  sutured  should  not  be  very  liable  to  hernia.  Catheters  may  be 
previously  placed  in  the  ureters.  The  ovarian  artery  is  secured  by  a  liga- 
ture at  the  edge  of  the  broad  ligament,  the  latter  is  cut  across,  and  the 
uterine  artery  is  then  sought  for,  followed  back  to  its  origin,  and  ligated 
there.  The  bladder  is  separated  from  the  uterus  in  front,  and  the  ureters 
are  found  and  dissected  out  of  the  ligaments.  The  broad  ligament  is  tied 
close  to  the  iliac  vessels  and  cut  away.  The  other  side  is  treated  in  the  same 
way,  and  then  the  vagina  is  tied  off  by  a  series  of  ligatures  and  divided. 
In  cutting  away  the  broad  ligament  at  the  iliac  vessels  the  lymphatic  glands 
of  that  region  should  be  removed.  (Clark.)  Polk  ligates  the  anterior 
branch  of  the  internal  iliac,  and  claims  that  this  gives  a  bloodless  field  of 
operation.  The  wound  is  closed  as  in  the  similar  operation  for  fibroids. 
Wertheim  begins  by  locating  the  ureters  above  the  broad  ligament  and 
dividing  the  peritoneum  over  them,  then  ligating  the  ovarian  vessels  and 
round  ligaments  separately.  He  detaches  the  bladder  from  the  uterus,  dis- 
sects out  the  ureters,  and  then  ligates  the  broad  ligaments  close  to  the  pelvis. 
I^ext  the  rectum  is  detached,  a  clamp  is  apijlied  to  the  vagina  and  the  latter 
is  divided  below  the  clamp,  and  the  uterus  lifted  out.  Finally  all  the  pelvic 
glands  are  carefully  dissected  out  up  to  the  bifurcation  of  the  aorta.  In 
some  cases  after  very  thorough  dissection  a  fistula  forms  from  sloughing  of 
the  ureter,  due  to  interference  with  its  vessels,  the  dangerous  spot  appearing 
to  be  just  posterior  to  the  uterus.  Some  surgeons  perform  hysterectomy  by 
dividing  the  u]Dper  attachments  of  the  uterus  after  ligation  of  the  vessels, 
then  close  the  abdominal  wound  and  complete  the  removal  of  the  uterus  by 
the  vagina. 

Sacral  Hysterectomy. — The  uterus  may  also  be  removed  by  the  sacral 
method,  the  pelvis  being  opened  by  partial  resection  of  the  sacrum,  as  iu 

"  73 


1142 


C.ESAEIAX   SECTION. 


Kraske's  resection  of  the  rectum,  or  by  Hochenegg's  "trap-door"  method. 
The  advantage  of  this  route  is  the  free  access  it  gives  to  the  pelvic  cellular 
tissue,  especially  posteriorly,  which  allows  removal  of  infected  glands.  The 
operation  is,  however,  difi&cult,  and  there  are  few  cases  in  which  it  presents 
any  advantage  over  vaginal  hysterectomy. 

Results  of  Hysterectomy  for  Cancer. — The  results  of  these  operations 
are  now  excellent,  the  mortality  of  the  vaginal  operation  having  come  down 
to  a  very  low  figure,  while  the  percentage  of  permanent  cures  is  constantly 
increasing.  Some  authorities  claim  as  much  as  fifty  per  cent.,  and  it  is  cer- 
tain that  twenty-five  per  cent,  of  cures  can  be  obtained  without  selection  of 
favorable  cases.  The  chances  of  cure  are  very  much  greater  in  cancer  of  the 
body  than  in  cancer  of  the  cervix,  because  the  parametrium  is  involved 
earlier  in  the  latter. 

Incurable  Cases. — Extirpation  should  be  strictly  limited,  however,  to 
those  cases  in  which  there  is  a  chance  of  radical  cure,  although  the  excessive 
hemorrhage  and  foul  discharge  of  incurable  cases  may  be  lessened  by  a  thor- 
ough curetting  of  the  diseased  parts.  Application  of  live  steam  (Pinkus) 
will  arrest  hemorrhage  after  curetting  and  will  have  a  partial  caustic  effect. 
The  thermo-cautery,  or  cauterization  by  chloride  of  zinc,  may  be  used  to 
remove  these  tissues.  The  difficulty  with  the  method  of  cauterization  is 
that  the  limits  of  the  operation  are  less  easily  defined  and  there  is  more 
risk  of  injiu'ing  the  bladder  and  rectum.  Life  is  sometimes  much  prolonged 
by  these  means. 

High  Amputation  of  the  Cervix. — In  epithelioma  involving  only  the 
lower  portion  of  the  cervix  and  of  small  size,  it  is  possible  that  high  ampu- 
tation of  the  cervix  may  effect  a  cure, 
and  the  operation  is  sim^jler  than  entire 
removal  of  the  organ.  The  first  steps 
in  the  operation  are  similar  to  those  de- 
scribed for  vaginal  extirjjation,  but  when 
the  level  of  the  internal  os  is  reached  all 
that  part  of  the  uterus  below  it  is  removed 
with  the  scissors,  the  line  of  dissection 
being  made  conical,  and  reaching  higher 
up  at  the  level  of  the  uterine  canal  than 
on  the  external  surface  of  the  organ.  The 
entire  operation  may  be  performed  with- 
out ligatiu'es  by  the  thermo-cautery-knife. 
(Byrne.)  (Fig.  886.)  This  operation 
should  be  limited  to  the  very  mildest 
cases  of  superficial  epithelioma  seen  very 
early,  for  it  is  dangerous  to  leave  a  part  of  a  carcinomatous  uterus.  The 
tumor  shown  in  the  cut  is  extensive  and  not  suited  for  this  operation,  but 
the  cut  is  intended  to  show  the  line  of  section  and  the  relations  of  the  bladder 

and  rectum. 

CJiSAEIAN   SECTION. 

The  Csesarean  section  is  the  opening  of  the  uterus  through  an  abdominal 
ncision  at  term  in  order  to  remove  a  child  which  cannot  be  delivered 


Amputation  of  cervix  with  cautery-knife. 
The  dotted  lines  show  the  conical  excision  at 
various  levels.    (Boldt.) ' 


SALPINGITIS.  1143 

normally.  The  incision  is  made  in  the  median  line  from  the  pubes  to  the 
umbilicus,  and  the  uterus  is  brought  out  of  the  wound,  the  latter  being 
partly  closed  by  temporary  sutures  or  clamps.  Towels  are  laid  around  the 
utei'us,  and  a  rubber  ligature  is  placed  around  the  neck  and  the  ends  held 
by  an  assistant.  The  organ  is  incised  in  front  in  the  middle  line  while 
auother  assistant  compresses  it  laterally.  The  incision  should  be  large 
enough  to  deliver  the  child,  and  may  extend  downward  to  the  middle  of 
the  lower  third  of  the  uterus,  but  it  should  not  open  the  cavity,  being 
carried  down  only  to  the  membranes  at  first.  The  placenta  may  be  incised 
if  it  is  in  the  way.  The  membranes  are  then  opened,  and  the  child 
delivered  and  handed  to  an  assistant  after  clamping  and  dividing  the  cord. 
The  placenta  is  then  removed,  aud  uterine  contraction  stimulated  with  hot 
towels  or  the  faradic  current  directly  applied  by  sterilized  gauze  electrodes, 
the  rubber  ligature  being  loosened  at  the  same  time.  If  contraction  sets 
in,  the  wound  may  be  closed  by  sutures,  the  first  tier  including  the  entire 
thickness  of  the  uterine  wall  except  the  endometrium,  and  the  second 
tier  being  passed  as  Lembert  sutures.  The  abdominal  wound  is  raiiidly 
closed.  If  uterine  contraction  cannot  be  brought  about,  the  uterus  should 
be  removed.  Hysterectomy  is  also  indicated  when  Ciesarean  section  is 
performed  for  the  deformity  of  osteomalacia,  because  that  disease  improves 
after  removal  of  the  uterus.  It  is  also  advisable  if  septic  infection  is  feared, 
and  sometimes  when  the  uterus  is  the  seat  of  malignant  disease.  In  cases 
of  irremediable  obstruction  of  the  parturient  canal  by  deformity  or  other- 
.wise,  the  woman  should  be  given  the  choice  whether  she  will  have  the  organ 
removed  or  run  the  chance  of  a  subsequent  imjiregnation.  Oophorectomy 
might  also  be  considered  in  such  cases.  If  hysterectomy  is  decided  upon, 
it  should  be  comfdeted  in  the  most  rapid  way,  transfixing  the  pedicle  with 
pins  above  the  rubber  ligature  which  is  left  in  place,  and  securing  it  extra- 
peritoneally  in  the  lower  angle  of  the  wound.  If  the  mother  is  in  good 
condition,  the  intraperitoneal  method  may  be  emi^loyed,  as  in  an  operation 
for  fibroids,  or  the  edges  of  the  stump  may  be  inverted  through  the  soft  and 
dilatable  cervix  into  the  vagina  after  hemorrhage  has  been  controlled  by 
ligating  the  ovarian  arteries  at  the  edge  of  the  broad  ligament  and  securing 
the  uterine  vessels  by  tying  the  anterior  branches  of  the  internal  iliacs  on 
both  sides.  (Polk.)  The  results  of  the  Cfesarian  oi^eration  are  now  excel- 
lent, only  one-tenth  of  the  mothers  dying,  and  less  than  that  number  of  the 
children. 

DISEASES  OF  THE  TUBES  AND  OVAEIES. 

Salpingitis. — The  majority  of  the  diseases  of  the  Fallopian  tubes  are 
due  to  inflammations  from  gonorrhoeal  or  septic  infection,  the  latter  occur- 
ring after  labor,  or  from  the  introduction  of  septic  instruments  into  the  uterus. 
A  purulent  salpingitis  may  run  a  chronic  course  of  a  catarrhal  type,  simply 
thickening  the  walls  of  the  tubes  and  causing  the  formation  of  adhesions 
about  them,  the  tubes  remaining  patent  and  draining  into  the  uterus,  and 
a  jjurulent  endometritis  being  associated  with  the  tubal  disease.  More  com- 
monly, the  connection  with  the  uterus  is  obstructed,  although  the  uterine 
end  is  never  completely  closed,  and  the  tube  is  distended  by  the  accumulating 
purulent  secretion.     The  open  end  of  the  tube  at  the  fimbriated  extremity 


1144  PYOSALPINX. 

is  closed  very  early  by  adhesions,  and  the  result  is  a  pus-sac  formed  by  the 
distended  and  usually  convoluted  walls  of  the  tube  which  are  firmly  adherent 
to  all  the  parts  about  it,  and  especially  to  the  ovary, — pyosalpinx.  In 
milder  cases  the  disease  may  not  ijrogress  so  far  as  to  produce  a  pus-sac,  but 
may  cause  obliteration  of  the  uterine  extremity  of  the  tube,  and  then  blood 
and  serum  may  collect  in  the  latter.  In  the  former  case  we  have  haemato- 
salpinx,  in  the  latter  hydrosalpinx.  The  inflammation  may  involve  the 
ovary  also,  forming  an  abscess  the  cavity  of  which  may  communicate  with 
that  of  the  tube.  These  tubo-ovarian  inflammatory  cysts  may  also  originate 
from  the  union  of  a  pyosalpinx  or  hydrosalpinx  with  an  ovary  already  in  a 
cystic  condition.  The  connection  between  the  two  may  be  the  orifice  of  the 
tube  or  an  abnormal  lateral  opening.  In  connection  with  inflammation  of 
the  tubes,  abscesses  are  occasionally  found  in  the  pelvis  developing  in  the 
peritoneal  cavity  or  in  the  cellular  tissue,  or  involving  the  ovary.  Occa- 
sionally these  abscesses  discharge  externally  beneath  Poupart's  ligament,  or 
pass  out  through  the  obturator  or  sciatic  foramina,  but  more  frequently  they 
burst  into  the  vagina,  the  rectum,  or  the  bladder. 

Pyosalpinx. — Symptoms. — A  patient  with  salpingitis,  even  of  the 
mildest  type,  is  liable  to  attacks  of  local  peritonitis,  especially  at  the  time 
of  the  menstrual  flow,  and  may  have  constant  j)ain,  increased  by  motion, 
sexual  intercourse,  micturition,  and  defecation,  and  sometimes  shooting- 
down  the  lower  extremities  owing  to  the  pressure  on  the  nerves.  There 
may  also  be  frequent  micturition  and  constipation  from  pressure  on  the 
bladder  and  rectum,  often  associated  with  a  slight  septic  condition,  as 
shown  by  anaemia  and  an  irregular  rise  of  temperature.  The  temperature, 
however,  is  a  very  uncertain  guide  to  the  presence  of  pus  in  these  cases,  for 
even  when  there  is  a  large  amount  of  pus  the  temperature  may  be  perfectly 
normal.  There  are  various  disturbances  of  menstruation,  such  as  men- 
orrhagia,  dysmenorrhcea,  and  too  frequent  menstruation,  or  if  anaemia  is 
present  the  flow  will  be  scanty  and  infrequent.  Leucorrhcea  is  the  rule, 
and  pressure  upon  the  appendages  and  uterus  may  cause  a  slight  bloody, 
purulent  discharge  from  the  latter.  The  patient  is  generally  but  not  invari- 
ably sterile.  Pelvic  examination  shows  the  uterus  more  or  less  fixed,  often 
retroverted,  and  i)ain  is  caused  by  attempts  at  motion.  Indurated  masses 
are  felt  on  one  or  both  sides  and  perhaps  in  Douglas's  cul-de-sac,  which  are 
immovable  and  usually  tender.  All  the  pelvic  organs  may  be  fiLsed  into  one 
mass,  so  that  nothing  can  be  distinguished,  and  the  position  of  the  uterus 
can  be  determined  only  by  the  passage  of  the  sound.  Pyosalpinx  may  com- 
plicate fibromyoma  or  cancer  of  the  uterus,  and  is  sometimes  caused  by 
infection  from  a  sloughing  tumor. 

Prognosis. — A  mild  salpingitis  usually  resolves,  but  adhesions  are  apt 
to  remain  and  cripijle  the  tubal  and  ovarian  functions  in  some  degree. 
Severe  cases  may  end  in  a  general  peritonitis,  abscess,  or  pyosalpinx,  but 
more  frequently  they  quiet  down  into  the  chronic  form,  which  does  not 
threaten  life,  although  it  renders  the  patients  more  or  less  invalids  and  sub- 
ject to  acute  exacerbations  caused  by  exposure  to  cold  during  menstruation, 
by  overwork,  or  by  excessive,  sexual  intercourse.  General  peritonitis  from 
salpingitis  is  rarely  fatal,  usually  becoming  localized  and  forming  an  abscess. 


TREATMENT  OF  PYOSALPINX.  1145 

Treatment. — Choice  of  Treatment. — The  treatment  of  chronic  sal- 
pingitis will  depend  upon  the  severity  of  the  symptoms.  Sometimes 
treatment  directed  to  the  accompanying  endometritis  will  be  sufficient. 
Operations  should  be  limited  to  cases  which  prove  obstinate  under  thorough 
general  and  local  treatment,  and  the  operations  themselves  should  be  as 
conservative  as  possible.  A  very  acute  salpingitis,  with  acute  peritoneal 
infection,  as  shown  by  great  tenderness  and  high  temperature,  should  be 
treated  by  cold  or  hot  applications  externally,  very  hot  vaginal  douches, 
rest  in  bed,  oiiium,  and  laxatives,  and  operation  should  be  delayed  until 
the  acute  sym^jtoms  have  passed,  for  fear  of  exciting  a  general  peritonitis 
by  separating  the  adhesions.  Should  signs  of  general  peritonitis  or  acute 
sepsis  make  their  apj)earance,  however,  the  surgeon  will  be  forced  to  operate 
in  spite  of  the  danger  of  interference.  The  diagnosis  of  these  cases  from 
appendicitis  may  be  very  difficult.     (See  Appendicitis,  page  946.) 

Removal  of  the  Tubes. — When  pyosalpinx  forms,  extirpation  of  the 
affected  tube  and  corresponding  ovary  is  the  best  method  of  treatment. 
Vaginal  incision  and  drainage  of  the  sac  is  sometimes  useful  when  the 
patient  is  too  feeble  for  the  more  serious  operation,  but  it  seldom  produces 
a  lasting  cure.  In  cases  of  chronic  catarrhal  salpingitis  marked  by  a  thick- 
ening of  the  walls  and  adhesions,  without  the  formation  of  a  pus-sac,  if  the 
changes  have  not  progressed  too  far  a  cure  can  sometimes  be  obtained  by 
simply  freeing  the  adhesions,  but  in  advanced  cases  extirpation  alone  gives 
permanent  relief. 

The  tubes  and  ovaries  may  be  removed  by  a  laparotomy  in  the  median 
line,  care  being  taken  to  pack  back  the  intestines  with  pads  or  sponges,  so 
that  there  can  be  no  possibility  of  infection  from  the  fluid  which  is  likely 
to  be  discharged  from  the  tubes  by  their  rupture  during  the  operation.  The 
size  of  the  laparotomy  incision  is  immaterial ;  easy  cases  may  be  completed 
by  an  incision  which  will  admit  only  two  fingers,  but  the  difficult  ones  may 
necessitate  an  opening  extending  nearly  to  the  umbilicus,  in  order  to 
deal  with  the  complicated  conditions  with  due  regard  to  the  safety  of  the 
patient.  The  Trendelenburg  position  is  invaluable  in  difficult  cases,  but 
it  is  dangerous  if  large  amounts  of  infectious  fluid  are  evacuated,  no  matter 
how  carefully  the  pelvis  is  surrounded  by  sponges.  It  is  our  custom  to 
begin  the  separation  of  adhesions  without  it  until  the  fluid  has  been  removed, 
and  if,  having  raised  the  pelvis,  we  are  sur^jrised  later  in  the  operation  by  a 
sudden  outburst  of  fluid,  the  pelvis  is  lowered  at  once.  The  irrigation  also 
must  not  be  undertaken  until  the  pelvis  has  been  lowered. 

The  surgeon  first  separates  the  adhesions  around  the  affected  tube,  one 
ovary  and  tube  usually  being  found  in  the  cul-de-sac  and  the  other  higher 
up  in  the  pelvis.  The  strength  of  the  adhesions  is  tested,  and  those  which 
are  not  too  strong  are  broken  down  with  the  fingers,  but  the  strong  adhesions 
must  be  divided  with  the  scissors  or  knife  under  the  guidance  of  the  eye, 
for  fear  of  injury  to  other  parts.  Bleeding  vessels  are  secm-ed  by  clamps 
and  tied,  and  vascular  adhesions  may  be  tied  before  they  are  divided.  The 
separation  of  the  adhesions  should  be  begun  at  the  fundus  of  the  uterus,  if 
this  can  be  found,  and  the  finger  gradually  worked  down  to  Douglas's  cul- 
de-sac  and  then  curved  upward,  foUo-nang  around  the  border  of  the  mass. 


1146  HYDROSALPINX. 

When  the  diseased  tube  and  ovary  hare  been  freely  separated  they  may  be 
ligated  en  masse,  like  a  tumor,  the  broad  ligament  and  tube  forming  the 
pedicle  and  the  ligature  placed  close  to  the  uterus.  The  pedicle  is  then 
divided.  It  is  preferable,  however,  to  tie  the  ovarian  vessels  separately  at 
the  outer  part  of  the  broad  ligament,  and  then  the  ovary  can  be  partly 
detached  and  the  size  of  the  pedicle  reduced.  Some  surgeons  prefer  not  to 
ligate  the  tube  itself,  but  to  isolate  it  after  tying  the  ovarian  vessels  and 
applying  ligatures  to  all  bleeding  points,  and  then  to  make  a  wedge-shaped 
excision  of  the  uterine  end,  closing  the  little  wound  in  the  uterus  with  a 
suture.  When  pus  escapes  from  the  tubes  and  when  the  infection  is  recent 
and  an  active  peritonitis  is  going  on,  irrigation  and  drainage  must  be 
employed.  If  pus  escapes,  it  should  be  sponged  out  at  once  and  the  cavity 
irrigated. 

Pyosalpinx  tumors  may  also  be  removed  by  the  vagina,  the  fingers  being 
inserted  through  an  incision  into  Douglas's  cul-de-sac,  the  adhesions  broken 
down,  and  the  tubes  and  ovaries  brought  into  the  vagina,  where  they  are 
ligated  and  cut  away.  In  very  bad  cases  vaginal  hysterectomy  is  wise,  and 
the  uterus  should  be  removed  first,  when  the  tubes  will  be  more  easily 
reached.  The  uterus  may  be  found  high  \i])  and  difficult  of  access,  and  in 
such  cases  it  is  removed  by  morcellement,  clamping  the  lateral  attachments 
as  the  organ  is  cut  away.  Removal  of  the  uterus,  however,  should  be  limited 
to  the  very  severest  cases  of  pyosalpinx,  with  complete  functional  destruc- 
tion of  the  pelvic  organs,  as  cures  can  undoubtedly  be  obtained  without 
resorting  to  that  extreme  measure  in  ordinary  cases. 

Hydrosalpinx. — The  bacteria  in  a  pyosalpinx  may  die  and  the  pus- 
cells  disappear,  leaving  a  sterile,  straw-colored  fluid  in  the  distended  tube. 
This  condition  is  known  as  hydrosalpinx.  It  is  also  possible  that  the 
orifices  of  a  tube  with  catarrhal  inflammation  may  become  occluded  and  the 
cavity  become  distended  with  the  secretion,  the  mucous  membrane  being 
atrophied  and  the  contents  of  the  tube  serous.  This  form  of  disease  is 
generally  unilateral,  and  occurs  in  young  women.  The  symptoms  of  hydro- 
salpinx are  those  of  a  tumor  in  the  pelvis,  pressing  upon  the  surrounding 
organs,  displacing  the  uterus  and  sometimes  causing  xsaiu  and  febrile  symp- 
toms by  the  tension  of  the  sac  at  the  menstrual  period.  Treatment. — 
A  cure  may  be  obtained  by  simple  drainage  of  the  sac  after  suturing  it  to 
the  abdominal  wall ;  but  this  results  in  a  fistula  with  an  annoying  discharge 
of  blood  at  the  menses,  and  complete  removal  of  the  tube  is  preferable. 

Haematosalpinx. — The  tube  may  be  distended  with  blood  as  the  result 
of  an  extra-uterine  pregnancy,  or,  rarely,  from  hemorrhagic  inflammation, 
or  retained  menstrual  blood  when  there  is  obstruction  to  the  genital  passages. 
The  symptoms  of  haematosalpinx  are  those  of  ectoi^ic  gestation  or  simply 
those  of  hydrosalpinx.  Treatment. — The  tube  should  be  removed  by 
abdominal  or  vaginal  operation. 

Tumors  of  the  Tubes. — Adenoma  of  a  pai^illomatous  type  and  cancer 
may  affect  the  Fallopian  tubes  primarily,  but  are  uncommon.  The  tubes 
may  be  involved  in  cancer  spreading  from  neighboring  organs. 

Conservative  Surgery  of  the  Ovary. — Attempts  have  been  made  of 
late  years  to  preserve  portions  of  the  ovaries  in  order  to  avoid  the  disagree- 


TUMOES   OF  THE  OVARY. 


1147 


able  symptoms  generally  produced  by  their  early  removal  for  salpingitis  or 
tumors.  Healtliy  ovaries  should  be  spared  in  hysterectomy  unless  for  cancer. 
After  removal  of  dermoid  or  parovarian  cysts  portions  of  the  ovary  may  be 
left  if  they  seem  healthy,  as  these  tumors  affect  only  one  part  of  the  ovary. 
Ovaries  with  moderate  development  of  cystic  follicles  may  be  treated  by 
incision,  curetting  the  follicles,  and  sutxire.  The  ovary  may  be  split  in  half 
down  to  the  hilum  without  permanent  injury.  When  the  tubes  are  removed 
for  salpingitis  the  ovary  may  be  left  if  healthy,  but  there  is  some  risk  in  so 
doing,  because  inflammation  is  very  apt  to  develop  later,  necessitating  a 
second  operation.  Attempts  at  transplantation  of  ovarian  tissue  have  also 
been  made  with  fair  success.  The  ovary  has  been  transplanted  to  various 
places,  such  as  the  subcutaneous  tissue  and  the  cavity  of  the  uterus  ;  and  in 
the  lower  animals  an  ovary  from  another  individual  has  also  been  trans- 
planted. The  permanent  value  of  such  grafting  is  doubtful,  for  the  trans- 
planted gland  tends  to  atrophy. 

Ovarian  Abscess. — Inflammation  of  the  ovary  resulting  in  abscess  is 
usually  found  in  connection  with  salpingitis,  but  in  rare  cases  it  occurs  inde- 
pendently. In  the  latter  cases  a  tumor  is  found  upon  one  side  of  the  uterus, 
usually  globular  in  shape,  with  a  fairly  distinct  outline,  and  there  is  a 
previous  history  of  pain  in  the  back  and  j^elvic  distress,  with  the  symptoms 
of  pressure  upon  the  bladder  or  rectum.  A  rise  of  temperature  may  be 
found  in  these  cases.     The  treatment  is  similar  to  that  for  pyosalpinx. 

Tumors  of  the  Ovary. — Pathology. — Tumors  of  the  ovary  are 
most  fi'equently  cystic,  and  their  origin  can  best  be  understood  by  reference 
to  the  accompanying  diagram  of  Doran.  (Fig.  887. )  They  may  arise  from 
the  oophoron,  as  the  ac- 
tive part  of  the  ovary  is  Fig.  887. 
termed,  or  from  the  paro- 
ophoron, as  the  hilum  is 
called.  With  the  ovaiian 
tumors  are  to  be  consid- 
ered tumors  arising  from 
the  parovarium,  and  in 
the  broad  ligament  inde- 
pendent of  that  organ. 
The  practically  important 
tumors  of  the  ovary  are 
as  follows :  (1)  Follicu- 
lar Cysts. — The  sinixjlest 
form  of  ovarian  cyst  is 
the  dilated  Graafian  fol- 
licle. These  tumors  are 
unilocular,  and  contain  a 
single  cavity,  with  very 
thin  walls,  filled  with  se- 
rous fluid.    They  are   of 

small  size,  rarely  reaching  the  size  of  an  English  walnut,  and  of  no  clinical 
significance.     When  associated  with  hydrosalpinx  the  distended  tube  may 


Diagram  showmsf  the  oiis:iii  of  tumois  of  the  o\ary  and  broad 
ligament :  J,  paiench\  m  i  of  o\  ar's  1 1  glandulai  multilocular  cyst : 
;?,  hilum  :  5,  papillomatous  c"\'^t  h  c\  st  of  broad  luriment;  5,  similar 
cyst  above  and  not  connected  with  FiUopiin  tube  6  similar  cyst 
close  to  7,  ovarian  fimbria  of  tube ;  5,  h>  datid  of  Morgagni ;  9,  cyst 
from  horizontal  tube  of  JO,  parovarium  ;  11,  cyst  from  vertical  tube 
of  same  ;  1-2,  duct  of  Gartner,  traversing  uterine  wall  at  13.    (Doran. ) 


1148 


TUMORS   OF  THE  OVARY. 


Multilocular  cyst. 


Fig.  SS9. 


become  agglutinated  to  the  ovary,  and  tlie  cyst  in  the  latter  may  connect 
with  the  cavity  of  the  distended  tube,  a  condition  known  as  a  tubo-ovarian 
cyst.     (2)  Multilocular  Cysts. — The  larger  cysts  of  the  oophoron  do  not 

develop  from  these  small  cysts, 
but  originate  independently  from 
the  germinal  ei)ithelium,  forming 
multilocular  cysts,  which  may 
attain  an  immense  size,  furnish- 
ing the  largest  of  these  tumors. 
There  may  be  a  large  amount  of 
solid  adenomatous  growth  in  the 
walls  of  the  cyst,  usually  with 
secondary  cystic  degeneration. 
(Fig.  888.)  The  external  wall  of 
these  cysts  is  white,  but  where 
it  is  very  thin  it  allows  the  dark- 
green  or  brown  color  of  the  con- 
tents to  shine  through.  These  cysts  grow  first  upon  one  side,  but  assume 
the  median  position  as  they  rise  out  of  the  true  pelvis,  and  may  extend  up 
to  the  ensiform  cartilage  and  contain  many  quarts  of  fluid.  They  are  found 
at  any  period  of  life.  (3)  Cysts  of  the 
Paroophoron. — Cysts  with  papilloma- 
tous growths  on  the  interior  surface  of 
their  wall  may  be  single  or  multilocular, 
and  originate  from  the  remains  of  the 
parovarium  in  the  hilum  of  the  ovary. 
(Fig.  889.)  The  cysts  generally  grow  in 
the  substance  of  the  broad  ligament,  and 
can  hardly  be  distinguished  from  cysts 
of  the  parovarium  itself  These  cysts 
are  usually  bilateral.  (4)  Parovarian 
Cysts. — The  parovarian  cysts  are  luii- 
locular,  and  are  filled  with  clear  serum 
or  contain  ]3apillomatous  growths.  They 
may  attain  a  large  size.  They  are  easily 
shelled  out  of  the  ligament,  and  the  Fal- 
lopian tube  is  found  on  the  upjjer  surface 
of  the  ovary  at  one  side.  They  usually 
come  to  operation  between  the  sixteenth 
and  twenty-fifth  years  of  the  patient's 
age.  The  papillomatous  growths  of  both 
varieties  of  proliferating  cysts  may  ijer- 
forate  the  capsule,  and  small  portions 
may  be  transplanted,  being  carried  into 
different  j)arts  of  the  j)eritoneum,  where 
they  become  fixed  and  grow.  They  even  invade  the  blood-vessels,  and  are 
transferred  to  distant  parts  of  the  body,  giving  rise  to  metastatic  growths 
in  the  lungs.    True  malignant  degeneration  is  also  frequent  in  these  tumors,. 


Papillomatous  ovarian  cyst.    (Coe.) 


TUMORS   OF  TPIE   OVARY. 


1149 


Dermoid  cyst.     (Coe.) 


an  irregular  epithelial  growth  begimiing  in  the  papillomatous  parts  and 
involving  the  entire  cyst,  or  only  a  portion  of  it.  In  such  cases  it  acquires 
all  the  chai-acteristics  of  carcinoma.  Adenomatous  growth  is  also  frequent 
in  the  iiapillomatous  cysts,  producing  a  structure  more  nearly  resembling 
a  normal  ovary.  (5)  Der- 
moid cysts  (Fig.  890)  are 
common  ill  the  ovary,  and 
it  is  probable  that  they  are 
not  due  to  the  turning  in 
of  epithelial  structures  fi'om 
the  sui-face  of  the  body,  but 
arise  from  the  ovarian  cells. 
The  germinal  cells  of  the 
ovary  apparently  have  the 
power  of  producing  the 
three  layers  of  the  ovum 
(epiblast,  hypoblast,  and 
mesoblast)  even  without 
fecundation,  and  tissues  rep- 
resenting all  of  these  layers  are  found  in  the  ovarian  dermoids.  The  same 
peculiarity  exists  in  dermoid  tumors  of  the  testicle.  (6)  Solid  tumors  of 
the  ovary  are  uncommon.  They  may  be  benign",  such  as  fibroma  or  ade- 
noma.    Very  rarely  warty  growths  are  found  covering  the  external  surface 

of  the  organ.     (Fig.  891.)     Sarcoma 
^^^'-  ^^^-  and  carcinoma  are  not  uncommon  ; 

epithelioma  is  also  found.  These 
tumors  rarely  attain  a  large  size,  sel- 
dom- being  six  inches  in  diameter. 
Usually  they  are  globular,  with  a 
rather  smooth  surface.  Solid  tu- 
mors of  the  broad  ligaments 
occur  rarely.  Myofibroma,  devel- 
oping from  the  unstrix^ed  muscular 
fibres  of  the  ligaments,  and  lipoma 
are  found.  Secondary  malignant 
growths  are  common  in  the  broad 
ligament,  develoj)ing  from  the 
lymphatics  in  the  neighborhood. 

Course. — Tumors  growing  from 
the  ovary  usually  develoji  from  its 
free  surface  and  extend  directly  into 
the  peritoneal  cavity,  but  they  may 
enlarge  in  the  opposite  direction 
between  the  folds  of  the  broad  liga- 
ment, and  thus  become  almost  entirely  extraperitoneal  tumors.  The  paro- 
varian cysts  develop  between  the  folds  of  the  broad  ligament,  the  peritoneum 
over  them  usually  not  being  adherent ;  but  the  ovarian  cysts  which  develop 
from  the  hilum  may  also  penetrate  the  broad  ligament.    As  the  tumor  grows 


Papilloma  of  ovary.    (Cleveland.) 


1150  TUMORS   OF  THE  OVARY. 

upward  in  the  peritoneal  cavity  it  presses  upon  different  organs,  and  forms 
adhesions  with  them  or  with  the  parietal  peritoneum.  Occasionally,  how- 
ever, the  tumor  does  not  form  adhesions,  even  when  it  is  of  large  size  and  long- 
duration.  When  both  ovaries  are  cystic  the  two  cysts  may  become  adherent, 
and  an  opening  may  form  between  their  cavities,  so  that  the  cyst  will  appear 
to  be  a  single  cyst  with  two  ijedicles.  As  the  tumor  grows  outward  towards 
the  peritoneal  cavity  the  hilum  of  the  ovary  is  not  much  altered,  and  as  the 
vessels  enter  the  tumor  through  the  hilum  the  latter  forms  the  pedicle.  The 
pedicle  varies  in  size  and  shaj)e,  usually  being  somewhat  flattened,  and  a 
couple  of  inches  in  breadth  by  half  an  inch  iu  thickness ;  but  in  some 
cases  it  becomes  immensely  elongated,  and  the  tumor  may  be  rotated  upon 
its  pedicle,  the  latter  being  twisted  so  severely  as  to  cut  off  the  circulation 
and  cause  gangrene.  The  symptoms  of  this  condition  resemble  those  of 
acute  peritonitis  or  intestinal  obstruction,  the  patient  falling  into  a  con- 
dition of  shock,  with  subnormal  temperature,  vomiting,  which  may  become 
fecal,  and  absolute  constipation,  with  great  abdominal  pain.  Occasionally 
the  twisting  takes  place  slowly,  the  pedicle  is  torn  through,  but  in  the 
majority  of  cases  the  tumor  has  already  formed  strong  adhesions  to  the 
parietal  peritoneum  or  to  the  viscera,  and  its  vitality  is  preserved  by  the 
vessels  derived  from  those  sources.  Cysts  may  therefore  be  found  attached 
only  to  the  upper  part  of  the  abdomen  which  really  had  their  origin  in  the 
pelvis,  but  have  lost  all  trace  of  connection  with  that  part.  Ovarian  cysts 
may  rupture  spontaneously  or  as  the  result  of  injury,  causing  severe  shock, 
hemorrhage,  peritonitis,  or  the  diffusion  of  papillomatous  growths  in  the 
abdominal  cavity.  Sometimes  repeated  ruptures  have  been  noted,  each 
marked  by  attacks  of  peritonitis.  An  ovarian  cyst  may  become  infected 
and  suppurate,  the  infection  probably  taking  place  through  an  adherent 
loop  of  bowel.  In  such  an  event  the  symptoms  are  those  of  an  acute  abscess, 
which  may  burst  either  externally  or,  more  commonly,  into  some  of  the 
hollow  organs.  A  cure  may  result  under  these  circumstances,  although  it 
is  rare.     Dermoid  cysts  are  especially  liable  to  suppuration. 

Symptoms. — The  symptoms  of  ovarian  and  broad  ligament  tumors 
depend  upon  their  size,  consistency,  and  situation.  The  tumors  are 
unnoticed  until  they  attain  a  considerable  size,  unless  they  are  accidentally 
discovered  by  the  i^hysician  in  a  pelvic  examination.  When  small  they 
excite  very  few  symptoms  unless  they  become  impacted  in  the  lower  part 
of  the  pelvis  and  displace  the  uterus  or  press  ujion  other  organs.  The  solid 
tumors  are  more  likely  to  occasion  symptoms,  even  when  they  are  of  small 
size,  owing  to  their  greater  weight  and  consistency  and  their  tendency  to 
develop  downward  and  iinder  the  peritoneum  rather  than  to  grow  upward. 
When  the  tumor  is  large  it  interferes  with  the  functions  of  the  abdominal 
viscera,  and  the  patient  becomes  cachectic  and  ausemic,  the  face  assuming  a 
peculiar,  anxious  expression  in  advanced  cases.  The  ureters  may  be  com- 
l^ressed  and  hydrouei^hrosis  or  pyonephrosis  develop,  or  intestinal  obstruc- 
tion may  be  caused  bj'  pressure  on  the  bowel.  The  cyst  may  be  so  large  as 
to  embarrass  respiration,  and  the  interference  with  digestion  may  be  so  great 
that  the  patient  is  reduced  to  extreme  emaciation.  While  ovarian  cysts  are 
most  common  in  early  adult  life,  they  may  be  found  at  any  time  from  infancy 


DIAGNOSIS  OF  OVARIAN  TUMORS.  1151 

to  old  age.  Owing  to  their  slow  growth,  dermoid  cysts  often  fail  to  be 
recognized  until  after  middle  life.  Their  presence  does  not  always  prevent 
pregnancy  or  interfere  with  its  comi^letion,  and  as  a  healthy  Graafian  follicle 
has  been  seen  in  the  walls  of  such  cysts,  pregnancy  is  possible  even  when 
both  ovaries  are  cystic.  But  these  cysts  are  always  a  dangerous  compli- 
cation of  pregnancy.  The  cysts  ai-e  frequently  bilateral,  but,  as  a  rule,  one 
ovary  is  fairly  healthy.  The  menstrual  function  is  usually  unaltered, 
although  some  tumors  cause  meuorrhagia,  and  the  menses  gradually  cease 
as  the  cachexia  develops.  The  symptoms  of  twisted  pedicle,  rupture,  and 
suppuration  have  been  given  above. 

Diagnosis. — Physical  Examination. — An  ovarian  tumor  while  it  is 
small  usually  lies  in  Douglas's  cul-de-sac.  It  is  frequently  movable,  and  is 
hard  or  cystic  to  the  touch  according  as  it  is  solid  or  fluid,  the  dermoid  cysts 
having  a  peculiar  doughy  consistency.  Dermoid  cysts  are  usually  very  firm 
and  round  in  outline.  It  is  difficult  in  this  stage  to  demonstrate  the  attach- 
ment of  the  tumor  to  the  uterus,  but  it  is  usually  possible  to  determine 
which  is  the  diseased  ovary  by  the  detection  of  the  normal  ovary  and  tube 
upon  the  other  side.  The  uterus  will  be  felt  in  front  of  the  tumor  or  slightly 
to  one  side.  The  fingers  can  usually  be  passed  between  the  fundus  of  the 
uterus  and  the  tumor,  unless  the  latter  has  developed  in  the  folds  of  the 
broad  ligament  and  gained  its  position  behind  the  uterus  by  stripijing  up 
the  peritoneum  from  that  organ,  in  which  case  it  will  be  impossible  to 
execute  this  manoeuvre.  Tumors  of  the  broad  ligament  fix  the  uterus  com- 
pletely and  displace  it  towards  the  opposite  side.  The  diagnosis  of  tumors 
of  this  kind  from  subperitoneal  fibroid  tumors  of  the  uterus  may  be  very 
difficult,  and  they  may  also  be  mistaken  for  the  retroflexed  pregnant  uterus. 
As  the  tumor  enlarges,  it  rises  out  of  the  pelvis,  and  at  this  stage  its  con- 
nection to  one  horn  of  the  uterus  by  a  pedicle  can  generally  be  demonstrated, 
especially  if  the  uterus  is  well  drawn  down  by  an  assistant  with  a  volsellum 
fixed  in  the  cervix,  and  the  examiner  passes  two  fingers  of  one  hand  into 
the  rectum  and  presses  above  the  pubes  with  the  other  hand  while  another 
assistant  makes  u^jward  traction  on  the  tumor  through  the  abdominal  wall. 
The  diagnosis  from  fibroid  tumors  may  be  made  by  the  introduction  of  the 
uterine  sound,  which  will  show  an  elongated  canal  if  fibroids  are  present,  or 
by  feeling  the  round  ligaments  or  tubes  upon  the  side  of  the  tumor  if  it  is  a 
fibroid.     (See  page  1133.) 

When  the  tumor  attains  a  large  size,  which  will  occur  only  in  the  cystic 
tumors,  it  may  fill  the  abdomen  and  resemble  ascites  (Fig.  892),  but  the 
diagnosis  may  be  made  as  has  been  explained  in  speaking  of  tumors  of  the 
abdomen.  In  ovarian  tumors  there  will  be  dulness  from  the  pubes  upward 
towards  the  navel  in  the  median  line  of  the  abdomen,  oi-  somewhat  to  one 
side,  while  the  flanks  will  be  resonant.  In  ascites,  on  the  other  hand,  there 
is  dulness  in  the  flanks,  and  the  central  part  of  the  abdomen  is  resonant 
usually  well  down  towards  the  pubes.  The  areas  of  dulness  may  be  altered 
in  both  cases  by  changes  in  the  position  of  the  jiatient,  but  will  be  much 
more  marked  in  ascites  than  in  the  cyst.  The  tumor  is  in  contact  with  the 
abdominal  wall  in  front,  bowel  very  rarely  intervening.  Fluctuation  may 
be  obtained  in  these  large  cysts,  and  usually  the  cyst  outline  can  be  made 


1152 


TREATMENT   OF  OVARIAN  TUMORS. 


out,  although  if  the  cyst  is  not  very  tense  and  is  thiu-walled  these  tests  may 
be  impossible.  True  ovarian  cysts,  as  a  rule,  have  a  thick  wall,  and  may  be 
lobulated  or  vary  in  consistency  in  different  parts,  as  may  be  appreciated 
upon  palpation,  while  cysts  of  the  broad  ligament  are  generally  globular  and 
thin-walled.  In  the  large  tumors  it  is  usually  impossible  to  demonstrate  the 
existence  of  the  pedicle  which  attaches  them  to  the  uterus.     With  ovarian 

Fig.  892. 


Ovarian  cvst. 


cysts  the  uterus  is  generally  low  down,  whereas  with  uterine  fibroids  it  is 
drawn  up  and  elongated.  The  most  confusing  cases  are  those  in  which  there 
is  ascites  encapsulated  by  adhesions,  or  in  which  an  ovarian  cyst  of  large 
size  is  complicated  with  ascites,  and  often  in  the  latter  case  the  diagnosis  can 
be  made  only  by  drawing  off  the  free  fluid,  wheu  the  cyst  can  generally  be 
demonstrated. 

Treatment. — The  best  treatment  for  tumors  of  the  ovary  or  of  the  broad 
ligament  is  removal  by  oj)eration,  for  aspiration  followed  by  the  injection 
of  irritating  fluids,  tried  in  old  times,  is  too  dangerous  a  procedure.  Even 
when  complicated  with  pregnancy  modern  opinion  is  in  favor  of  removal  of 
the  cyst  as  the  safest  treatment  for  mother  and  child.  The  removal  of  an 
ovarian  cyst  is  commonly  known  as  ovariotomy.  A  median  abdominal 
incision  is  made  just  above  the  pubes  large  enough  to  insert  three  or  four 
fingers.  A  sound  is  swept  around  the  tumor  to  ascertain  if  there  are  any 
•  adhesions,  and  if  none  are  found  a  trocar  is  plunged  into  the  cyst,  the 
patient  having  been  turned  on  one  side  so  that  any  escaping  fluid  shall  not 
enter  the  peritoneal  cavity.  As  the  cyst  collapses  the  flaccid  walls  are 
seized  with  forceps  near  the  point  of  insertion  of  the  trocar  and  drawn  out 
of  the  abdominal  wound,  the  entire  cyst  being  graduallj^  pulled  out  until 
nothing  remains  but  the  pedicle.  This  is  tied  off  (see  page  906)  by  trans- 
fixing it  with  a  double  ligature  of  heavy  silk,  the  loops  of  which  should 
intersect,  and  tlie  knots  should  be  tied  on  the  thin  edges  of  the  flat  pedicle. 
The  pedicle  is  then  divided  on  the  distal  side  of  the  ligature,  and  the 
abdomen  closed.  (See  page  908. )  If  adhesions  are  found,  and  they  are  not 
extensive,  the  procedure  may  be  the  same,  the  adhesions  being  separated 
as  the  cyst  is  drawn  out  of  the  abdomen  by  careful  sponging,  or  by  dividing 
them  between  two  ligatures.  If  extensive  adhesions  are  found,  however, 
the  incision  should  be  enlarged,  and  the  adhesions  separated  freely  before 


PELVIC  H/EMATOCELE.  1153 

the  sac  is  punctured  by  the  trocar,  so  that  the  operatiou  can  be  abandoned 
with  safety  if  it  is  found  that  the  adhesions  are  too  serious  to  permit  removal 
of  the  tumor.  If  the  bowel  is  too  adherent  to  the  sac  to  allow  of  separation, 
the  adherent  loop  may  be  resected  and  the  two  ends  united  by  a  Murphy's 
button  or  by  sutures.  If  several  loops  ai-e  adherent  it  will  be  best  to 
abandon  the  operation.  If  the  large  intestine  is  resected  for  adhesions,  the 
end&  may  be  sutured,  or  they  may  be  included  in  the  abdominal  wound  and 
an  artificial  anus  established  which  can  be  remedied  later.  The  adhesions 
to  the  omentum  are  most  frequent  and  easiest  to  deal  with,  for  they  are 
readily  tied  off.  Adhesions  to  the  parietal  peritoneum  may  compel  the 
sacrifice  of  a  portion  of  that  membrane.  When  the  adhesions  are  extensive 
there  is  usually  considerable  oozing  from  the  raw  surfaces  left  by  their 
separation,  and  it  is  best  to  drain  after  operations  in  such  cases.  Occasion- 
ally it  will  be  necessary  to  leave  portions  of  the  cyst  adherent  at  various 
points,  in  which  case  their  epithelial  surfaces  should  be  thoroughly  removed 
by  the  curette  or  the  cautery. 

Solid  tumors  of  the  ov^ary  require  large  abdominal  incisions.  If  the 
growth  is  intraperitoneal  it  is  lifted  out  of  the  abdominal  wound  after  sepa- 
rating any  adhesions  which  may  exist,  and  the  pedicle  ligated  and  divided. 
If  it  lies  beneath  the  peritoneum,  the  latter  should  be  divided  over  the 
fundus  of  the  tumor,  and  the  growth  rapidly  enucleated,  large  vessels  being 
ligated  at  once  or  clamped  provisionally.  Cysts  of  the  broad  ligament  are 
removed  in  the  same  way.  When  hemorrhage  is  troublesome,  the  enuclea- 
tion should  be  rapidly  completed  and  the  cavity  packed  tightly  to  control  it. 

PELVIC   H^EMATOCELE. 

Pelvic  hematocele  is  a  collection  of  blood  in  the  pelvis,  either  external 
to  the  peritoneum  or  within  its  cavity.  Intraperitoneal  Haematocele. — 
Blood  may  collect  in  the  cavity  from  the  Fallopian  tubes  in  menstruation, 
although  it  may  come  from  a  vessel  in  a  ruptured  Graafian  follicle  or  from 
ruptured  adhesions  in  hemorrlwgic  peritonitis,  a  form  of  peritonitis  similar 
to  pachymeningitis  haemorrhagica,  with  many  new  thin-walled  blood-vessels. 
Extraperitoneal  Hsematocele. — An  extraj)eritoueal  collection  of  blood 
may  be  caused  by  the  rupture  of  a  vein  in  the  cellular  tissue.  These  hem- 
orrhages are  most  frequent  in  young  women,  and  are  apt  to  occur  during 
menstruation.  Hfematocele  is  not  a  very  common  condition,  and  probably 
many  of  the  cases  formerly  classed  under  this  head  were  really  instances  of 
very  early  extra-iiterine  pregnancy.  The  hemorrhage  usually  takes  place 
at  menstruation,  which  then  ceases,  although  an  irregular  flow  from  the 
uterus  may  continue  in  its  place.  The  patient  feels  severe  pain  in  the 
pelvis,  and  there  are  usually  signs  of  peritoneal  irritation,  in  some  cases 
amounting  to  a  true  peritonitis.  There  is  abdominal  tenderness,  with  a 
feeling  of  distention,  and  some  tympanites.  Examination  shows  nothing  at 
first,  the  blood  being  fluid,  but  after  the  blood  has  coagulated  a  doughy 
mass  becomes  evident  in  Douglas's  cul-de-sac  or  on  one  side  of  the  uterus 
in  the  broad  ligament.  The  blood-clot  is  usually  absorbed  in  time,  and  the 
symptoms  subside  unless  infection  takes  place,  when  an  abscess  may  form 
and  require  surgical  interference.     The  symptoms  of  a  suppurating  htema- 


1154  EXTRA-UTERINE  PREGNANCY. 

tocele  are  similar  to  those  of  pelvic  abscess  in  general,  and  the  treatment 
should  be  the  same,  the  pus  being  discharged  by  an  incision  into  Douglas's 
cul-de  sac  or  into  the  cavity  of  the  broad  ligament. 

EXTKA-UTEKINE   PREGNANCY. 

The  ovum  occasionally  becomes  impregnated  while  yet  in  the  ovary,  or 
in  the  abdominal  cavity  or  the  Fallopian  tube  during  its  passage  towards 
the  uterus,  and  may  develop  in  any  of  these  situations.  It  almost  invariably 
develops  in  the  Fallopian  tube,  but  may  make  its  -way  later  into  the  perito- 
neal cavity  or  between  the  folds  of  the  broad  ligament  by  rupture  of  the  sac. 
In  the  broad  ligament  the  foetus  usually  dies,  and  the  resulting  hsematocele 
becomes  absorbed.  In  the  peritoneal  cavity,  however,  the  foetus  may  con- 
tinue to  live,  and  even  if  it  should  die  the  sac  may  still  further  enlarge  by 
persistent  hemorrhage.  The  foetus  may  be  expelled  from  the  tube  into  the 
abdominal  cavity,  usually  with  profuse  hemorrhage  (tubal  abortion).  If  the 
foetus  dies  after  considerable  development,  the  tumor  may  persist  indefinitely 
as  a  cyst  containing  the  mummified  foetus,  or  it  may  sup^Durate  or  ulcerate 
into  some  of  the  hollow  organs  or  through  the  abdominal  walls,  and  thus 
dischai-ge  the  body  of  the  foetus  and  other  contents.  The  cause  of  ectopic 
pregnancy  is  generally  a  stricture  of  the  tubes  due  to  some  antecedent  in- 
flammation which  obstructs  the  outward  passage  of  the  ovum ;  hence  it  is 
most  commonly  seen  after  a  long  jjeriod  of  sterility. 

Symptoms. — The  symptoms  of  an  extra-uterine  pregnancy  may  be  so 
vague  as  to  be  unnoticed  by  the  patient.  Usually,  however,  the  menstrual 
flow  is  irregular,  one  or  two  periods  being  missed,  with  intermittent  flowing 
in  the  interval,  and  a  deciduous  membrane  may  be  expelled.  The  uterus 
is  generally  enlarged,  and  there  may  be  signs  of  mammary  development.  A 
doughy  rounded  tumor  will  be  felt  in  Douglas's  cul-de-sac,  or  at  one  side 
of  the  uterus,  the  size  corresponding  with  the  age  of  the  i^regnancy  if  rup- 
ture has  not  occurred.  If  hemorrhage  has  taken  jjlace  the  blood  may  form 
a  large  rounded  tumor  if  encapsulated  by  adhesions,  or  it  may  be  free  in  the 
abdomen  and  give  irregular  dulness  on  percussion.  The  extraperitoneal 
masses  will  fix  the  uterus  or  displace  it  to  the  opposite  side  like  intraliga- 
mentous cysts.  There  may  be  short,  sharp  attacks  of  pain  in  the  pelvis  and 
a  feeling  of  weight  and  bearing  down.  The  attacks  of  pain  ai-e  to  be 
ascribed  to  the  rupture  of  adhesions  or  to  the  bursting  of  small  blood-vessels 
about  the  sac.  Extensive  bleeding  may  occur,  sufticient  to  cause  syncope, 
and  if  the  sac  ruptures  the  symptoms  will  be  those  of  severe  shock  from  loss 
of  blood,  succeeded  by  a  commencing  peritonitis.  As  a  rule,  these  accidents 
happen  before  the  foetus  is  three  or  four  months  old,  but  in  some  cases  there 
is  no  rupture,  and  full  development  of  the  foetus  occurs,  the  woman  believing 
herself  naturally  pregnant.  There  may  be  continual  leaking  of  blood  into 
the  peritoneal  cavity  from  the  abdominal  orifice  of  the  tube  during  the 
growth  of  a  tubal  pregnancy.  The  diagnosis  is  not  easy,  because  the  pain 
may  be  accompanied  with  fever,  and  the  symijtoms  may  closely  resemble 
appendicitis,  renal  colic,  or  inflammation  due  to  gall-stones.  There  is  no 
question  that  many  cases  of  supposed  simple  htematocele  are  instances  of 
extra-uterine  pregnancy. 


TREATMENT  OF  EXTEA-UTERINE  PREGNANCY.  1155 

Treatment. — Successful  attempts  have  been  made  to  kill  the  foetus  by 
passing  a  strong  faradic  current  through  the  sac,  or  by  injecting  morjihine 
into  the  body  of  the  foetus.  These  methods,  however,  are  uncertain  and 
dangerous,  for  during  the  delay  necessary  to  obtain  evidence  of  the  death  of 
the  foetus  the  sac  may  continue  to  grow,  and  a  tatal  rupture  may  occur. 

Operation  at  full  term  has  succeeded  in  saving  the  mother,  but,  as 
a  rule,  in  such  cases  it  is  well  to  wait  until  the  foetus  dies  and  the  parts  have 
somewhat  atrophied,  so  that  their  vascularity  is  reduced.  If  the  diagnosis 
can  be  made  in  the  early  months,  however,  the  sac  should  be  removed  by 
early  laparotomy,  and  in  cases  of  rupture  with  symj^toms  of  hemorrhage 
not  a  moment  should  be  lost.  The  statistics  of  operations  for  this  condition 
have  very  much  improved  of  late.  The  operation  is  begun  by  a  median 
abdominal  incision,  the  patient  being  in  the  Trendelenburg  position.  If  the 
sac  is  very  adherent  or  has  developed  in  the  broad  ligament,  it  will  be 
advisable  to  ligate  the  vessels  passing  to  it  from  the  pelvic  wall  and  from 
the  uterus  before  attempting  to  remove  it.  If  the  sac  is  entirely  contained 
in  the  tube,  the  tumor  may  be  treated  like  a  pyosalpinx,  being  shelled  out 
of  its  adhesions,  the  pedicle  ligated,  and  the  mass  cut  away.  Intraliga- 
mentous sacs  must  be  treated  like  ovarian  cysts  in  the  same  situation.  In 
advanced  pregnancies  the  placental  site  may  bleed  freely  after  their  removal, 
and  the  hemorrhage  should  be  controlled  by  packing.  Some  surgeons 
advocate  packing  the  wound  and  leaving  the  placenta  to  slough  out  later. 
In  cases  of  collapse  from  loss  of  blood  before  the  operation,  no  time  should 
be  spent  in  trying  to  establish  reaction,  because  restoration  of  the  pulse  will 
only  cause  additional  hemorrhage.  The  operation  should  be  undertaken  at 
once,  and  stimulants  and  saline  injections  or  infusions  given  by  an  assistant 
while  the  surgeon  attends  to  the  lai^arotoray.  In  many  cases  old  clots  and 
fresh  blood  will  be  found  filling  the  abdomen.  These  should  be  removed 
and  the  cavity  thoroughly  irrigated  with  hot  sterile  saline  solution,  the 
pelvis  having  been  lowered.  Drainage  is  necessary  after  these  operations. 
The  abdominal  wound  is  closed  in  the  usual  manner.  When  the  sac  and 
hematocele  are  small,  they  may  be  removed  by  a  vaginal  incision,  as  in 
cases  of  pyosalpinx.     (See  page  1146.) 


CHAPTEK   XLII. 

SURGERY   OF  THE  ANUS  AND  THE  RECTUM. 
By  Heney  E.  Wharton,  M.D. 

Wounds  of  the  Anus  and  the  Rectum.— These  are  compara- 
tively rare  accidents,  by  reason  of  the  protected  position  of  these  parts,  but 
may  occur  from  bodies  thrust  into  the  anus  or  through  the  skin  of  this 
region,  or  from  pins,  needles,  pieces  of  glass,  shell,  bone,  or  other  hard 
substance  which  have  been  swallowed  and  injure  the  anus  or  rectum  in  their 
passage  from  the  body.  Gunshot  wounds  and  fragments  of  bone  in  ft-actures 
of  the  pelvis  may  involve  the  rectum  or  the  anus.  Incised  wounds,  except 
those  made  intentionally  by  the  sm-geon  in  operations  upon  these  parts,  or 
accidentally  in  the  operation  of  lithotomy,  are  rarely  seen,  while  lacerated 
wounds  occurring  during  j)arturition  are  not  uncommon.  Injuries  of  the 
rectum  caused  by  foreign  bodies  thrust  through  the  anus,  such  as  a  piece 
of  wood,  a  prong  of  a  hay-fork,  a  tooth  of  a  rake,  may  produce  extensive 
laceration  and  perforation  of  the  rectum,  and  even  open  the  peritoneal 
cavity  and  wound  the  intestines.  These  injuries  are  always  most  serious, 
and  are  ai^t  to  result  in  septic  cellulitis  of  the  pelvic  connective  tissue  or  in 
septic  peritonitis,  either  of  which  conditions  is  likely  to  be  followed  by  a 
fatal  result.  When  the  rectum  is  injured  by  a  hard  or  sharp  substance 
which  has  been  swallowed,  a  localized  ulceration  of  the  rectum  may  result, 
or,  if  perforation  has  occurred,  abscess  and  fistula  may  follow. 

Pi'Ognosis. — This  depends  largely  upon  the  thoroughness  of  the  drainage. 
In  incised  wounds  made  intentionally  by  the  surgeon  in  which  the  drainage 
is  free  the  prognosis  is  favorable  ;  in  extensive  lacerated  wounds  in  which 
the  rectum,  anus,  and  surrounding  skin  are  torn,  as  free  drainage  is  estab- 
lished a  favorable  termination  is  not  unusual ;  while  punctured  wounds,  in 
which  there  is  poor  drainage,  are  very  unfavorable,  being  followed  by 
extravasation  of  faeces,  cellulitis,  abscess,  and  grave  septic  complications. 

Treatment. — The  wound  and  the  surrounding  parts  having  been  thor- 
oughly sterilized,  it  should  be  closed  first  by  a  layer  of  deep  sutures  of  silk 
or  catgut,  and  next  by  superficial  sutures,  care  being  taken  to  bring  together 
the  ends  of  the  divided  sphincter  muscle.  If  the  surfaces  cannot  be  accu- 
rately brought  together,  a  drainage  tube  should  be  introduced  before  apply- 
ing the  sutures.  The  same  treatment  is  applicable  to  lacerations  of  the  anus 
and  the  rectum  occurring  as  a  result  of  j)arturition.  Accidental  wounds  of 
the  rectum  received  during  the  operation  of  lithotomy  usually  heal  promptly, 
and  as  the  rectal  wound  in  these  cases  is  low  dowu,  it  is  generally  possible 
to  bring  together  the  edges  by  a  few  sutures  introduced  through  the  perineal 
wound.  The  treatment  of  jpunctured  wounds,  with  or  without  wound  of  the 
anus,  consists  in  providing  drainage  by  dividing  the  sphincter  muscle,  if  not 
1156 


FOREIGN  BODIES  IN  THE  RECTUM.  1157 

already  divided,  aud  the  wall  of  the  rectum,  as  far' as  the  seat  of  injury, 
and,  after  controlling  the  bleeding,  loosely  packing  the  wound  with  a  strip 
of  iodoform  gauze.  Free  drainage  being  established,  the  wound  is  allowed 
to  heal  by  granulation  ;  if  after  heftling  it  is  found  that  the  sphincter  action 
has  been  lost,  a  plastic  operation  should  be  undertaken  to  repair  the  divided 
muscle. 

To  prevent  infection  after  wounds  or  operations  upon  the  rectum,  they 
should  be  freely  irrigated  with  antiseptic  solutions  and  dressed  with  iodo- 
form gauze  and  a  pad  of  bichloride  gauze  and  cotton  held  in  place  by  a 
T-bandage.  When  the  puncture  of  the  rectum  is  complicated  by  a  wound 
of  the  peritoneum  or  intestines,  the  abdomen  should  be  opened  and  the 
peritoneal  or  intestinal  wound  closed  with  sutures,  and,  after  flushing  the 
abdominal  cavity  with  warm  sterilized  water,  a  drainage-tube  should  be 
introduced  and  the  abdominal  wound  closed. 

Burns  and  scalds  of  the  anus  and  rectum  are  rare,  but  occasionally 
occur.  If  severe  and  not  immediately  fatal,  they  are  apt  to  be  followed  by 
marked  contraction,  giving  rise  to  stricture,  which  will  necessitate  a  subse- 
quent plastic  operation  or  colostomy.  Their  treatment  is  similar  to  that  of 
burns  and  scalds  of  other  j)arts  of  the  body. 

Foreign  Bodies  in  the  Rectum. — Foreign  bodies  may  reach  the 
rectum  through  the  anus  or  by  euteiing  the  rectum  from  the  colon.  A  great 
variety  of  substances  has  been  found  in  the  rectum,  such  as  nails,  jjins,  hair- 
pins, stones,  glass,  bottles,  and  sticks,  as  well  as  fecal  concretions  (coproUths). 
"VVe  recently  removed  a  hard,  smooth,  fecal  concretion,  the  size  and  shape 
of  a  hen's  egg,  from  a  pouch  in  the  rectum  of  the  patient,  which  had  caused 
her  more  or  less  discomfort  for  more  than  a  year.  Foreign  bodies  which 
have  been  swallowed  may  lodge  in  the  rectum  and  have  concretions  formed 
upon  them,  or  the  foreign  body  may  be  introduced  accidentally  through  the 
anus  ;  hysterical  subjects  and  those  suffering  from  perverted  sexual  impulse 
are  apt  to  introduce  foreign  bodies  into  the  rectum. 

Symptoms. — If  the  foreign  body  be  a  small  and  smooth  one,  the 
symptoms  caused  by  its  presence  may  not  be  marked,  consisting  principally 
of  a  sense  of  rectal  fulness  and  tenesmus ;  if  a  large  body  be  present,  more 
or  less  obstruction  may  exist  to  the  passage  of  fteces,  and  in  most  cases  the 
presence  of  the  foreign  body  soon  sets  up  a  teasing  diarrhoea.  If  the  body 
be  an  irregular  or  hard  one,  its  presence  sooner  or  later  causes  inflammation 
and  ulceration  of  the  rectal  walls,  followed  by  the  passage  of  blood-stained 
faeces  and  mucus  with  the  stools,  aud  perforation  of  the  rectal  wall  with  the 
formation  of  abscess  aud  fistula  may  subsequently  occur. 

Treatment. — As  soon  as  the  presence  of  a  foreign  body  is  recognized, 
its  removal  should  be  promptly  undertaken.  It  is  well  before  attempting  to 
remove  a  foreign  body  from  the  rectum  to  administer  an  anesthetic,  so  that 
the  resistance  of  the  sphincter  muscle  and  the  movements  of  the  patient 
may  be  eliminated.  Its  removal  is  best  accomplished  by  introducing  a 
bivalve  or  four-bladed  rectal  speculum,  and  after  thoroughly  dilating  the 
blades  so  as  to  expose  the  body,  grasping  it  with  the  forceps  and  gently 
withdrawing  it.  When  the  foreign  body  has  caused  ulceration,  the  greatest 
gentleness  should  be  practised  iu  the  manipulations,  to  avoid  perforation -of 

74 


1158      CONGENITAL  MALFORMATIONS  OF  THE  ANUS  AND  RECTUM. 

the  thinned  rectal  wall.  In  some  cases  it  may  be  necessary  to  divide  the 
body  with  forceps  before  it  can  be  removed ;  in  other  cases  a  scoop  or  a  wire 
loop  may  be  employed.  If  ulceration  of  the  rectum  has  occurred,  the  cav- 
ity should  be  irrigated  with  boric  acid  solution,  and  the  ulcerated  portion 
touched  with  a  ten-grain  solution  of  nitrate  of  silver.  The  same  applica- 
tion should  be  made  subsequently  until  the  ulcers  have  healed. 

Congenital  Malformations  of  the  Anus  and  the  Rectum. — 
Malformations  are  comparatively  rare  ;  it  has  been  computed  that  one 
child  in  ten  thousand  is  born  with  a  congenital  defect  of  these  parts,  result- 
ing from  arrested  development  in  early  foetal  life.  The  central  portion  of 
the  alimentary  canal  is  formed  from  the  hypoblast,  and  is  liuown  as  the 
mesenteron,  consisting  of  a  simple  tube  terminating  at  the  anterior  extremity 
of  the  embi-yo  in  a  blind  pouch,  and  in  a  pouch  at  the  posterior  extremity, 
which  communicates  by  a  minute  opening  with  the  neural  canal,  known  as 
the  neurenteric  canal.  An  invagination  of  the  epiblast  at  the  posterior 
extremity  of  the  embryo,  known  as  the  prododwum,  which  forms  the  anus 
and  the  genito-urinary  orifices,  communicates  with  the  mesenteron  about  the 
end  of  the  fifth  week.  The  lower  portion  of  the  primitive  intestine  termi- 
nates ■  at  first  in  a  cloaca,  common  to  it  and  the  genito-urinary  organs,  but 
by  the  end  of  the  tenth  week  the  anus  is  separated  from  the  genito-urinary 
organs  by  the  development  of  the  perineal  septum.  The  failure  of  develop- 
ment of  the  perineal  septum  explains  the  fi'equency  of  the  connection 
between  the  intestinal  tube  and  the  genito-urinary  tract  in  these  malforma- 
tions. The  various  malformations  depend  upon  imperfect  development  of 
the  proctodseum,  incomplete  formation  of  the  perineal  septum,  and  persist- 
ence of  the  post-anal  gut  or  neurenteric  canal. 

Varieties  of  Malformation. — 1.  Congenital  narrowing  of  the  rec- 
tum and  anus,  without  complete  occlusion.  This  malformation,  if  not 
sufficient  to  produce  marked  symi^toms  of  obstruction,  may  at  first  escape 
notice,  as  the  semifluid  fteces  of  the  infant  pass  readily  through  the  narrow 
orifice,  but  as  the  child  becomes  older  and  the  faeces  are  more  consistent 
accumulation  takes  place  in  the  rectum,  causing  obstruction,  and  an  exam- 
ination will  demonstrate  its  cause.  It  is  possible  also  that  in  many  cases 
where  the  stenosis  is  not  marked  the  passage  of  faeces  brings  about  the 
necessary  amount  of  dilatation.  Treatment. — This  consists  in  gradual 
dilatation  of  the  anus  and  the  rectum,  and  is  usually  followed  by  a  satisfac- 
tory result.  It  is  conducted  by  passing  daily  a  graduated  bougie,  or  the 
oiled  finger  of  the  mother  or  the  nurse,  which  is  by  far  the  best  and  safest 
of  all  bougies  for  this  purpose. 

2.  The  anus  is  absent,  and  the  rectum  terminates  in  a  blind 
pouch.  The  rectum  may  not  be  developed,  or  to  so  slight  an  extent  that 
it  terminates  in  the  abdomen  or  high  up  in  the  pelvis  (Fig.  893),  or  it  may 
terminate  near  the  perineum.     (Fig.  891. ) 

3.  The  anus  may  be  well  formed,  as  well  as  the  rectum,  but  they 
do  not  communicate,  a  membranous  diaphragm  or  fibrous  cord  existing 
between  them.     (Fig.  895.) 

4.  The  anus  is  absent  and  the  rectum  terminates  in  the  vagina^ 
usually  at  its  lower  portion.    (Fig.  896.)    This  is  the  most  common  vari- 


CONGENITAL  MALFORMATIONS  OF  THE  ANUS  AND  RECTUM.      1159 

ety,  representing  about  forty  per  cent,  of  all  these  malformations.     Where 
there  has  been  failure  in  the  development  of  the  perineal  septum,  the  anus 
is  usually  absent  and  the  rectum  terminates  in 
Fig  890  some  portion  of  the  genito  uiinaiy  tiact. 


Rectum  terminating  in  the  abdomen. 
(After  MolliJre.) 


Rectum  terminating  low  down    Anus  separated  from  the  rectum  by 
near  the  perineum.  a  membranous  diaphragm. 


5.  The  anus  is  absent,  and  the  rectum  terminates  in  a  narroAV 
sinus,  which  opens  beneath  the  prepuce.  (Fig.  897.)  In  this  variety 
of  malformation  the  rectum  may  terminate  in  a  iistula,  which  opens  on  the 
perineum. 

6.  The  anus  is  absent,  and  the  rectum  terminates  in  the  urethra 
or  the  bladder.     (Fig.  898.) 

7.  The  anus  is  present,  but  does  not  communicate  with  the  rec- 
tum, which  terminates  in  a  blind  pouch,  while  the  anus  terminates 
in  the  vagina. 

8.  Persistence  of  the  neurenteric  canal  or  post-anal  gut.  This  con- 
dition is  rarely  met  with.     The  anus  may  be  absent  and  the  rectum  may 


Fig.  896 


Fig.  897 


Fig.  898. 


The  anus  is  absent,  and  the  rectum       Rectum  terminating  at  the 
terminates  in  the  vagina.  prepuce.  (After  Mollil^re.) 


Rectum  terminating  in  the 
bladder.  (After  MoUifre.) 


open  through  an  aperture  in  the  sacrum,  or  failure  of  obliteration  of  the 
post-anal  gut  may  result  in  a  diverticulum  of  the  rectum. 

Symptoms. — These  vary  with  the  variety  of  malformation.  When  the 
rectum  terminates  in  a  blind  pouch  the  freces  cannot  escape,  and  symptoms 
of  obstructiou  soon  develop,  such  as  vomiting  and  swelling  of  the  abdomen. 
In  cases  iu  which  the  rectum  terminates  in  the  vagina,  faeces  usually  escape 
freely,  and  no  obstructive  symptoms  are  present.  When,  however,  the  rec- 
tum terminates  in  the  bladder  or  the  urethra,  or  at  the  prepuce,  the  escape 


1160  EXAMINATION   OF  THE  EECTUM. 

of  faeces  is  usually  not  sufficiently  free,  and  obstructive  symptoms  soon 
develop.  In  cases  in  which  the  anus  is  absent  the  condition  is  usually  rec- 
ognized early,  but  when  the  anus  is  present  it  is  likely  to  be  overlooked 
until  the  fact  that  no  faeces  have  been  j)assed  has  been  noticed.  Absence  of 
a  fecal  discharge  within  a  reasonable  time  after  birth  should  lead  to  an 
examination  of  the  rectum,  which  will  reveal  the  cause.  Care  should  be 
taken  not  to  giv.e  purgatives  in  these  cases  before  making  an  examination. 

Treatment. — Where  the  rectum  ends  in  a  blind  pouch,  symptoms  of 
obstruction  are  soon  developed,  which  if  not  relieved  by  immediate  opera- 
tion soon  prove  fatal.  In  such  cases  an  opening  should  be  made  at  the  usual 
site  of  the  anus,  and  if  the  rectal  pouch  is  low  down  it  should  be  opened 
and  the  edges  of  the  rectum  brought  down  and  sutured  to  the  skin.  If 
however,  the  rectal  pouch  is  high  up  in  the  pelvis,  it  may  be  difficult  to 
reach  it,  but  an  attempt  should  be  made  to  do  so ;  excision  of  the  coccyx 
gives  the  operator  more  room  and  thus  facilitates  the  exposure  of  the  gut. 
When  the  rectal  pouch  is  exposed  and  opened  high  up,  it  is  not  possible  to 
suture  the  gut  to  the  edges  of  the  wound  ;  in  these  cases  a  good-sized  rubber 
tube  should  be  secured  in  the  wound  for  a  few  days.  When  the  jjelvis  is 
poorly  developed  and  narrow,  the  rectum  usually  ends  high  up,  and  cannot 
be  reached  from  a  perineal  wound. 

When  it  is  found  impossible  to  reach  the  gut  from  the  perineal  wound, 
this  should  be  closed,  and  the  descending  colon  should  be  opened  in  the  left 
iliac  region.  Where  the  anus  is  present  and  is  separated  from  the  rectal 
pouch  by  a  membranous  or  fibrous  septum,  this  should  be  carefully  opened 
by  a  crucial  incision,  and  should  subsequently  be  dilated  by  a  bougie  or  the 
finger.  In  cases  in  which  the  gut  opens  into  the  vagina,  if  the  fecal  dis- 
charge is  free  no  operation  need  be  undertaken  for  some  time  ;  it  is  better  in 
these  cases  to  wait  until  the  child  is  several  years  of  age,  when  an  incision 
should  be  made  in  the  region  of  the  anus,  the  gut  exposed  and  dissected 
loose  from  the  vagina,  and  the  vaginal  opening  transplanted  and  sutured  to 
the  anal  wound,  the  vaginal  wound  being  closed  with  sutures. 

Where  the  rectum  ends  in  the  bladder  or  the  urethra  an  artificial  anus 
should  be  established  in  the  left  iliac  region  bj^  colostomy,  and  if  the  patient 
survives  an  operation  may  be  undertaken  later,  to  close  the  communication 
with  the  bladder  or  the  urethra.  Except  in  cases  of  a  membranous  septum 
between  the  anus  and  the  rectum,  or  in  those  in  which  the  rectum  termi- 
nates low  down  in  the  pelvis  and  where  it  opens  into  the  vagina,  the  results 
of  operation  are  not  usually  satisfactory.  A  large  number  of  these  patients 
die  soon  after  the  operation,  but  occasionally  after  a  colostomy  it  has  been 
possible  later  to  expose  the  rectal  pouch  and  secure  it  at  the  site  of  the  anus 
and  subsequently  close  the  artificial  anus. 

DISEASES   OF   THE   ANUS   AND   THE    RECTUM. 

Examination  of  the  Anus  and  the  Rectum.— Before  under- 
taking the  treatiuent  of  any  case  of  disease  of  the  rectum  or  the  anus,  the 
surgeon  should  make  a  careful  j)hysical  examination  of  the  parts.  This  is 
most  important  from  the  fact  that  the  majority  of  patients  present  them- 
selves for  treatment  with  a  diagnosis  of  piles  or  fistula ;   we  can  call  to 


EXAMINATION   OF  THE  RECTUM.  1161 

miud  a  number  of  patients  who  have  come  under  our  care  who  stated  that 
they  were  suffering  from  or  had  been  treated  for  hemorrhoids,  in  whom 
an  examination  revealed  ischio-rectal  abscess,  fistula,  fissure,  or  carcinoma, 
and  in  whom  valuable  time  had  often  been  lost  by  the  lack  of  a  careful 
examination. 

In  making  an  examination,  the  i^atient  should  be  placed  upon  the  side 
in  the  Sims  position,  or  upon  the  back,  with  the  limbs  drawn  up  and  held 
aside  as  in  the  lithotomy  position.  An  enema  should  be  given  before  the 
examination,  to  empty  the  rectum  of  fecal  matter.  The  anus  should  first 
be  inspected,  and  the  presence  of  external  hemorrhoids,  protruding  polypus, 
or  a  fissure,  the  openings  of  fistulfe,  the  swelling  of  an  ischio-rectal  abscess 
in  the  anal  region,  or  the  presence  of  eczema  of  the  anus,  can  usually  be 
made  out  without  difficulty.  The  patient  should  be  asked  to  strain  slightly, 
and  at  the  same  time  the  folds  of  mucous  membrane  should  be  separated, 
so  that  the  presence  of  a  fissure  can  be  observed.  In  examination  of  the 
rectum  the  finger  should  be  covered  with  a  rubber  finger-stall,  or  after  filling 
the  nail  with  soap  it  should  be  anointed  with  cosmoline  and  introduced  into 
the  rectum  with  a  boring  motion,  and  as  it  is  introduced  the  condition  of  the 
sphincter  muscle  is  noted.  By  the  finger  from  three  to  four  inches  of  the 
rectum  can  be  explored,  and  the  presence  of  a  polypus,  the  internal  opening 
of  a  fistula,  a  stricture,  or  a  malignant  growth  can  be  made  out.  Internal 
hemorrhoids,  unless  they  are  well  developed,  cannot  well  be  felt  with  the 
finger.  The  use  of  a  rectal  si^eculum  will  enable  the  surgeon  to  expose  the 
rectal  walls  for  inspection.  This  instrument  cannot,  as  a  rule,  be  used  with 
satisfaction  unless  the  patient  is  under  the  influence  of  an  ansesthetic.  The 
rectal  specula  which  we  have  found  most  satisfactory  are  the  modified  Sims 
speculum  and  the  bivalve  speculum.     (Fig.  899.) 


f^, 


I 

/ 


/. 


/ 


Bivalve  speculum. 

A  cylindrical  speculum  from  five  to  fourteen  inches  in  length  fitted  with 
obturators  may  be  employed.  The  patient  is  placed  in  the  knee-elbow 
position,  and  as  soon  as  the  obturator  is  removed  the  rectum  becomes  dis- 
tended with  air.  A  head-mirror  or  an  electric  lamp  is  used  to  illuminate 
the  cavity.  By  the  long  speculum  it  is  possible  to  obtain  a  view  of  the 
sigmoid  flexure. 

Examination  with  a  siieculum  is  not  required  in  many  cases  if  a  careful 
examination  is  made  with  the  finger  ;  and  in  the  case  of  fistula,  the  use  of  a 


1162  PRUEITIS  ANI. 

flexible  silver  probe  will  show  tlie  course  and  termination  of  the  fistulous 
tracts.  Examination  of  the  rectum  by  the  introduction  of  the  whole  hand 
can  be  made  if  the  hand  be  a  moderately  small  one,  but  this  procedure  is 
not  unattended  with  danger,  and  has  been  followed  by  rupture  of  the  rectal 
wall  and  fatal  peritonitis. 

DISEASES   OF   THE   ANUS. 

Pruritis  Ani. — This  affection,  which  consists  in  a  painful  itching 
condition  of  the  anus,  is  attended  with  certain  changes  in  the  appearance 
of  the  parts.  The  skin  becomes  thickened  and  presents  a  parchment-like 
or  eczematous  appearance,  with  the  exudation  of  moisture,  and  is  usually 
covered  with  scratch-marks.  This  disease  may  result  from  the  presence  of 
internal  hemorrhoids  or  of  a  small  fistula,  from  eczema,  from  the  presence 
of  oxyuris  vermicularis,  or  seat- worms,  in  the  rectum,  from  pediculi,  or 
from  a  vegetable  parasite,  in  which  case  the  disease  is  known  as  eczema 
marginatum.  In  other  cases  no  cause  can  be  found  for  the  itching,  the  affec- 
tion being  due  to  constitutional  conditions,  such  as  gout,  or  to  neuroses 
of  the  rectum.  Symptoms. — The  principal  symptom  is  a  painful  itching, 
which  is  usually  much  aggravated  at  night,  so  that  it  interferes  with  sleep, 
the  tendency  being  to  scratch  the  part  constantly,  which  aggravates  the 
trouble.  Treatment. — This  consists  in  removing  the  cause,  if  it  can  be 
discovered.  If  internal  hemorrhoids  or  a  fistula  is  present  the  cure  of  this 
condition  by  an  operation  should  be  undertaken.  In  cases  in  which  the 
affection  arises  from  seat- worms,  an  enema  of  carbolic  acid,  3ss;  glycerin, 
3  i ;  water,  f  5  viii ;  or  of  infusion  of  quassia,  o  i  to  Oil,  will  relieve  the 
trouble.  When  arising  from  pediculi  the  application  of  tincture  of  lark- 
spui'  or  of  fishberries  will  destroy  the  parasites.  When  the  affection  is  due 
to  eczema  marginatum,  the  rise  of  a  weak  solution  of  sulphurous  acid  or 
hyposuljjhite  of  sodium,  followed  by  an  ointment  of  oleate  of  bismiith,  will 
act  well.  In  cases  of  eczema,  the  use  of  hot  water  and  green  soap  and  an 
ointment  of  oxide  of  zinc,  or  of  chloroform,  f3i,  simiile  ointment.  Si,  or  of 
dilute  citrine  or  tar  ointment,  often  is  followed  by  good  results.  Where 
no  distinct  cause  can  be  found,  the  diet  should  be  regulated,  meat  being- 
diminished  and  stimulants  and  tobacco  avoided  or  used  very  sparingly ; 
the  free  use  of  lithia  water  is  often  followed  by  benefit. 

Abscess  of  the  Anus. — This  aifection,  sometimes  known  as  mai-glnal 
abscess,  arises  from  suppuration  iu  an  external  hemorrhoid,  in  the  mucous 
follicles  of  the  anus,  or  in  a  small  fissure  of  the  anus,  giving  rise  to  more  or 
less  pain  in  the  part ;  when  it  ax-ises  from  an  external  hemorrhoid  a  super- 
ficial fistula  may  result,  but  it  usually  is  attended  with  no  serious  conse- 
quences. It  is  not  uncommon  in  children.  Treatment. — This  consists  in 
making  a  free  opening  with  a  bistoury,  in  doing  which  the  tip  of  the  index 
finger  should  be  passed  into  the  rectum  to  steady  the  abscess  and  make  it 
more  prominent  before  it  is  incised.  After  opening  the  abscess,  a  narrow 
strip  of  gauze  should  be  introduced  into  the  cavity  and  a  gauze  dressing 
applied.     The  wound  usually  heals  in  a  few  days. 

Fissure  or  Irritable  Ulcer  of  the  Anus.— This  consists  of  a  small 
linear  ulcer  of  the  mucous  membrane,  which  is  usually  situated  at  or  near 


FISSURE  OF  THE  ANUS.  1163 

tlie  posterior  commissure,  but  may  occur  at  any  other  part  of  the  anus,  and 
may  arise  from  a  slight  traumatism,  or  from  a  rent  in  the  mucous  membrane 
caused  by  the  laassage  of  hard  fiBces,  or  from  a  broken-down  herpetic  vesicle. 
(Fig.  900.)  Ball  considers  that  this  ulcer  results  from  an  injury  of  one  of 
the  anal  valves  by  some  irregularity  in  the  fecal  mass  which  separates  its 
lateral  attachments,  and  that  the  ulcer  thus 
formed  is  reopened  at  each  movement  of  the 
bowels,  so  that  it  cannot  heal,  the  condi- 
tions presented  being  very  similar  to  those 
in  hang-nail.  The  peculiar  symptoms  pre- 
sented by  this  ulcer  seem  to  depend  not 
upon  its  special  cause,  but  upon  the  fact 
that  the  ulcer  is  within  the  grasp  of  the  - 
sphincter  muscle,  and,  being  subjected  to 
constant  motion,  cannot  heal. 

Fissure  of  the  anus  is  iisually  observed 
in  adults,  but  occurs  also  in  children.     We 
have  seen  several  cases  of  fissure  of  the    •=s>,^     ^ 
anus  with  well-marked  symptoms  in  this 
class  of  patients,  and  Jacobi  thinks  that 

fissure  of  the  anus  in  children  is  a  much  more  common  affection  than  is  gen- 
erally suj)posed.  The  frequency  of  seat-worms  in  children,  causing  them  to 
scratch  and  injure  the  mucous  membrane  of  the  anus,  may  be  a  factor  in  its 
production. 

Symptoms. — The  most  characteristic  symptom  is  intense  paroxysmal 
pain,  which  comes  on  immediately  or  a  short  time  after  a  movement  of  the 
bowels.  The  pain  may  be  so  severe  that  it  comjaletely  incapacitates  the 
patient  for  woi-k  or  exercise,  and  he  is  compelled  to  rest  until  it  has  passed 
away.  When  it  has  once  subsided  it  does  not  appear  until  the  bowels  are 
again  moved.  The  patient  is  apt  to  postpone  going  to  stool  for  a  number  of 
days,  and  when  the  bowels  move  the  affection  is  aggravated  by  the  passagfe 
of  large  and  hard  fecal  masses.  Occasionally  a  few  droj)S  of  blood  from  the 
ulcer  escape  with  the  fteces.  During  the  paroxysm  of  pain  reflected  pains 
may  be  felt  in  the  neck  of  the  bladder,  in  the  loins,  and  in  the  thighs.  The 
pain  may  last  for  only  a  few  minutes  or  may  persist  for  hours. 

Treatm.ent. — This  consists  in  local  ai^iilications  to  the  ulcer,  or  in  partial 
division  or  stretching  of  the  sphincter,  which  causes  a  temporary  paralysis 
of  the  muscle  and  puts  the  ulcer  at  rest  until  repair  can  take  place.  The 
results  of  treatment  are  usually  most  satisfactory.  In  some  cases  the  daily 
application  to  the  ulcer  of  a  ten-grain  solution  of  nitrate  of  silver,  and  an 
ointment  of  calomel,  gr.  xvi ;  extract  of  belladonna,  extract  of  opium,  each, 
gr.  viii ;  ointment  of  i^etroleum,  5ss,  with  the  use  of  laxatives  to  produce 
a  daily  soft  motion,  will  be  followed  by  a  cure.  The  application  of  pure 
carbolic  acid  to  the  fissuie  may  also  be  followed  by  good  results. 

Stretching  of  the  sphincter  under  ether  or  nitrous  oxide  aufesthesia  may 
also  be  practised.  This  produces  laceration  of  the  muscular  fibres,  and 
paralysis  of  the  muscle  results.  A  method,  howe^'er,  which  is  more  certain 
consists  in  having  the  bowels  moved  by  a  laxative  or  an  injection,  and  after 


1164 


AVARTS   OF  THE  ANUS. 


Stretching  the  sphincter 


admiuistering  an  aiifestlietic  the  anus  is  irrigated  with  a  solution  of  boric 
acid  ;  the  base  of  the  ulcer  is  then  incised  with  a  sharp  bistoury,  partially 
dividing  the  sphincter,  the  thumbs  are  introduced  into  the  rectum,  and  the 
sphincter  is  well  stretched.     (Fig.  901.) 

After  the  sphincter  has  been  divided  or  stretched,  an  opium  suppository 
is  introduced  into  the  rectum  and  a  small  gauze  dressing  is  applied  to  the 

anus.     The  bowels  should  be  kept- 
''^  ^^^-  quiet  for  three  days,  and  after  this 

/^<  daily  movements  should  be  secured 
I  by  laxatives.  The  first  movement 
I  is  generally  painless,  and  at  the 
end  of  a  few  days  the  ulcer  is  usu- 
ally healed.  Ball,  after  adminis- 
tering an  anaesthetic,  dilates  the 
anus  and  makes  a  V-shaped  inci- 
sion, removing  the  torn-down  anal 
valve. 

Vegetations  or  Warts  of 
the  Anus. — These  are  papillary 
overgrowths,  similar  in  structure 
to  warts  observed  in  other  parts  of  the  body,  and  are  covered  with  squa- 
mous epithelium.  They  occur  in  both  adults  and  children,  and  often  attain 
great  size.  Prom  their  situation  they  are  compressed  between  the  nates, 
become  moist,  and  are  accompanied  with  an  offensive  discharge.  Treat- 
ment.— If  the  parts  can  be  kept  dry,  the  growths  shrink  and  may  dis- 
appear. In  growths  of  moderate  size,  dusting  them  with  a  powder  composed 
of  oxide  of  zinc  and  lycopodium,  equal  parts,  will  often  be  followed  by  their 
I'apid  disappearance.  The  daily  application  of  an  ointment  of  salicylic  acid, 
gss,  lanolin,  gi,  will  also  cause  their  removal.  When  the  growths  are  large, 
the  application  of  the  solid  stick  of  nitrate  of  silver,  or  of  a  saturated  solu- 
tion of  chromic  acid,  may  be  employed  with  advantage,  or  they  may  be 
removed  with  a  knife,  curette,  or  scissors,  or  by  the  use  of  the  actual  cautery. 
The  only  objection  to  their  removal  bj'  the  former  means  is  the  hemorrhage  ; 
this,  however,  can  easily  be  controlled  by  the  use  of  a  comiDress. 

Syphilitic  Affections  of  the  Anus.— These  consist  in  the  presence 
of  macous  patches,  moist  i^aijules,  and  condylomata,  which  occur  both  in 
acquired  and, in  inherited  syphilis.  Allingham  has  called  attention  to  the 
presence  of  numerous  tracks  or  fissures  in  the  mucous  membrane  of  the  anus 
in  children  suffering  from  hereditary  syphilis.  Condylomatous  growths 
appear  frequently  upon  previously  existing  papules  or  mucous  patches,  and 
are  accompanied  by  a  very  fetid  discharge.  These  growths  are  to  be  dis- 
tinguished from  the  simple  form  of  vegetations  which  is  observed  in  the 
anal  region.  Treatment. — This  should  be  both  constitutional  and  local. 
The  constitutional  treatment  consists  in  the  administration  of  mercury  or 
of  iodide  of  potassium,  or  of  both  combined.  The  local  treatment  consists 
in  touching  them  with  acid  nitrate  of  mercury,  or  in  dusting  them  with  a 
powder  composed  of  equal  parts  of  calomel  and  oxide  of  zinc.  Under  this 
treatment  they  usually  disa^jpear  rapidlj'. 


STKICTURE  OF  THE  ANUS.  1165 

Epithelioma  of  the  Anus. — This  affectiou  may  have  its  origin  in  the 
mucous  membrane  or  in  the  stiu  of  the  anus,  or  these  structures  may  be 
involved  by  an  extension  of  the  disease  from  the  rectum.  Primary  ej)ithe- 
lioma  of  the  anus  is  of  the  squamous  type,  and  is  comparatively  rare.  Epi- 
thelioma of  the  anus  is  often  confounded  with  hemorrhoids,  which  mistake 
should  not  occur  if  a  careful  examination  of  the  part  is  made.  Treat- 
ment.— If  the  disease  is  confined  to  the  mucous  membrane  and  skin  of  the 
anus,  the  diseased  tissue  should  be  freely  excised  and  the  mucous  membrane 
brought  down  and  sutured  to  the  edges  of  the  skin.  In  cases  in  which  the 
anus  is  involved  in  the  growth  by  extension  of  a  similar  growth  from  the 
rectum,  no  operation  upon  the  anus  can  be  employed  with  advantage,  but, 
if  the  rectum  is  not  too  extensively  involved,  excision  of  the  anal  and  rectal 
growth  should  be  j)ractised.     (See  page  1191). 

Stricture  of  the  Anus. — This  condition  may  be  congenital,  or  may 
result  from  wounds,  burns,  scalds,  or  malignant  growths  of  the  anus,  and 
occasionally  results  from  operations  upon  the  anus  or  rectum,  in  which 
there  has  been  free  removal  of  the  structures.  Sloughing  of  the  tissues  after 
the  injection  treatment  for  hemorrhoids  and  subsequent  contraction  have  not 
infrequently  resulted  in  a  marked  stricture  of  the  anus.  We  had  recently 
under  our  care  a  man  who  had  suifered  from  a  stricture  of  the  anus,  through 
which  the  point  of  a  No.  21  bougie  could  be  passed  only  with  difSculty. 
The  stricture  in  this  case  resulted  from  sloughing  following  the  injection 
of  hemorrhoids  by  an  irregular  rectal  specialist.  Symptoms. — The  patient 
usually  suffers  from  gradually  increasing  difficulty  in  passing  formed 
motions,  and  notices  that  the  stool  when  passed  is  tape-like  in  appear- 
ance. Examination  shows  that  the  anal  orifice  is  contracted,  and  in  severe 
cases  the  finger  cannot  be  passed  through  the  stricture.  Treatment. — 
The  treatment  of  congenital  strictures  of  the  anus  has  been  described  (page 
1160).  When  the  stricture  results  from  malignant  disease  of  the  anus,  the 
growth  should  be  excised.  If  it  is  due  to  cicatricial  contraction  following 
injuries  or  operations,  gradual  dilatation  should  first  be  employed,  and 
this  may  be  done  with  the  finger  or  with  graduated  rubber  bougies.  If 
this  is  not  followed  by  good  results,  the  cicatricial  tissue  should  be  excised 
and  the  mucous  membrane  brought  down  and  sutured  to  the  edges  of  the 
skin. 

Diphtheria  of  the  Anus. — This  condition  is  occasionally  seen  in 
patients  suffering  from  diphtheritic  deposits  in  the  throat  and  nose  ;  the 
deposit  of  diphtheritic  membrane  appears  upon  the  mucous  membrane  of 
the  anus,  and  may  extend  to  the  buttocks  or  the  vulva.  The  prognosis  is 
extremely  unfavorable.  The  few  cases  that  have  come  under  our  notice 
have  all  terminated  fatally.  Treatment. — This  consists  in  the  use  of  such 
constitutional  remedies  as  are  of  service  in  the  treatment  of  diphtheria,  the 
injection  of  antitoxine  and  the  free  use  of  stimulants.  The  local  treatment 
consists  in  the  application  of  a  solution  of  bichloride  of  mercury  1  to  2000. 

DISEASES  OF  THE  KECTUM. 

Proctitis. — Proctitis,  or  inflammation  of  the  rectum,  may  be  traumatic, 
catarrhal,  dysenteric,  or  gouorrhceal. 


1166  PROCTITIS. 

Traumatic  Proctitis. — This  may  result  from  iujury  to  the  walls  of  the 
rectum  received  from  without,  from  foreign  bodies  lodged  in  the  rectum, 
from  the  careless  use  of  an  enema  syringe,  or  from  injury  to  the  macous 
membrane  by  hardened  faeces  or  materials  contained  in  them. 

Acute  Catarrhal  Proctitis. — This  results  from  the  irritation  produced 
by  the  imj)action  of  masses  of  hardened  fteces  in  the  rectal  pouch,  from  the 
use  of  drastic  purgatives,  or  from  prolonged  sitting  upon  a  cold  or  wet  seat, 
and  in  children  may  follow  the  irritation  produced  by  seat-worms.  It  may 
also  develop  in  connection  with  internal  hemorrhoids,  prolapsus,  stricture, 
or  tumor  of  the  rectum.  The  mucous  membrane  alone  is  involved,  and  is 
congested  and  hypersemic.  Symptoms. — These  are  pain  and  tenderness, 
and  the  frequent  passage  of  fteces  mixed  with  mucus  and  blood ;  oedema 
and  often  slight  prolapse  of  the  mucous  membrane  of  the  anus  are  also 
observed.  The  patient  also  complains  of  a  sense  of  heat  and  weight  in  the 
pelvis,  and  often  suffers  from  vesical  irritation. 

Chronic  Catarrhal  Proctitis. — This  affection  generally  follows  acute 
proctitis,  but  may  result  from  the  presence  of  growths  in  the  rectum,  or 
from  pressure  u^dou  the  rectal  wall  caused  by  uterine  displacements.  In 
this  form  of  the  disease  the  mucous  membrane  is  thickened  and  indurated, 
and  ulceration  of  the  surface  at  various  points  is  usually  present.  Symp- 
toms.— Pain  and  tenesmus  are  not  prominent  symptoms,  and  constij)ation 
is  apt  to  be  present.  The  patient  often  complains  of  a  sense  of  fulness  or 
weight  in  the  rectum  ;  the  dischai'ge  of  blood  is  not  excessive,  and  mucus 
and  purulent  matter  escape  from  the  rectum  when  a  movement  occurs. 

Treatment. — This  in  the  acute  form  consists  in  putting  the  patient  at 
rest  in  bed,  and  in  the  administration  of  purgatives  to  emjity  the  lower 
bowel.  Saline  purgatives,  such  as  sulphate  of  magnesium  or  Eochelle  salt, 
act  well.  Compound  licorice  powder  may  also  be  used.  If  pain  and 
tenesmus  continue  after  the  rectum  has  been  emptied,  an  injection  of  thirty 
minims  of  laudanum  to  an  ounce  of  starch  water  should  be  thrown  into  the 
rectum,  or  a  sui^pository  containing  extract,  opii,  gr.  ss,  if  its  introduction 
does  not  give  the  patient  pain,  can  often  be  used  with  advantage.  The  diet 
should  also  be  restricted  to  meat  broths,  milk,  and  eggs. 

In  the  chronic  form  of  the  affection  the  same  treatment  as  regards  rest  in 
bed,  emptying  the  rectum,  and  restriction  of  the  diet  should  be  employed, 
and  in  addition  the  rectum  should  be  carefully  irrigated  with  warm  steril- 
ized water  by  means  of  a  tube,  and  an  enema  of  nitrate  of  silver  solution, 
five  grains  to  two  ounces  of  water,  should  be  injected  and  allowed  to  remain 
for  a  few  minutes,  the  rectum  afterwards  being  washed  out  with  warm  water. 
This  injection  should  be  used  daily  or  on  alternate  days,  and  in  addition 
suppositories  of  extract  of  opium,  belladonna,  and  iodoform  may  often  be 
employed  with  advantage. 

Dysenteric  Proctitis. — This  may  exist  as  an  acute  or  as  a  chronic  affec- 
tion. In  its  acute  form  it  is  not  apt  to  come  under  the  care  of  the  sui-geon, 
but  the  chronic  form  of  the  disease  gives  rise  to  ulceration  or  stricture  of  the 
rectum,  which  condition  sooner  or  later  demands  surgical  treatment. 

Gonorrhceal  Proctitis. — If  gonorrhoeal  discharge  is  brought  in  contact 
with  the  mucous  membrane  of  the  rectum,  there  is  rapidly  set  up  an  acute 


PERIPROCTITIS.  1107 

l^urulent  inflammatiou,  the  mucous  membraue  becoming  congested  and  red 
or  purple  in  appearance,  and  a  profuse  purulent  or  muco-pui-iilent  discharge 
occurs,  infection  in  most  cases  occurring  from  the  gonorrhceal  discharge 
running  backward  and  reaching  the  anus  and  from  this  point  finding  its  way 
into  the  rectum.  Infection  in  this  manner  is  more  apt  to  occur  in  women 
than  in  men.  Infection  may  also  occur  from  the  discharge  being  brought 
directly  in  contact  with  the  mucous  membrane  of  the  rectum  by  unnatural 
intercourse.  Symptoms. — The  prominent  symptoms  are  pain,  tenesmus, 
and  a  profuse  muco-purulent  discharge.  A  microscopic  examination  of  the 
discharge  will  generally  reveal  the  presence  of  gonococci.  Treatment. — 
This  consists  in  irrigation  of  the  rectum  with  warm  water,  and  in  the  injec- 
tion of  a  solution  of  sulphate  of  zinc,  gr.  v,  water,  5  i,  or  one  of  nitrate  of 
silver,  gr.  ss,  water,  si.  After  either  of  these  solutions  has  remained  for  a 
few  minutes,  it  should  be  allowed  to  escape  and  the  rectum  irrigated  with 
warm  water.  The  injections  should  be  increased  in  strength  if  they  do  not 
cause  pain,  and  administered  until  the  discharge  ceases. 

Periproctitis. — This  is  an  inflammation  of  the  tissues  sui-rounding  the 
rectum,  resulting  from  septic  infection.  It  may  follow  accidental  wounds  of 
the  rectum  or  of  the  surrounding  tissues,  or  may  result  from  surgical  opera- 
tions upon  these  parts,  and  may  be  localized  or  diffused. 

Localized  Periproctitis,  or  Perirectal  Abscess. — Inflammation  of 
the  perirectal  tissues  may  give  rise  to  abscess,  which  may  involve  the  super- 
ficial tissues  in  the  region  of  the  anus,  the  wall  of'  tlie  rectum,  or  the  ischio- 
rectal fossa.  Treatment. — This  consists  in  an  incision  into  the  inflamed 
tissues  to  evacuate  the  pus,  and  the  introduction  of  a  gauze  drain. 

Diffused  Periproctitis. — This  is  a  septic  inflammation  of  the  perirectal 
connective  tissue  which  follows  traumatism  and  operations  upon  the  rectum, 
and  is  characterized  by  high  temperature,  rigors,  sweating,  vomiting,  pelvic 
pain,  and  abdominal  distention.  The  infective  process  involves  the  connec- 
tive tissue  of  the  ischiorectal  fossa,  and  extends  by  the  lymph-paths  to  the 
pelvis,  and  if  not  arrested  is  apt  to  terminate  in  septic  peritonitis  and  death. 
The  difficulty  of  obtaining  and  maintaining  asepsis  in  wounds  of  this  region 
is  fully  recognized,  and  the  surgeon,  therefore,  should  be  most  careful  as 
regards  asepsis  in  all  wounds  or  operations  upon  the  rectum.  Free  drainage 
is  one  of  the  most  important  means  that  can  be  employed  in  these  cases  to 
prevent  septic  infection.  Treatment. — As  soon  as  the  condition  is  recog- 
nized free  incision  should  be  made  to  expose  the  infected  tissues  and  secure 
free  drainage,  the  parts  thoroughly  irrigated  with  a  bichloride  solution,  and 
rubber  or  gauze  drains  introduced.  The  patient  should  be  given  stimu- 
lants, such  as  strychnine,  alcohol,  and  digitalis,  and  if  peritonitis  has  not 
developed  recovery  may  occur. 

Gangrenous  Periproctitis. — This  affection,  which  consists  in  an 
intense  septic  infection  of  the  perirectal  cellular  tissues,  generally  follows 
wounds  of  the  rectum,  although  in  the  cases  reported  by  Jordan  no  history 
of  an  injury  could  be  discovered,  but  it  occurred  in  persons  who  were  heavy 
drinkers.  This  disease  presents  many  symptoms  in  common  with  traumatic 
spreading  gangrene,  and  probably  arises  from  the  same  infection.  Symp- 
toms.— The  skin  in  the  region  of  the  anus  and  buttocks  becomes  brawny 


1168  GANGRENE  OF  THE  RECTUM. 

and  hard,  and  upon  deep  pressure  crepitation  can  be  felt,  the  temperature 
is  elevated,  the  pulse  is  rapid,  and  death  usually  results  from  extension  of 
the  gaugreuous  process  into  the  pelvis  and  septicsemia.  Treatment. — 
This  consists  in  earlj^  and  free  incisions  to  secure  good  drainage,  antiseptic 
irrigation,  and  the  internal  use  of  stimulants  and  tonics.  We  had  under 
our  care  recently  a  case  of  gangrenous  periproctitis  in  a  lady,  who  about 
thirty-six  hours  before  we  saw  her  had  her  sphincter  stretched  for  the  relief 
of  hemorrhoids  by  an  irregular  rectal  specialist.  Inspection  of  the  anal 
region  showed  a  brawny  swelling  of  the  skin,  exteliding  to  the  buttocks  on 
both  sides  of  the  anus,  and  upon  deep  pressure  creiDitation  could  be  dis- 
tinctly felt  in  the  subcutaneous  tissues.  The  patient  was  etherized,  and  a 
curved  incision  several  inches  in  length  was  made  on  each  side  of  the  anus 
through  the  indurated  tissues  outside  of  the  edge  of  the  sphincter,  exposing 
the  cellular  tissue,  which  was  found  to  be  of  a  leaden  color  and  gangrenous. 
The  wound  was  thoroughly  irrigated,  and  two  large  rubber  drainage-tubes 
were  introduced  to  a  depth  of  four  inches,  as  well  as  strips  of  iodoform  gauze, 
to  secure  free  drainage.  After  the  incisions  were  made,  the  local  and  consti- 
tutional condition  of  the  patient  soon  improved,  and,  although  sloughs  were 
discharged  from  the  wounds  for  several  weeks,  she  made  a  good  recovery. 

Gangrene  of  the  Rectum. — This  condition  is  an  extremely  rare  one. 
It  is  said,  however,  to  be  not  uncommon  in  tropical  climates.  The  con- 
dition seems  to  bear  no  relation  to  wounds  of  the  rectum,  but  develops  in 
persons  of  intemperate  habits  upon  exposure  to  cold  and  dampness.  The 
symptoms  are  those  of  diffused  periproctitis.  In  a  patient  fifty  years  of 
age  recently  under  our  care  who  presented  these  symptoms,  an  incision 
showed  that  the  lower  portion  of  the  rectum  was  gangrenous  although  the 
anus  and  the  surrounding  skin  were  not  affected.  This  patient  a  few  days 
afterwards  passed  about  three  inches  of  the  lowest  part  of  the  rectal  tube 
through  one  of  the  incisions,  and  was  in  a  fair  way  to  recovery,  when  she 
suffered  from  an  attack  of  heat  exhaustion,  during  a  period  of  intense  heat, 
which  ended  fatally.  Treatment. — All  reported  cases  of  extensive  gan- 
grene of  the  rectum  have  terminated  fatally.  The  treatment  indicated  is 
division  of  the  si^hincter  muscle  with  free  incision  of  the  tissues  in  relation 
with  the  rectum  to  establish  drainage  and  facilitate  the  escape  of  the 
sloughing  bowel,  and  if  recovery  should  occur  an  inguinal  colostomy  would 
probably  be  required  later  to  relieve  the  obstruction  to  the  passage  of 
ffeces  following  the  contraction  resulting  from  the  cicatrization  of  the  gran- 
ulating cavity. 

Superficial  Rectal  Abscess. — This  affection  is  characterized  by  pain 
and  swelling  in  the  anal  region.  This  variety  of  abscess  is  not  apt  to  lead 
to  serious  consequences,  although  if  not  opened  promptly  it  may  give  rise 
to  a  superficial  rectal  fistula.  Treatment. — This  consists  in  making  a  free 
incision  in  the  inflamed  part,  even  before  the  presence  of  pus  can  be  demon- 
strated ;  a  strip  of  iodoform  gauze  should  be  packed  in  the  wound  to  prevent 
adhesion  of  the  edges.  Under  this  treatment  promj)t  healing  usually  occurs 
in  a  few  days. 

Ischio-Rectal  Abscess. — This  may  be  acute  or  chronic.  The  latter 
form  of  abscess  often  results  from  tuberculous  infection,   and  is  apt  to 


ISCHIO-RECTAL  ABSCESS.  1169 

become  iufected  with  pyogenic  organisms  and  present  the  symptoms  of 
the  acute  affection.  Ischio-rectal  abscess  may  result  from  traumatisms  of 
the  perirectal  tissues  produced  by  kicks,  blows,  or  falls,  giving  rise  to  acute 
phlebitis,  from  infection  of  wounds  of  the  mucous  surface  of  the  rectum 
resulting  from  opei'ations  or  injuries,  from  materials  contained  in  the  faeces, 
such  as  fish-bones,  pieces  of  bone,  or  any  other  hard  substance.  It  may  also 
occur  as  the  result  of  ulceration  of  the  rectum,  or  from  rupture  or  perforation 
of  the  rectal  wall  in  connection  with  stricture  or  cancer  of  the  rectum. 

Sjmiptoms. — The  development  of  ischio-rectal  abscess  is  usually 
attended  with  fever,  and  a  well-marked  rigor  or  chill  often  occurs.  Pain  of 
a  dull,  throbbing  character  is  a  prominent  symptom,  and  is  very  much 
increased  by  the  act  of  defecation.  A  symjitom  upon  which  we  lay  great 
stress,  and  which  is  not  generally  described,  is  jjaiu  in  the  anal  region  upon 
coughing.  This  we  have  found  an  early  and  constant  symptom,  and  one 
which  is  present  when  the  pus  is  deeply  seated  and  many  of  the  other  symp- 
toms are  wanting.  Irritability  of  the  bladder  or  retention  of  urine  may  also 
be  present.  The  abscess  is  usually  situated  upon  the  lateral  aspect  of  the 
anus,  aud  may  present  a  prominent  fluctuating  swelling,  or  it  may  be  scarcely 
marked,  and  the  situation  of  the  abscess  be  recognizable  only  by  a  localized 
brawny  and  thickened  condition  of  the  skin,  with  some  cedema.  Exami- 
nation of  the  rectum  with  the  finger  will  sometimes  reveal  bulging  of  the 
rectal  wall  in  the  region  of  the  abscess.  Ischio-rectal  abscess,  if  left  to 
itself,  usually  opens  into  the  rectum,  and  a  second  opening  is  apt  to  occur 
on  the  cutaneous  surface  near  the  anus  ;  or  it  may  open  first  upon  the  skin, 
and  subsequently  an  opening  occurs  into  the  i-ectum,  and  there  results  a 
persistent  sinus,  which  is  known  as  a  fistula  in  ano,  or  rectal  sinus. 

Treatment. — In  no  abscess  is  the  indication  for  early  incision  more 
urgent,  for  an  opening  relieves  the  pain  and  renders  extremely  favorable 
the  prospect  of  recoverj'^  witliout  the  formation  of  a  fistula.  The  treatment 
of  this  condition,  therefore,  consists  in  early  aud  free  incision  ;  the  surgeon 
should  not  wait  until  the  presence  of  pus  is  evident,  but  should  make  an 
incision  if  deep  induration  of  the  tissues  in  the  anal  region  can  be  felt  on 
palpation.  The  patient  should  be  anaesthetized  and  placed  upon  his  back 
with  the  pelvis  resting  upon  the  edge  of  the  table,  and  the  region  of  the  anus 
and  buttocks  thoroughly  sterilized.  A  curved  incision,  several  inches  iu 
length,  is  made  over  the  swelling  or  indui-ated  tissue  outside  of  the  edge  of 
the  sphincter  muscle,  and  the  tissues  are  carefully  divided  until  the  pus- 
cavity  is  reached,  care  being  taken  that  the  dissection  does  not  go  too  close 
to  the  wall  of  the  rectum.  When  the  abscess-cavity  is  reached,  this  should 
be  incised  to  its  full  extent,  the  finger  introduced  to  break  down  any  bands 
or  pockets,  and  the  cavity  gently  curetted.  To  expose  the  cavity  fully,  one 
or  more  incisions  at  right  angles  to  the  first  incision,  extending  out  upon 
the  buttock,  may  be  required.  As  drainage  is  the  most  important  factor, 
the  incisions  should  be  free.  The  cavity  should  next  be  thoroughly  utI- 
gated  with  bichloride  solution,  and  lightly  packed  with  strips  of  iodoform 
or  sterilized  gauze,  after  which  a  good-sized  j^ad  of  sterilized  gauze  aud  a 
pad  of  cotton  should  be  placed  over  the  wound  and  held  in  place  by  a 
T- bandage.     The  opening  of  these  abscesses  by  a  small  puncture  is  apt  to 


1170 


FISTULA  IN  ANO. 


result  in  a  ijermanent  sinus,  which  is  likely  soon  to  communicate  with  the 
rectum,  because  of  the  lack  of  drainage. 

The  after-treatment  consists  in  introducing  a  one-grain  opium  sup- 
pository into  the  rectum  and  keeping  the  bowels  at  rest  for  three  days,  at 
which  time  a  laxative  should  be  given.  The  dressing  is  usually  changed 
upon  the  third  day  :  the  packing  is  gently  removed,  the  wound  is  irrigated, 
and  a  few  strips  of  iodoform  gauze  are  loosely  packed  into  it ;  and  this 
method  of  dressing  should  be  continued  until  the  wound  has  healed  from 
the  bottom  by  granulation.  In  deep  and  extensive  abscesses  it  is  often 
some  weeks  before  the  wound  is  solidly  healed,  but,  as  a  rule,  if  they  are 
treated  in  this  manner  healing  without  the  formation  of  a  rectal  fistula  is 
usual. 

Fistula  in  Ano,  or  Rectal  Sinus. — This  consists  in  a  sinus  resulting 
from  an  ischio-rectal  abscess  which  communicates  with  the  cavity  of  the 
rectum  or  is  in  close  relation  with  its  wall. 

A  complete  fistula  is  one  in  which  a  communication  exists  between 
the  rectum  and  the  cutaneous  surface  by  means  of  a  sinus.  (Fig-  902.) 
A  blind  internal  fistula  consists  of  a  suppurating  tract  communicating 
with  the  rectum,  but  having  no  external  opening  upon  the  skin.  (Fig.  903.) 
A  blind  external  fistula  consists  of  a  suppurating  tract  in  close  relation 
with  the  wall  of  the  rectum,  having  an  opening  upon  the  cutaneous  surface 
in  the  region  of  the  auus.      (Fig.  904.)      A  form  of  rectal  fistula  is  also 


Fig. 


Complete  tistula  in  ano. 


Blind  internal  fibtula. 


Blind  external  Hstula. 


occasionally  seen  which  is  known  as  a  horseshoe  fistula,  in  which  the  pus 
has  burrowed  around  the  rectum  from  its  point  of  origin,  and  communicates 
with  the  cavity  of  the  rectum  on  opposite  sides  of  the  bowel  and  with  the 
cutaneous  surface  at  one  or  more  points.     (Fig.  906.) 

Examination  of  Rectal  Fistulse. — In  examining  a  patient  suffering 
from  fistula,  he  should  be  placed  upon  his  back  and  a  fine  silver  i^robe 
introduced  into  the  external  opening,  the  index  finger  being  jjassed  into  the 
rectum.  By  gently  manipulating  the  probe,  while  at  the  same  time  the 
finger  in  the  rectum  is  made  to  follow  its  direction,  if  an  internal  opening  is 
present  it  may  be  brought  in  contact  with  the  finger.  A  small  bunch  of 
granulations  can  often  be  felt  in  the  wall  of  the  rectum,  indicating  the  posi- 
tion of  the  internal  opening.     The  sinus  leading  to  the  rectal  opening  may 


SYMPTOMS  OF  FISTULA  IN   ANO.  1171 

be  very  tortuous,  or  may  be  branclied  so  that  great  patience  and  delicate 
manipulation  will  be  required  before  the  end  of  the  probe  can  be  made  to 
enter  the  rectum.  If  the  internal  opening  is  very  small,  it  may  be  impossi- 
ble to  pass  the  probe  through  it  and  thus  locate  it.  In  cases,  therefore, 
where  an  internal  opening  is  suspected,  a  little  colored  fluid  or  i)eroxide  of 
hydrogen  may  be  injected  into  the  siuus,  and  if  an  internal  opening  exists  it 
will  be  seen  to  escape  from  the  rectum,  when  the  position  of  the  opening- 
may  be  located  by  the  use  of  a  rectal  speculum. 

In  Mind  external  fistula  the  probe  can  usually  be  felt  near  the  wall  of  the 
rectum  at  some  point,  but  cannot  be  made  to  enter  the  cavity  of  the  gut.  In 
examining  a  patient  suffering  from  blind  internal  fistula,  the  finger  should  be 
placed  in  the  rectum,  when  the  site  of  the  internal  opening  can  often  be 
felt.  Palpation  of  the  skin  in  the  anal  region  will  usually  reveal  an 
indurated  spot  which  marks  the  point  where  the  sinus  api^roaches  the  skin. 
A  bent  probe  introduced  into  the  internal  opening  may  be  passed  into  the 
sinus  and  can  be  felt  under  the  skin.  In  cases  of  horseshoe  fistula  and  very 
tortuous  fistula,  a  satisfactory  examination  of  the  fistulous  tracts  cannot 
usually  be  made  without  the  aid  of  an  anaesthetic.  In  examining  cases  of 
fistula  the  fact  should  not  be  lost  sight  of  that  abscesses  connected  with  dis- 
eases of  the  spine,  sacrum,  or  hip  sometimes  opens  into  the  rectum,  or  the 
pus  reaches  the  cutaneous  surface  in  the  region  of  the  anus  by  following  the 
rectal  fascia.  In  such  cases  a  careful  examination  of  the  patient  will  usually 
reveal  the  source  of  the  abscess. 

Symptoms. — These  vary  greatly,  and  depend  largely  upon  the  charac- 
ter of  the  fistula  and  whether  there  is  active  suppuration  in  the  fistulous 
tract.  In  complete  fistula  there  may  be  an  escape  of  faeces,  if  liquid,  from 
the  fistula,  and  also  of  pus,  and  the  involuntary  discharge  of  flatus.  Pain 
is  usually  not  a  prominent  symptom  if  drainage  from  the  fistulous  tracts  is 
free,  but  if  they  are  closed  by  granulations  acute  pain  may  be  experienced, 
followed  by  a  discbarge  of  pus  and  relief  from  pain.  lu  blind  internal 
fistula  pain  and  the  escai^e  of  pus  with  the  stool  are  more  apt  to  occur  than 
in  the  other  varieties,  and  in  this  fistula,  as  well  as  in  the  complete  one,  a 
few  drops  of  blood  may  be  noticed  upon  the  fteces. 

Treatment. — In  complete  fistula  the  division  of  the  tissues  between  the 
rectal  and  cutaneous  oi^enings  is  the  only  operation  which  is  followed  by  a 
cure.  The  parts  should  be  sterilized,  and  after  the  patient  has  been  anaes- 
thetized a  director  should  be  passed  into  the  external  opening  and  its 
extremity  brought  out  of  the  anus.  The  tissues  upon  the  director  should 
then  be  divided,  care  being  taken  that  the  division  of  the  sphincter  muscle 
is  at  a  right  angle  to  its  fibres  (Fig.  905),  for  such  a  division  is  less  likely  to 
be  followed  by  incontinence  than  an  oblique  division.  If  branching  sinuses 
are  present  these  should  be  freely  opened  up  by  incisions,  curetted  and 
irrigated,  and  loosely  packed  with  strips  of  iodoform  gauze.  If  the  suppu- 
rating tract  is  a  straight  one,  it  may  be  thoroughly  curetted,  or  the  cicatricial 
tissue  may  be  excised,  and,  after  being  irrigated,  the  deep  portions  of  the 
wound,  as  well  as  the  divided  sphincter  muscle,  may  be  brought  together 
by  sutures.  This  method  has  recently  been  employed  with  success,  but  we 
think  it  should  be  practised  only  in  selected  cases,  such  as  have  just  been 


1172 


TREATMENT  OF  FISTULA   IN  ANO. 


mentioned,  and  that  in  the  majority  of  cases  the  method  of  packing  to 
secure  healing  of  the  wound  from  the  bottom  by  granulation  is  the  procedure 
most  likely  to  be  followed  by  a  permanent  cure.     After-Treatment. — 

After  packing   or  closing 

Fig.  905. 

- i^> 


the  wound  with  sutures,  an 
opium  suppository  should 
be  introduced  into  the  rec- 
tum, and  a  pad  of  sterilized 
gauze  and  cotton  placed 
over  the  wound  and  held 
in  position  by  a  T-bandage. 
The  bowels  should  be  kept 
quiet  for  three  or  four 
days,  and  then  moved  by 
a  laxative.  The  wound 
should  be  dressed  at  the 
end  of  the  third  day,  and 
after  the  packing  has  been 
removed  it  should  be  irri- 
gated and  a  few  strips  of 
iodoform  gauze  loosely 
packed  in  the  wound,  subsequent  dressings  being  made  in  the  same  manner 
until  the  wound  has  healed,  which  usually  requires  several  weeks. 

A  single  division  of  the  sphincter  is  not  apt  to  be  followed  by  inconti- 
nence. In  cases,  however,  in  which  two  or  more  internal  openings  exist,  or 
in  a  horseshoe  fistula,  or  where  there  are  a  number  of  external  openings  with 
a  single  internal  opening,  the  greatest  judgment  must  be  exercised  by  the 
surgeon  to  obtain  a  satisfactory  result  as  regards  healing  of  the  sinuses 
without  the  production  of 
incontinence.       When    a 


Division  of  fistula  in  ano. 


Fig.  906. 


number  of  sinuses  exist 
with  one  internal  open- 
ing, they  should  be  laid 
open  freely,  and  finally 
the  sphincter  and  super- 
imposed tissues  should  be 
divided.  When  a  horse- 
shoe fistula,  with  two  or 
more  openings  into  the 
rectum,  exists,  the  inci- 
sions should  be  so  planned 
that  the  sinuses  shall  be  uorsesiioe  fistula 
opened  freely,  and  the 
sphincter  muscle  divided  at  one  point  only,  corj-esponding  to  the  opening 
of  one  of  the  sinuses  (Fig.  906),  for  if  the  sphincter  is  divided  at  two  points 
incontinence  is  almost  certain  to  follow.  After  all  the  sinuses  have  healed, 
with  the  exception  of  the  one  leading  down  to  the  second  rectal  opening, 
this  can  be  divided  with  little  risk  of  incontinence. 


iistulous  tract ;  b,  lines  of  incision  exposing  the 
sinuses  and  dividing  the  sphincter. 


HEMORRHOIDS.  II73 

In  the  treatment  of  blind  internal  fistula  the  incomplete  fistula  should  be 
converted  into  a  complete  one  by  making  an  external  opening  at  the  lowest 
point  of  the  sinus ;  a  director  should  be  introduced  into  the  external  open- 
ing and  brought  out  at  the  internal  opening,  and  the  tissues  divided  upon 
it ;  the  subsequent  treatment  of  the  wound  Is  similar  to  that  in  the  case  of 
complete  fistula.  In  blind  external  fistula  the  sinus  should  be  freely  laid  open 
and  curetted,  and  after  being  irrigated  should  be  loosely  packed  with  strips 
of  gauze.  In  this  variety  of  fistula,  if  the  end  of  the  fistula  is  separated 
from  the  rectum  by  the  mucous  membrane  only,  and  is  low  down  in  the  rec- 
tum, it  is  advisable  to  make  the  fistula  a  complete  one  by  jierforating  the 
mucous  membrane  with  the  end  of  the  director  and  dividing  the  tissues  and 
the  sphincter. 

In  patients  who  refuse  operative  treatment,  or  iu  cases  of  fistula  in  which 
the  internal  opening  is  very  high  up  in  the  rectum,  an  elastic  ligature  may  be 
introduced  through  the  external  and  the  internal  opening  and  brought  out 
of  the  anus  and  firmly  tied,  and  will  in  a  few  days  cut  its  way  out.  The 
resulting  wound  should  be  dressed  as  iu  cases  of  division  of  the  tissues  with 
the  knife.  This  method  of  treatment  is  painful,  and  is  not  as  efficient  as 
that  by  incision. 

Incontinence  following  single  division  of  the  si^hincter  is  rare,  but  is 
very  apt  to  follow  multiple  section  of  the  sphincter.  It  is  not  likely  to  be  a 
troublesome  symptom  unless  the  bowels  are  loose.  If  incontinence  exists, 
the  edges  of  the  sphincter  muscle  should  be  exposed  by  incision  and  brought 
together  by  deep  sutures,  and  the  skin  approximated  by  superficial  sutures. 
This  condition  can  also  be  remedied  by  the  application  of  the  cautery  to  the 
skin  and  mucous  membrane  over  the  sphincter,  the  Paquelin  cautery  being 
used  and  three  or  four  radiating  eschars  being  made,  in  the  healing  of  which 
the  skin  and  tJie  mucous  membrane  become  drawn  to  one  side  and  puckered, 
so  that  involuntary  escape  of  fteces  does  not  take  place. 

Hemorrhoids. — Hemorrhoids,  or  piles,  which  arise  from  dilatation 
and  increase  in  the  blood-vessels  in  the  lower  end  of  the  rectum,  are 
extremely  common,  and  are  met  with  iu  all  conditions  of  life.  They  are 
most  frequently  observed  in  middle  life  and  are  rarely  seen  in  children. 

Various  causes  have  been  assigned  to  account  for  the  frequency  of  hem- 
orrhoids in  man,  but  the  most  satisfactory  explanation  of  their  etiology  is 
upon  anatomical  grounds,  the  erect  posture,  and  the  fact  that  the  veins  of 
the  interior  of  the  rectum  emptj'  into  the  superior  hemorrhoidal  veiu,  which 
in  turn  empties  into  the  portal  vein,  favoring  their  development.  The  veins 
in  leaving  the  rectum  i^ass  obliquely  through  the  muscular  coat  of  the 
bowel,  and  are  frequently  subjected  to  pressure.  They  are  without  valves, 
and  the  blood-current  may  feel  the  effect  of  obstruction  in  the  portal  vein. 

Pathology. — In  all  forms  of  hemorrhoids  tliere  are  dilatation  and 
increase  in  the  blood-vessels,  with  more  or  less  proliferation  of  the  con- 
nective tissue.  A  sudden  increase  in  size  of  hemorrhoidal  tumors  may 
result  from  phlebitis,  thrombosis,  or  perivascular  inflammation,  which 
causes  a  clotting  of  blood  within  the  previously  existing  varicose  veins. 
Hartmaun  and  Lieffering  consider  that  'phlebitis  of  the  hemorrhoidal  veins 
is  due  to  the  presence  within  the  veins  of  the  bacterium  coU  communis. 

75 


1174  EXTERNAL  HEMOREHOIDS. 

Hemorrhoids,  for  pi'actical  purposes,  may  be  classified  as  external  or 
internal,  according  as  they  are  below  or  above  the  external  sphincter  muscle. 
An  external  hemorrhoid  consists  of  a  dilatation  of  an  inferior  hemorrhoidal 
vein,  is  covered  by  skin,  is  situated  below  the  external  sphincter,  and  is  in 
connection  with  the  general  venous  system.  An  internal  hemorrhoid,  on 
the  other  hand,  consists  of  a  dilated  branch  of  the  middle  or  superior 
hemorrhoidal  veins,  is  covered  by  mucous  membrane,  is  above  the  external 
sphincter,  and  is  in  connection  with  the  visceral  venous  system.  As  the 
anastomosis  between  these  sets  of  veins  is  very  free,  hemorrhoids  are  often 
observed  which  arise  from  both  sources  and  are  known  as  intero-external 
hemorrhoids. 

External  Hemorrhoids. — This  variety  of  hemorrhoids  is  due  to  a 
dilatation  of  the  external  hemorrhoidal  veins,  and  exists  as  small  venous 
tumors,  from  the  size  of  a  pea  to  that  of  a  filbert,  containing  fluid  blood,  or 
as  tumors  composed  of  varicose  veins  with  a  slight  proliferation  of  the 
connective  tissue,  or  as  tags  of  skin  and  connective  tissue  situated  at  the 
verge  of  the  anus.  The  last-named  variety  often  results  from  external  hem- 
orrhoids which  have  been  inflamed  and  have  iindergone  either  resolution 
or  suiDpuration.  Symptoms. — External  hemorrhoids,  as  a  rule,  unless 
inflamed,  cause  the  patient  little  discomfort ;  whea,  however,  thrombosis 
occurs,  or  the  hemorrhoid  becomes  inflamed,  the  pain  is  severe,  and  is 
increased  by  exercise  and  by  movement  of  the  bowels.  Spasmodic  contrac- 
tion of  the  sphincter  and  levator  ani  muscles  in  this  condition  is  quite 
common,  and  adds  greatly  to  the  patient's  discomfort.  If  the  inflamed 
hemorrhoid  does  not  suppurate  and  resolution  takes  place,  the  swelling 
gradually  subsides  and  the  pain  diminishes.  If.  however,  suppuration 
occurs  in  the  tumor,  after  the  pus  is  discharged  the  pain  quickly  disap- 
pears, and  the  tumor  gradually  shrinks,  leaving  a  tag  composed  largelj'  of 
skin  and  connective  tissue.  External  hemori-hoids  composed  of  skin  and 
connective  tissue  are  apt  to  give  rise  to  eczema  of  the  anus,  and  may  be 
accompanied  with  pruritis,  or  a  small  fissure  may  exist  at  the  base  of  one 
of  these  tags. 

Treatment. — Unless  inflamed,  external  hemorrhoids  rarely  require 
treatment ;  when  inflamed  it  is  either  palliative  or  radical.  The  palliative 
treatment  consists  in  rest  in  the  recumbent  posture,  the  administration  of  a 
saline  purgative,  and  the  local  use  of  an  ointment  of  ext.  belladonnse,  gr. 
XV ;  ext.  opii,  gr.  x ;  ext.  hamamelidis,  oi ;  adipis,  si,  and  the  application 
of  an  ice-cap  to  the  anus.  Under  this  treatment  the  pain  and  swelling 
subside  in  two  or  three  days.  If  the  inflammation  is  not  arrested  and  sup- 
puration occurs  in  the  tumor,  hot  applications  should  be  used,  or,  better, 
the  tumor  should  be  incised,  for  if  this  is  not  done  the  patient  may  suffer 
for  several  days  before  a  spontaneous  evacuation  of  the  pus  takes  place. 

The  radical  treatment  consists  in  incision  or  excision.  Incision. — The 
tumor  should  be  gently  washed  with  soap  and  water,  and  finally  with 
bichloride  solution,  and  after  it  has  been  fixed  with  the  finger  it  should  be 
freely  split  open  with  a  narrow,  sharp  bistoury,  and  the  contained  blood-clot 
turned  out ;  little  bleeding  usually  occurs,  and  after  irrigating  the  cavity  a 
small  strip  of  gauze  is  pressed  into  it,  or  it  may  be  dusted  with  powdered 


INTERNAL  HEMORRHOIDS.  1175 

boric  acid,  and  a  gauze  pad  is  placed  over  the  wound  and  held  in  place 
by  a  T-bandage.  The  pain  is  quickly  relieved  by  this  procedure,  and  the 
wound  is  usually  healed  in  three  or  four  days.  Excision. — This  oper- 
ation is  especially  applicable  to  the  cutaneous  variety  of  external  hemor- 
rhoids, and,  as  it  is  painful,  and  as  a  number  of  individual  tumors  are  often 
to  be  removed  at  the  same  time,  local  or  general  annesthesia  is  required.  The 
parts  being  sterilized,  each  tumor  is  grasped  with  forceps  and  two  short 
skin-flaps  are  dissected  from  its  base,  and  the  base  of  the  tumor  is  divided 
below  the  line  of  the  flaps.  The  flaps  are  next  approximated  with  sutures 
of  catgut  or  silk.  The  same  procedure  is  repeated  until  all  the  tumors  have 
been  removed.  Bleeding  in  this  operation  is  usually  very  slight.  The 
tumor  may  also  be  cut  off,  leaving  a  short  stump  close  to  its  attachment  to 
the  skin,  and  the  base  cauterized  with  the  ijoint  of  a  Paquelin  cautery  at  a 
dull-red  heat.  The  parts  should  next  be  dressed  with  powdered  boric  acid, 
and  a  gauze  pad  applied  and  held  in  jilace  with  a  T-bandage. 

Internal  Hemorrhoids. — These  tumors  are  of  two  varieties,  capillary 
and  venous  hemorrhoids.  The  capillary  hemorrhoid  is  a  tumor  made  up  of 
arteries,  veins,  and  capillaries,  usually  of  moderate  size  and  a  bright-red 
color,  with  a  granular  surface,  covered  by  a  thin  layer  of  mucous  membrane. 
This  variety  of  hemorrhoids  bleeds  freely,  and  is  generally  found  to  be 
present  in  cases  in  which  free  hemorrhage  is  a  prominent  symptom.  The 
venous  hemorrhoid  is  a  tumor  composed  of  freely  anastomosing  dilated  and 
tortuous  veins  which  contain  pouches  and  are  bound  together  by  connective 
tissue.  The  tumor  is  supplied  with  blood  by  one  or  more  arteries  of  consid- 
erable size  which  enter  at  its  base.  Venous  hemorrhoids  are  usually  much 
larger  than  capillary  hemorrhoids,  but  the  two  varieties  may  exist  in  the 
same  case,  a  small  capillary  hemorrhoid  growing  from  the  surface  of  a  venous 
hemorrhoid.  Symptoms. — The  most  marked  symptom  of  internal  hemor- 
rhoids is  bleeding,  which  may  be 
profuse  in  the  capillary  variety, 
but  is  also  ijresent  in  venous  hem- 
orrhoids after  they  have  existed 
for  soiae  time,  and  may  be  so 
free  after  each  movement  of  the 
bowels  as  to  cause  the  patient  to 
present  marked  symptoms  of  ane- 
mia, and  is  occasionally  so  pro- 
fuse as  to  produce  syncope.  Pro- 
lapse of  internal  hemorrhoids  at 
stool  Is  common,  but  the  tumors 
can  usually  be  returned  within 
the  sphincter  without  difficulty. 
(Fig.  907. )    Pain  in  internal  hem-  „   ,      ^    ^      , ,         ,     , 

^      o  Prolapsed  internal  hemorrhoKk. 

orrhoids   is   not  common,  unless 

the  tumors  become  inflamed  or  strangulated.  Strangulation  and  gangrene 
may  occur  if  the  hemorrhoids  are  extruded  from  the  anus  and  are  tightly 
grasped  by  the  sphincter.  Mucous  discharge  from  the  anus  may  also  be 
quite  free  in  case  of  internal  hemorrhoids. 


1176  TREATMENT  OF  INTERNAL  HEMORRHOIDS. 

Diagnosis. — Internal  hemorrhoids  may  be  confounded  with  cancer  of 
the  rectum,  polypus,  and  prolapsus,  as  these  diseases  present,  in  common 
with  internal  hemorrhoids,  bleeding,  and'  a  tumor.  A  prolapsed  and  con- 
gested polypus  presents  some  resemblance  to  an  internal  hemorrhoid,  but 
upon  reducing  the  polypus  and  introducing  the  finger  its  attachment  to  the 
rectal  wall  by  a  pedicle  can  easily  be  felt.  The  appearance  of  a  case  of  pro- 
lapsus is  characteristic,  and  a  malignant  growth,  with  its  comparatively  firm 
structiire  and  its  surrounding  induration,  cannot,  after  careful  exploration, 
be  confounded  with  hemorrhoids. 

Treatment. — Operative  treatment  is  not  required  in  all  cases  of  hemor- 
rhoids. Internal  hemorrhoids  may  be  symptomatic  of  other  diseases,  such  as 
disease  of  the  liver  or  of  the  kidneys,  or  may  be  due  to  malignant  or  benign 
stricture  of  the  rectum  at  a  higher  point,  or  to  the  presence  of  a  vesical 
calculus,  stricture  of  the  urethra,  or  enlarged  prostate,  and  in  women  preg- 
nancy or  uterine  disease  may  be  the  cause  of  their  development.  In  such 
cases  the  condition  which  is  a  factor  in  their  production  should  be  removed 
by  medical  treatment  or  by  operation,  and  often  after  this  is  removed  the 
hemorrhoids  disappear.  If  they  do  not,  an  operation  for  their  removal 
should  be  undertaken. 

The  treatment  of  internal  hemorrhoids  may  be  ijalliative  or  radical. 
Palliative  Treatment.— This  consists  in  the  regulation  of  the  bowels,  and, 
as  constipation  always  aggravates  the  condition,  the  patient  should  be  given 
a  saline  laxative  each  morning,  sulphate  of  sodium  or  of  magnesium  being 
the  best,  to  secure  a  soft  movement  daily  ;  the  use  of  a  small  enema  of  water 
after  each  stool  may  also  be  followed  by  good  results.  An  ointment  of 
ext.  belladonnfe,  gr.  x  ;  ext.  opii,  gr.  v ;  ext.  stramonii,  gr.  xl ;  ext.  hama- 
melidis,  3i ;  adipis,  si,  can  also  often  be  employed  with  advantage.  If 
hemorrhage  is  a  ]prominent  symptom,  an  astringent  ointment  containing 
tannic  acid  or  persulphate  of  iron  may  be  smeared  over  the  tumor  when  it 
is  prolapsed,  or  may  be  introduced  into  the  rectum.  Suppositories  contain- 
ing these  substances  may  also  be  employed.  If  a  patient  suffering  from  in- 
ternal hemorrhoids  pays  attention  to  the  condition  of  his  bowels  and  uses 
some  of  the  remedies  mentioned,  he  will  often  be  able  to  get  on  comfortably 
for  years  without  having  his  piles  operated  upon.  When,  however,  hemor- 
rhage is  persistent,  nothing  short  of  an  operation  can  entirely  relieve  the 
condition. 

Radical  Treatment. — This  may  be  accomplished  by  various  procedures, 
among  the  most  important  of  which  are  :  1,  chemical  caustics  ;  2,  the  injec- 
tion of  coagulating  fluids ;  3,  ligature  ;  4,  the  clamp  and  cautery ;  5,  ex- 
cision ;  6,  electrolysis.  Preceding  any  of  the  radical  operations  for  internal 
hemorrhoids,  tlie  patient's  bowels  should  be  moved  by  a  laxative  and  the 
rectum  thoroughly  emptied  by  an  enema  a  few  hours  before  the  time  fixed 
for  the  operation.  In  all  cases  it  will  be  found  advisable  to  perform  the 
operation  under  general  autesthesia.  After  the  patient  has  been  anaes- 
thetized he  should  be  placed  in  the  lithotomy  position,  and  the  index  fingers 
or  the  thumbs  should  be  introduced  into  the  rectum  and  the  sphincter 
thoroughly  stretched  until  it  is  felt  that  its  resistance  has  been  overcome. 
Forced  dilatation  of  the  sphincter  is  employed  by  some  surgeons  as  a  curative 


TREATMENT  OF  INTERNAL  HEMORRHOIDS.  II77 

measure  in  the  treatment  of  internal  hemorrhoids.  By  this  procedure  the 
hemorrhoids  can  be  brought  into  view  and  the  cavity  of  the  rectiiui  can  be 
inspected.  After  stretching  the  •sphincter  the  rectum  should  be  irrigated 
with  a  solution  of  green  soap,  or  may  be  wiped  out  with  a  gauze  pad  satu- 
rated with  soap  solution,  and  is  finally  irrigated  with  boric  acid  solution. 

Chemical  Caustics. — This  method  of  treatment  is  not  often  employed  ; 
the  caustic  to  be  preferred  is  nitric  acid.  In  small  capillary  hemorrhoids 
cauterization  with  nitric  acid  will  effect  a  cure,  but  the  application  may 
have  to  be  repeated  more  than  once  before  the  desired  result  is  obtained. 

Injection  of  Coagulating  Fluids. — This  method  is  sometimes  em- 
ployed, tincture  of  iron,  carbolic  acid,  and  other  substances  being  used. 
Carbolic  acid,  from  fifteen  to  fiftj^  per  cent.,  in  sterilized  glycerin,  is  the 
drug  ui3on  which  most  reliance  is  placed.  The  hemorrhoids  are  exposed, 
and  two  or  three  drops  of  the  carbolic  acid  solution  are  injected  in  the 
centre  of  the  hemorrhoid  by  means  of  a  hypodermic  syringe  with  a  very 
fine  needle.  The  injections  have  to  be  repeated  a  number  of  times ;  the 
results  following  this  treatment  are  uncertain,  and  its  use  is  not  without 
danger  ;  inflammation  and  sloughing  of  the  hemorrhoid  may  occur,  as  well 
as  periproctitis.  This  method  is  a  favorite  one  in  the  hands  of  irregular 
rectal  specialists.  We  have  seen  extensive  sloughing  of  the  hemorrhoid, 
and  of  the  skin  in  the  region  of  the  anus,  follow  the  use  of  these  injections. 
The  method  is  therefore  not  to  be  recommended,  and  should  be  employed 
only  in  cases  in  which  patients  refuse  to  have  any  more  certain  operation 
performed.  If  employed,  care  should  be  taken  to  have  the  solution  freshly 
made  and  the  needle  and  syringe  thoroughly  sterilized. 

The  Ligature. — This  method  of  treatment  is  an  old  and  well-established 
one,  and  the  results  folh  iwing  its  employment  are  very  satisfactory.  In  the 
operation  of  ligating  liemorrhoids,  after  the  sphincter  has  been  well  dilated, 
a  hemorrhoidal  tumor  is  grasped  with  forceps, — ring  forceps  being  the  best, 
as  they  do  not  tear  the  tumor, — and  a  blunt  needle  attached  to  a  handle  is 
threaded  with  a  double  ligature  of  strong  sterilized  silk  and  passed  through 
the  base  of  the  tumor  and  brought  out  upon  the  skin  surface  ;  the  ligature  is 
next  divided,  and  the  needle  is  withdrawn.  Before  tying,  a  groove  is  cut  in 
the  mucous  membrane  at  its  junction  with  the  skin,  in  which  the  ligature  is 
to  rest.  By  this  procedure  the  subsequent  pain  is  diminished.  By  firmly 
tying  the  corresponding  ends  of  the  ligatures  the  pile  is  tightly  strangulated 
in  two  portions.  Care  should  be  exercised  that  the  strangulation  of  the 
mass  is  complete.  After  the  ligatures  have  been  secured  th6  ends  are  cut 
short,  and  a  portion  of  the  pile  may  be  cut  away  with  scissors,  leaving  a 
good  stump,  so  that  the  ligature  cannot  slip.  The  same  procedure  is  repeated 
until  all  the  hemorrhoids  have  been  strangulated.  The  stumps  are  then 
pushed  back  within  the  sphincter,  an  opium  suppository  is  introduced  into 
the  rectum,'  and  a  pad  of  gauze  and  compress  of  cotton  are  placed  over  the 
anal  region  and  held  firmly  in  place  with  a  T-bandage.  Eetention  of  urine 
is  apt  to  occur  after  the  ligation  of  hemorrhoids,  and  necessitates  the  use  of 
a  catheter  for  a  few  days.  Tiae  ligature  may  be  applied  after  dissecting  the 
stump  of  the  pile  well  up  in  the  bowel ;  the  stump  is  then  ligated  and  the 
pile  cut  off,  and  the  wound  is  sutured  below.     By  this  procedure  pain  and 


1178 


TREATMENT  OF  INTERNAL  HEMORRHOIDS. 


retention  of  m-ine  are  less  likely  to  occur.  The  patient  should  be  confined 
to  bed  for  about  ten  days,  and  the  bowels  opened  by  a  laxative  and  an  enema 
upon  the  third  or  fourth  day,  after  which  the  bowels  should  be  moved  on 
alternate  days.  Accidents  following  the  use  of  the  ligature  are  rare  ;  if  a 
ligature  slips,  bleeding  may  occur,  and  a  few  deaths  from  tetanus  following 
this  treatment  have  been  observed,  but  these  cases  of  infection  can  hardly 
be  credited  to  the  use  of  the  ligature.  The  results  following  the  ligature  are 
satisfactory  as  regards  a  cure  of  the  afi"ection,  and  the  only  objections  to  its 
use  are  the  pain  which  is  often  experienced,  and  the  fact  that  retention  of 
urine  is  common,  calling  for  the  use  of  the  catheter. . 

The  Clamp  and  Cautery. — This  method,  which  was  revived  by  Mr. 
Smith,  of  London,  is  now  very  widely  employed  in  the  treatment  of  hemor- 


Ivelsey's  hemorrhoid  clamp. 

rhoids.  The  instniments  required  are  pile-forceps,  a  clamp,  and  a  cautery 
iron,  or,  better,  a  Paquelln  cautery.  The  clamp  we  prefer  is  Kelsey's 
(Pig.  908),  which  is  not  ]3rovided  with  ivory  plates,  thus  rendering  the 
blades  thinner  and  enabling  one  to  grasp  a  larger  amount  of  the  hemorrhoid, 

— a  matter  of  importance  when 
Fig.  909.  small  growths  are  being  operated 

upon. 

In  operating  by  this  method 
the  hemorrhoid  is  grasped  with 
forceps  and  drawn  outward  ;  the 
clamp  is  then  applied  to  its 
base,  and  the  handles  are  firmly 
pressed  together  and  secured  by 
a  screw.  (Fig.  909.)  The  hem- 
orrhoid is  next  cut  off  with  scis- 
sors, leaving  a  stump  extending 
above  the  clamp  for  about  one- 
eighth  to  one-quarter  of  an  inch. 
The  stump  of  the  tumor  is  next 
thoroughly  cauterized  with  the 
Paquelin  cautery  at  a  dull-red 
heat.  (Pig.  910.)  In  small  hem- 
orrhoids it  is  better  not  to  cut 
away  any  portion  before  applying  the  cautery.  After  the  hemorrhoid  has 
been  thoroughly  cauterized,  the  clamp  is  gradually  loosened,  and  if  any 
bleeding  occuis  the  cautery  is  reapplied.  This  procedure  is  repeated  until 
all  the  tumors  have  been  clamped  and  cauterized.     The  seared  surfaces  are 


Forceps  and  clamp  applied  to  hemorrhoids 


TREATMENT  OF  INTERNAL  HEMORRHOIDS. 


1179 


Fk,  010 


dusted  with  boric  acid,  or  covered  with  iodoform  ointment,  and  pi-essed  back 
within  the  sphincter,  and  an  opium  suppository  is  introduced  into  the 
rectum,  after  which  a  gauze  pad  is  applied  and  held  firmly  in  place  by  a 
T-bandage.  The  patient  is  con- 
fined to  bed  for  about  ten  days, 
and  the  bowels  are  kept  qiiiet 
until  the  fourth  day,  when  they 
are  moved  by  a  laxative  or  an 
enema.  The  use  of  the  cautery  is 
not  followed  by  pain,  and  very 
seldom  by  retention  of  urine,  and 
the  results  following  its  emj)loy- 
ment  as  regards  the  permanent 
cure  of  the  hemorrhoids  are  most 
satisfactory.  We  prefer  the  clamp 
and  cautery  to  any  of  the  other 
methods  emjiloyed  in  the  treat- 
ment of  internal  hemorrhoids, 
considering  it  much  less  painful 
and  fully  as  safe  and  efficient  as 
the  ligature. 

Excision. ^This  method  was 
introduced  by  Whitehead,  and  is 
a  very  radical  one,  as  it  com- 
pletely removes  the  whole  pile- 
bearing  area. 


Application  of  cautery  to  hemorrhoids. 


In  this  operation  au  incision  is  made  around  the  anus  a  little  inside  of 
the  junction  of  the  skin  with  the  mucous  membrane,  and  the  latter  with  the 
hemorrhoidal  tumors  is  dissected  up  until  the  ui^per  limit  of  the  hemor- 
rhoids is  passed,  when  they  are  removed  by  a  circular  incision.  Vessels 
which  bleed  are  clamped  with  hisemostatic  forceps  or  tied  during  the  opera- 
tion. Weir  cuts  through  some  of  the  hemorrhoidal  tissue  in  the  first  steps 
of  the  operation,  instead  of  dissecting  it  off,  as  the  piles  invade  the  sub- 
mucous connective  tissue.  After  all  bleeding  has  been  arrested,  the  wound 
is  irrigated,  and  the  mucous  membrane  is  brought  down  and  sutured  to  the 
edge  of  the  mucous  membrane  below  by  a  number  of  interrupted  sutures  of 
catgut  or  silk.  It  is  important  to  approximate  the  edges  of  the  mucous 
membrane  accurately,  and  if  any  bleeding  occurs  between  the  stitches  a  few 
additional  points  of  suture  should  be  introduced.  A  pad  of  gauze  should 
next  be  applied  and  held  in  place  by  a  T-bandage.  The  after-treatment  is 
similar  to  that  employed  in  the  case  of  the  ligature  or  the  clamp  and  cautery, 
with  the  exception  that  the  bowels  should  be  kept  quiet  for  a  longer  time, 
usually  a  week.  If  anj'  skin  is  removed,  the  mucous  membrane,  after  heal- 
ing has  occurred,  extends  beyond  the  edge  of  the  anus,  and  is  apt  to  be  irri- 
tated by  the  clothing  and  cause  the  patient  discomfort ;  and  if  primary 
union  does  not  take  place,  and  the  wound  heals  bj^  granulation,  stricture  of 
the  anus  is  apt  to  occur.  The  results  obtained  by  this  method,  if  carefully 
done,  are  excellent ;  but  the  operation  requires  considerable  time,  and  there 


1180  ULCERATION   OF  THE  RECTUM. 

is  often  a  large  quantity  of  blood  lost,  so  that  we  do  not  think  it  jjossesses 
sufficient  advantages  over  the  operation  by  the  ligature  or  by  the  clamp  and 
cautery  to  render  its  general  adoption  advisable. 

Electrolysis  has  also  been  employed  in  the  treatment  of  hemorthoids. 
The  method  of  its  application  is  similar  to  that  employed  in  the  treatment 
of  nsevus. 

Hemorrhage. — One  of  the  most  serious  complications  after  operations 
for  hemorrhoids  is  hemorrhage.  When  this  occurs,  ice  should  be  inserted 
into  the  rectum,  or  it  should  be  packed  with  iodoform  gauze  around  a  large 
rubber  catheter,  which  will  permit  the  escape  of  flatus ;  if  the  bleeding 
still  continues,  the  patient  should  be  ansesthetized,  the  cavity  of  the  rectum 
exposed  by  the  use  of  a  speculum,  and  the  bleeding  point  found  and  secured 
by  ligature,  or  cauterized  with  a  hot  iron  or  the  Paquelin  cautery. 

Ulceration  of  the  Rectum. — Ulceration  of  the  rectum  of  a  non- 
malignant  character  may  arise  from  a  number  of  causes,  and  is  classified  as 
follows  :  1,  traumatic ;  2,  catarrhal ;  3,  tuberculous ;  4,  syphilitic ;  5,  dys- 
enteric. 

Traumatic  Ulceration. — This  may  arise  from  wounds  accidentally 
received,  or  those  inflicted  upon  the  rectum  in  surgical  operations,  such  as 
those  for  the  relief  of  hemorrhoids  or  fistula.  In  such  cases,  from  not  keej)- 
ing  the  patient  at  rest  for  a  sufficient  time  or  from  constitutional  conditions, 
healing  of  the  wound  may  be  delayed  and  an  ulcer  persist.  Foreign  bodies 
in  the  faeces  or  the  pressure  of  hardened  faeces  may  also  cause  ulceration  of 
the  rectum.  These  ulcerations  are  generally  above  the  sphincter  and  cause 
little  pain,  and  the  patient's  attention  is  usually  called  to  the  condition  by 
the  discharge  of  a  little  blood  and  pus  with  the  stool.  A  digital  examina- 
tion, or  one  with  the  speculum,  will  disclose  the  site  of  the  ulcer. 

Catarrhal  Ulceration. — This  may  result  from  acute  proctitis,  from  the 
impaction  of  hardened  faeces  in  the  rectum,  from  the  presence  of  polypi,  or- 
in  women  may  occur  from  the  pressure  of  a  displaced  uterus.  It  is  charac- 
terized by  a  sense  of  fulness  and  discomfort  or  pain  in  the  rectum,  and  by 
the  discharge  of  a  little  blood  and  pus  mixed  with  mucus,  and  unless 
relieved  by  treatment  is  apt  to  run  a.  very  chronic  course.  If  the  rectum  is 
examined  with  a  speculum,  ulcers  with  elevated  irregular  edges,  confined  to 
the  mucous  membrane  and  situated  well  above  the  sphincter,  are  found. 

Tuberculous  Ulceration. — This  may  exist  as  a  primary  affection,  or  it 
may  be  secondary  to  tuberculosis  of  the  lungs  or  other  organs.  As  a 
primary  affection,  it  may  result  from  direct  inoculation,  from  contact  of  food 
which  contains  tubercle  bacilli,  or,  as  has  been  pointed  out  by  Klebs,  from 
the  swallowing  of  sputa  containing  these  organisms.  The  ulcers  aie  under- 
mined and  irregular,  and  marked  infiltration  of  the  mucous  membrane  is- 
present.  They  have  a  tendenc3'  to  perforate  the  coats  of  the  bowel,  by 
reason  of  which  the  formation  of  sinuses  and  fistulas  is  a  frequent  complica- 
tion. In  this  affection  pain  is  not  usually  marked,  and  the  condition  may 
exist  for  some  time  before  the  patient's  attention  is  directed  to  it.  A  slight 
discharge  of  blood  and  pus  with  the  stool  sooner  or  later  occurs.  If  a, 
patient  suffering  from  tuberculosis  of  other  organs  presents  these  rectal 
symptoms,  the  nature  of  the  trovible  should  be  suspected. 


TREATMENT   OF  ULCERATION   OF  THE   RECTUM.  1181 

Syphilitic  Ulceration. — This  occurs  late  in  the  disease,  and  often 
results  from  the  breaking  down  of  a  gumma.  It  is  accompanied  by  the 
usual  symptoms  of  ulceration  of  the  rectum,  and  runs  a  very  chronic  course. 
In  all  cases  of  chronic  ulceration  of  the  rectum  the  patient  should  be  care- 
fully examined  to  ascertain  if  he  has  had  syphilis. 

Dysenteric  Ulceration. — Ulceration  of  the  rectum  following  dysen- 
tery, especially  if  the  latter  affection  has  been  of  a  chronic  form,  is  occa- 
sionally met  with.  The  ulceration  in  these  cases  appears  to  originate  in  the 
solitary  follicles.  The  symptoms  presented  are  those  common  to  ulceration 
of  the  rectum.  This  variety  of  ulceration,  if  extensive,  may  subsequently 
cause  stricture. 

Treatment. — The  general  treatment  of  ulceration  of  the  rectum,  which 
is  applicable  to  all  the  varieties,  consists  in  absolute  rest  in  bed,  usually  for 
some  weeks,  and  careful  regulation  of  the  diet  to  preveiit  irritating  material 
in  the  faeces  from  coining  in  contact  with  the  ulcerated  surfaces.  A  diet 
composed  of  milk  and  animal  broths  is  the  best.  The  bowels  should  also  be 
regulated  so  that  soft  movements  are  obtained,  saline  laxatives  being  admin- 
istered. The  local  treatment  may  be  accomplished  by  the  use  of  enemata  or 
suppositories,  or  by  direct  applications  made  to  the  ulcerated  surface.  The 
latter  method  requires  the  use  of  a  speculum,  which  is  painful  and  should 
be  avoided  except  in  special  cases. 

In  cases  of  traumatic,  catarrhal,  or  dysenteric  ulceration,  the  iise  of  an 
enema  of  bismuth,  subnit.,  gr.  xx  ;  tr.  opii,  "ix;  mucil.  acacife,  f  ,^  ii,  morning 
and  evening,  or  of  a  solution  of  argent!  nitratis,  gr.  vi ;  aquse,  foil,  may  be 
followed  by  good  results  ;  or  the  following  suppository  may  be  used  morn- 
ing and  evening  in  place  of  the  enema :  pulv.  opii,  gr.  ss ;  pulv.  iodoformi, 
gr.  v;  ol.  theobrom.,  q.  s.  It  is  sometimes  desirable  to  make  direct  appli- 
cations, in  which  case  a  solution  of  nitrate  of  silver,  gr.  v  to  x  to  the 
ounce,  should  be  gently  brushed  over  the  ulcerated  surfaces.  In  tuber- 
culous ulceration  the  best  results  are  obtained  by  carefully  curetting  the 
ulcerated  surface  and  subsequently  touching  it  with  a  ten -grain  solution  of 
nitrate  of  silver,  and  by  the  daily  use  of  suppositories  containing  iodoform. 
If  the  treatment  is  applied  early  in  tuberculous  ulceration,  perforation  of  the 
bowel  and  the  formation  of  flstulse  may  be  avoided.  In  this  form  of  ulcera- 
tion the  administration  of  tonics  and  cod-liver  oil  is  often  of  the  greatest 
benefit.  If,  however,  fistulse  already  exist,  these  should  be  laid  open  and 
curetted.  Syphilitic  ulceration  should  be  treated  by  the  local  use  of  nitrate 
of  silver  and  iodoform,  and  at  the  same  time  iodide  of  potassium,  alone,  or 
combined  with  biniodide  of  mercury,  should  be  administered  internally. 

Encysted  Rectum.— This  is  an  affection  occasionally  observed,  con- 
sisting in  ulceration  and  occlusion  of  the  lacuuse  or  sinuses  of  Morgagni, 
which  are  situated  just  above  the  external  sphincter.  The  symptoms  are 
pain  and  discomfort  in  the  rectum,  the  pain  not  usually  being  so  severe  as 
in  the  case  of  fissure.  The  treatment  consists  in  exposing  the  lower  portion 
of  the  rectum  with  a  speculum,  when  the  distended  or  ulcerated  sinuses  may 
often  be  seen.  A  probe  bent  in  the  form  of  a  hook  should  be  passed  into 
these  sinuses,  and  they  should  be  laid  open,  which  causes  their  obliteration, 
and  is  usually  followed  by  relief  of  the  symptoms. 


1182 


NON-MALIGNANT  STRICTURE   OF  THE   RECTUM. 


Non-Malignant  Stricture  of  the  Rectum.— Strictures  of  the  rec- 
tum, independent  of  those  resulting  congenitally,  which  have  already  been 
considered,  and  those  due  to  cancer  and  the  presence  of  tumors  outside  of 
the  bowel,  may  result  from  the  cicatrization  and  contraction  following- 
wounds,  or  from  extensive  ulceration  of  the  rectum  following  proctitis, 
dysentery,  tuberculosis,  chancroid,  or  syphilis.  Spasmodic  stricture  of  the 
rectum,  aside  from  spasmodic  contraction  of  the  si^hincter  muscle,  is  a  rare 
affection,  but  a  few  well-authenticated  cases  have  been  reported  in  which 
this  condition  existed.  These  strictures  are  more  common  in  females  than 
in  males,  and  are  generally  observed  in  adults. 

The  stricture  may  consist  of  a  ring-like  constriction  or  a  narrowing  of  the 
tube  several  inches  in  length.  The  mucous  membraae  is  often  ulcerated  at 
the  seat  of  stricture  and  is  replaced  by  dense 
cicatricial  tissue.  In  stricture  of  the  rectum  due 
to  the  presence  of  external  growths  the  mucous 
membrane  is  generally  normal.  Marked  dilata- 
tion of  the  bowel  above  the  seat  of  stricture  is 
usually  i^resent,  and  the  walls  of  the  rectum 
may  be  so  thin  that  rujtture  may  occur.  (Fig. 
911.)  The  formation  of  fistula  in  connection 
with  stricture  is  often  observed. 

Symptoms.  — These  may  not  be  marked  until 
the  contraction  of  the  rectal  canal  is  well  ad- 
vanced, and  consist  of  slight  morning  diarrhoea 
and  the  discharge  of  a  little  bloody  mucus  and 
thin  brown  fluid.  The  tape-like  shape  of  the 
stool  is  supijosed  to  be  characteristic  of  stricture, 
but  this  is  not  always  the  case,  for  in  strictures 
high  up  in  the  canal  the  fseces  may  accumulate 
in  the  bowel  below  the  stricture  and  be  j^assed 
in  large  masses.  Stricture  of  the  rectum  may 
cause  death  by  complete  obstruction  of  the 
bowels,  or  by  rupture  of  the  bowel  above  the 
stricture,  resulting  in  abscess  or  peritonitis,  or  the  patient  may  be  worn  out 
by  long-continued  irritation  and  suppuration  resulting  from  the  affection. 

Diagnosis. — Stricture  of  the  rectum  can  usually  be  recognized  by  a 
digital  examination,  and  its  differentiation  from  malignant  growth  is  made 
by  observing  the  following  conditions.  It  is  a  disease  of  adult  life,  and 
exists  a  long  time  without  producing  constitutional  disturbances  ;  the  mucous 
membrane,  if  present,  is  not  indurated,  and  pain  is  usually  complained  of 
only  during  the  act  of  defecation. 

Treatment. — This  may  be  either  constitutional  or  local.  Stricture  of 
the  rectum  due  to  gummatous  infiltration  of  the  anus  or  the  rectum,  which 
is  a  comparatively  rare  affection,  may  disappear  under  the  use  of  mercury 
and  iodide  of  potassium,  but  that  resulting  from  the  cicatrization  of  chan- 
croidal or  gummatous  ulceration  is  not  affected  by  constitutional  treatment. 
Internal  Incision. — This  is  attended  with  so  much  danger  that  it  is 
rarely  employed. 


Non-maliguant  stricture  of  the 
rectum.    ( Aguew. ) 


PROLAPSE   OF  THE  EECTUiM.  1183 

Dilatation. — When  the  stricture  is  situated  well  clown  in  the  rectum, 
dilatation  may  be  accomplished  by  the  use  of  the  finger  or  of  bougies,  and 
the  best  bougie  to  use  for  this  purjiose  is  a  soft  rubber  one.  In  using  bougies 
extreme  gentleness  should  be  exercised  in  their  manipulation,  and  the  dila- 
tation should  be  very  gradual ;  forcible  dilatation  is  a  dangerous  procedure, 
and  should  not  be  employed.  Their  use  is  always  attended  with  some  risk 
of  rupture  of  the  gut,  as  very  little  force  may  rupture  a  thin  portion  of  the 
wall  of  the  gut  in  connection  with  a  stricture.  This  accident  may  cause  no 
pain,  and  cases  have  occurred  in  which  neither  the  surgeon  nor  the  patient 
was  aware  of  its  occurrence  at  the  time.  By  gradual  dilatation  the  canal 
may  be  so  much  increased  in  size  that  obstructive  symptoms  disappear  and 
the  patient  experiences  great  comfort,  but  a  permanent  cure  of  the  stricture 
does  not  result,  so  that  the  regular  passage  of  the  bougie  should  be  practised 
to  maintain  the  dilatation. 

Linear  Proctotomy. — This  is  employed  with  advantage  in  strictures 
where  the  passage  of  the  bougie  is  followed  by  great  pain  and  constitutional 
disturbance,  or  where  the  dilatation  cannot  satisfactorily  be  accomplished 
by  its  use.  The  patient  should  be  anaesthetized  and  placed  in  the  lithotomy 
position.  After  washing  out  the  rectum  below  the  stricture  and  sterilizing 
the  skin  of  the  anal  region,  an  incision  is  made  directly  backward  to  the 
hollow  of  the  sacrum,  through  the  anus,  posterior  rectal  wall,  aud  stricture  ; 
after  irrigating  the  wound  it  is  loosely  packed  with  strips  of  iodoform  gauze, 
and  allowed  to  heal  by  granulation.  As  the  si^hincter  has  been  divided, 
incontinence  results,  and  di-ainage  is  free,  so  that  extravasation  of  faeces  into 
the  cellular  tissue  does  not  occur.  The  relief  of  obstruction  resulting  from 
this  procedure  is  complete,  but  as  healing  occurs  narrowing  may  again  take 
place,  so  that  a  bougie  should  occasionally  be  passed  until  the  wound  is 
cicatrized. 

Excision. — In  strictures  situated  low  down  in  the  rectum  excision  has 
been  practised  with  success,  and  is  accomplished  in  the  same  manner  as 
when  the  rectum  is  excised  for  the  relief  of  cancer.  The  operation  will  be 
described  under  cancer  of  the  rectum.  This  operation  is  jjreferable  to  linear 
proctotomy,  as  it  leaves  the  patient  with  control  of  the  sphincter. 

Colostomy. — This  operation  is  also  employed  for  the  relief  of  stricture 
of  the  rectum,  aud  the  iliac  is  to  be  preferred  to  the  lumbar  operation. 

Prolapse  of  the  Rectum. — This  affection  presents  three  distinct 
varieties  :  1.  The  mucous  membrane  alone  may  be  prolapsed  and  protrude 
from  the  anus,  known  as  imrtial  prolapse.  2.  All  the  coats  of  the  rectum, 
including  the  peritoneum,  if  the  protrusion  is  extensive,  may  protrude  from 
the  anus,  complete  prolapse.  3.  There  may  be  invagination  of  the  intestine, 
as  well  as  i^rolapse,  produciug  an  external  intussusception. 

Partial  Prolapse. — In  this  form  the  mass  protruded  consists  of  the 
mucous  membrane  of  the  lower  portion  of  the  rectum,  the  other  coats  of  the 
bowel  remaining  in  their  normal  position.  (Fig.  912.)  This  variety  of 
prolapse  of  the  rectum  is  of  frequent  occurrence.  Its  comijarative  frequency 
is  explained  by  the  anatomical  fact  that  the  submucous  connective  tissue  is 
loosely  attached  to  the  walls  of  the  rectum.  A  slight  protrusion  of  the 
mucous  membrane  maj^  be  produced  voluntarily,    and  occurs  normally 


1184 


PROLAPSE   OF  THE  RECTUM. 


during  defecation.  Partial  prolapse  is  frequent  in  childhood,  is  rarely- 
seen  between  the  ages  of  fifteen  and  fifty,  and  is  comparatively  frequent  in 
the  aged. 

Causes. — This  condition  may  arise  from  inflammatory  effusions  into  the 
submucous  connective  tissue,  as  in  catarrhal  proctitis  or  dysentery ;   the 

presence  of   hemorrhoids    or   of 
F'<^'  '^^-  polypi,  which  have  a  tendency  to 

drag  the  mucous  membrane  down- 
ward and  also  to  produce  severe 
straining  ;  severe  and  long-con- 
tinued efforts  in  defecation  in 
cases  of  obstinate  constipation,  or 
straining  efforts  from  obstruction 
to  the  free  passage  of  urine  from 
the  bladder,  caused  by  a  tight 
phimosis,  a  vesical  calculus,  a 
stricture  of  the  urethra,  or  an 
enlarged  prostate.  In  childi-en 
the  presence  of  angular  flexures 
in  the  lower  part  of  the  colon, 
requiring  severe  straining  to  pro- 
duce fecal  evacuations,  and  the 
straightness  of  the  coccyx,  are 
anatomical  factors  which  tend  to 
its  production.  Improper  diet 
and  overfeeding,  and  the  custom 
of  allowing  children  to  eat  con- 
tinually through  the  day,  as  the  result  of  which  there  occur  a  large  number 
of  passages,  may  also  give  rise  to  this  affection.  We  have  often  seen  chil- 
dren sent  to  the  hospital  for  operation  in  whom,  after  a  few  days'  stay,  with 
a  j)roperly  regulated  diet,  the  prolapse  failed  to  appear  at  stool,  and  often 
could  not  be  made  to  appear  even  with  the  use  of  enemata.  The  practice, 
so  common  with  mothers  and  nurses,  of  keeping  the  child  upon  the  chamber 
utensil  for  a  long  time  tends  to  the  production  of  prolapse. 

Symptoms. — The  most  marked  symj)tom  of  this  affection  is  the  pro- 
trusion during  defecation  of  a  red  mass,  composed  of  folds  of  mucous  mem- 
brane with  sulci  between  them.  The  protrusion  is  usually  unaccompanied 
by  pain,  and  generally  undergoes  spontaneous  reduction  as  soon  as  the 
straining  efforts  cease.  If,  however,  the  prolapsed  mucous  membrane  is 
allowed  to  remain  out  for  a  time,  it  may  become  congested,  or  even  ulcerated, 
and  some  difiiculty  may  be  experienced  in  its  reduction. 

Diagnosis. — In  cases  of  partial  prolapse  the  diagnosis  is  usually  not 
difficult.  The  appearance  of  the  folds  of  mucous  membrane  with  a  central 
depressed  orifice  is  characteristic.  The  condition  may  be  confounded  with 
hemorrhoids  or  with  polypus  of  the  rectum,  but  a  careful  examination  will 
reveal  its  true  nature. 

Complete  Prolapse. — This  condition,  which  consists  in  the  xsrotrusion 
of  all  the  coats  of  the  rectum,   usually  develops  gradually  from  cases  of 


Partial  prolapse  of  the  rectum. 


TREATMENT   OF  PROLAPSE   OF  THE   RECTUM.  1185 

partial  prolapse  which  have  existed  for  some  time,  but  may  develop  sud- 
denly as  the  result  of  violent  exjiulsive  efforts.  "When  the  lirotrusion 
reaches  a  considerable  size  the  jjossibility  of  the  peritoneum  being  included 
in  the  mass  should  always  be  remembered,  and,  owing  to  the  fact  that  the 
peritoneum  descends  lower  upon  the  anterior  than  upon  the  posterior  surface 
of  the  rectum,  it  is  more  apt  to  be  found  in  the  anterior  portion  of  the  mass. 
In  some  cases  the  prolapsed  mass  is  very  large,  and  cases  have  been  obser^'ed 
in  which  the  gi'eater  part  of  the  colon  was  included  in  the  protrusion.  The 
appearance  of  complete  prolapse  is  very  characteristic — the  semi-ovoid 
tumor  covered  with  mucous  membrane,  the  sulci  parallel  to  the  anus  (Fig. 
913),  and  the  greater  size  of  the  mass  serving  to  distinguish  it  from  partial 
prolapse. 

Treatment. — This  is  either  palliative  or  radical.     The  palliative  treat- 
ment consists,   first,  in  the  reduction  of  the  mass.     This  can  generally  be 
accomplished  best  by  placing  the  patient 
upon  his  abdomen   and   making   gentle 
pressure  upon  the  central  portion  of  the 
mass  with  the  greased  finger,  or  with  a 
piece  of  soft  muslin  which  has  been  well 
oiled,   when   it  can  usually  be  reduced 
without  difficulty.     After  reduction  vari- 
ous methods  may  be  employed  to  prevent 
the  recurrence  of  the  prolapse.     The  pa- 
tient should  have  the  bowels  moved  upon 
a  bed-pan  or  while  resting  upon  the  side. 
In  the  case  of  children  the  nurse  should     complete  prolapse  of  tiu-  rectum.   (After 
be   instructed  to  draw  the  skin   of  the  sne") 

anus  to  one  side  during  the  passage  of  the  faeces.  The  local  use  of  astrin 
gent  injections  of  tannic  acid  or  oak-bark  may  be  employed  with  advantage, 
or  the  protruded  mass  may  be  washed  with  a  solution  of  alum,  gi ;  water, 
§viii ;  or  one  of  tine,  of  iron,  "ixxv ;  water,  fiiv.  The  diet  should  be 
also  regulated.  If,  however,  the  bowel  continues  to  protrude  with  each  act 
of  defecation,  radical  means  for  the  cure  of  the  affection  should  be  under- 
taken, for  it  is  to  be  remembered  that  an  unrelieved  partial  prolapse  may 
gradually  develoj)  into  a  complete  one. 

Radical  Treatment. — This  may  be  accomplished  by  cauterizing  the 
mass  with  nitric  acid,  the  actual  cautery,  or  the  clamp  and  cautery,  or  by 
excision  of  the  prolapsed  tissue.  Cauterization  with  Nitric  Acid. — In 
prolapse  of  the  rectum  in  children  cauterization  with  nitric  acid  usually 
results  in  a  cure.  The  patient  should  be  given  an  enema  to  wash  out  the 
rectum  and  bring  down  tlie  prolapse:  an  anaesthetic  should  next  be  given, 
and,  after  the  surface  of  the  protruded  mass  has  been  carefully  dried  with 
gauze,  the  skin  surrounding  the  anus  should  be  rubbed  over  with  ^-aseline 
or  oil  and  the  surface  of  the  prolapsed  mass  painted  over  with  nitric  acid, 
applied  by  means  of  a  swab,  care  being  taken  that  the  acid  does  not  come 
in  contact  with  the  skin.  After  the  mucous  membrane  has  been  painted  over 
with  the  acid  it  becomes  of  a  whitish-yellow  color.  The  cauterized  surface 
is  next  gently  smeared  over  with  boric  acid  ointment,  and  the  mass  reduced. 


1186  PROLAPSE  AVITH   IIJVAGINATION  OF  THE  INTESTINE. 

A  small  pad  of  gauze  is  placed  over  the  anus,  and  is  held  in  place  by  bring- 
ing together  the  buttocks  with  one  or  two  wide  strips  of  adhesive  plaster. 

The  bowels  are  allowed  to  remain  quiet  for  a  day  or  two,  and  are  then 
moved  by  a  saline  laxative  or  a  dose  of  castor  oil.  At  the  first  motion  the 
bowel  may  protrude.  If  this  occurs,  it  should  be  reduced  and  a  compress 
applied  over  the  anus.  One  application  usually  results  in  a  cure,  but  it  is 
sometimes  necessary  to  resort  to  a  second  cauterization  in  cases  of  extensive 
prolapse.  Although  this  method  is  satisfactory  in  children,  it  is  not  followed 
by  as  good  results  in  adults. 

Actual  Cautery. — This  is  the  most  satisfactory  method  of  treatment  for 
rectal  prolapse  in  adults.  The  patient  is  anfesthetized  and  placed  in  the 
lithotomy  position,  or  ujion  his  side  with  the  limbs  flexed,  and  the  cautery 
is  applied  to  the  unreduced  mass,  three  or  four  lines  being  made  from  the 
apex  of  the  tumor  to  the  sphincter  at  different  points,  the  deepest  eschars 
being  made  at  the  sphincter,  and  large  veins  being  avoided.  The  j)rolapse 
is  next  reduced,  an  opium  suppository  is  introduced  into  the  rectum,  and  a 
pad  is  applied  to  the  anal  region  and  held  in  place  by  a  T-bandage.  The 
bowels  should  be  moved  by  a  saline  laxative  on  the  third  day,  and  after  this 
time  daily  evacuations  encouraged,  and  the  patient  kept  in  bed  on  restricted 
diet  until  the  ulcers  resulting  from  the  cautery  have  healed.  The  cautery 
may  also  be  apx)lied  in  the  treatment  of  ]3rolapse  in  children,  a  small 
cautery  point  being  used  and  the  lines  of  cauterization  being  more  superficial. 

Clamp  and  Cautery. — This  method  of  treatment  may  be  employed  in 
prolaj)se  of  the  bowel,  and  seems  to  be  especially  useful  in  cases  of  per- 
sistent i^artial  prolapse  where  there  is  marked  induration  of  the  prolapsed 
mass  with  difficulty  in  its  reduction.  In  extensive  prolapse  care  should  be 
taken  not  to  clamp  the  mass  too  near  the  sphincter,  so  as  to  avoid  the  danger 
of  including  the  walls  of  the  bowel  or  the  peritoneum  in  the  grasp  of  the 
clamp.  The  operation  consists  in  grasping  longitudinal  sections  of  the  mass 
at  diffei-ent  points  in  the  clamp,  and  appljdng  the  cautery  iron  thoroughly 
to  the  clamped  portions. 

Excision. — Circular  excision  of  the  prolapsed  mass  has  also  been  em- 
ployed. The  operation  should,  however,  be  reserved  for  extensive  and 
irreducible  cases.  In  this  operation,  after  removing  the  mass  by  a  circular 
incision,  the  edges  are  secured  by  sutm-es  without  difficulty,  as  they  are 
already  in  contact.  Excision  of  elliptical  strips  of  mucous  membrane  from 
different  portions  of  the  mass  has  also  been  practised  with  good  results. 

Ventrofixation  of  the  Sigmoid  Flexure. — This  operation  has  been 
employed  in  cases  of  complete  ijrolapse.  It  consists  in  opening  the  abdo- 
men and  making  traction  upon  the  sigmoid  flexure  of  the  colon  until  the 
prolapse  disappears,  and  then  suturing  with  fine  silk  the  meso-sigmoid  to 
the  parietal  peritoneum. 

Prolapse  with  Invagination  of  the  Intestine. — In  this  condition 

there  is  present  in  the  rectum,  or  escapes  from  the  anus,  a  portion  of  the 
upper  intestine  which  has  been  invaginated.  i!^o  true  prolapse  of  the  rectum 
occurs  in  these  cases,  for  the  bowel  at  the  anus  remains  stationary  and  the 
intestine  above  is  telescoijed  within  it.  The  possibility  of  the  existence  of 
this  condition  should  always  be  borne  in  mind  in  examining  tumors  which 


POLYPUS   OF  THE  EECTrM. 


1187 


protrude  from  the  anus.  Symptoms.— These  are  the  escape  of  blood  and 
mucus  from  the  anus  preceding  the  appearance  of  the  tumor,  and  the  de- 
velopment of  signs  of  obstruction  of  the  bowels,  with  the  attendant  consti- 
tutional symptoms.  The  aflfeetion  is  a  most  serious  one,  and  is  always  fatal 
unless  the  obstruction  be  removed  by  operative  ti-eatment  or  sloughing  of 
the  iutussusceptum.  Treatment.— The  patient  should  be  anaesthetized 
and  attemijts  made  to  reduce  the  invaginated  gut  by  manipulations  or  by 
injections.  If  it  cannot  be  reduced,  an  artificial  anus  should  be  made  in 
the  left  or  right  groin  by  inguinal  colostomy,  or  resection  and  suture  of  the 
prolapsed  mass  should  be  undertaken.  The  method  of  Mikulicz  may  be 
emi^loyed,  which  consists  in  placing  the  patient  in  the  lithotomy  position, 
making  a  transverse  incision  through  the  anterior  portion  of  the  prolapse, 
dividing  the  serous  surface  of  the  intussnscipiens,  and  exposing  the  serous 
surface  of  the  intussusceptum.  The  two  serous  membranes  should  be  su- 
tured together  by  fine  silk  suture^  which  shut  off  all  communication  with 
the  peritoneal  cavity.  The  anterior  ijortion  of  the  intussusceptum  is  then 
cut  through  in  advance  of  the  line  of  sutures,  and  the  two  ends  of  the  gut 
are  approximated  with  silk  sutures.  After  securing  the  periphery  of  the 
two  intestinal  openings  and  tying  numerous  mesenteric  vessels,  a  few  addi- 
tional deep  sutures  are  introduced,  and  after  dusting  the  wound  with  iodo- 
form the  stumx)  of  the  prolapse  is  returned.  The  bowels  should  be  kept 
confined  for  a  week  by  the  use  of  opium.  Colostomy  seems  to  be  the  safer 
procedure,  and  a  subsequent  operation  on  the  prolapsed  gut  may  be  done  if 
the  intussusceptum  is  not  removed  by  sloughing. 

Polypus  of  the  Rectum. — This  term  is  applied  to  certain  benign 
tumors  growing  from  the  rectal  wall,  to  which  they  are  attached  by  a  more 
or  less  well  formed  pedicle.  These  may  exist  as  either  adenomatous,  fibro- 
matous,  or  paijillomatous  growths,  and  are 
comparatively  rare  affections.  Other  tumors, 
such  as  lipoma,  cystoma,  myoma,  chondroma, 
and  lymphoma,  are  occasionally  observed. 

Adenoid  Polypus. — This  form  of  growth, 
which  is  usually  attached  to  the  wall  of  the 
rectum  by  a  narrow  pedicle,  presents  a  red 
irregular  lobulated  surface,  and  may  vary  in 
size  from  that  of  a  pea  to  that  of  a  walnut. 
(Fig.  914. )  The  growth  may  be  single  or  mul- 
tiple. If  the  growth  possesses  a  sufficiently 
long  pedicle,  it  may  be  protruded  from  the 
anus  during  defecation,  and,  owing  to  the  con- 
striction of  its  circulation  by  the  sphincter, 
may  i^resent  a  dark  purple  color.  This  is  the  form  of  polypus  which  is 
usually  seen  in  children,  but  is  a  quite  rare  affection.  The  growth  originates 
in  an  hypertrophy  of  the  follicles  of  Lieberkiihn,  and  the  o\'erlying  mucous 
membrane  is  gradually  stretched  so  as  to  form  a  pedicle. 

Fibroid  Polypus. — This  is  a  benign  tumor,  of  the  connective-tissue 
type,  which  may  be  found  attached  to  the  wall  of  the  rectum  by  a  pedicle. 
It  usually  has  its  origin  low  down  in  the  rectum,  and  probably  often  origi- 


FiG.  914: 


Adenoid  polypi  of  the  rectum. 
Ball.) 


1188 


:MALIG^'ANT  GROWTHS  OF  THE  EECTUM. 


nates  from  internal  hemorrhoids,  is  often  multiple,  and  may  attain  consider- 
able size. 

Villous  Polypus. — Tins  is  a  papillomatous  growth  which  is  occasion- 
ally found  growing  fi-om  the  walls  of  the  rectum,  and  presents  much  the 
same  appearance  and  structm-e  as  the  villous  tumor  of  the  bladder.  It 
originates  from  the  papillse  of  the  mucous  membrane,  and  is  covered  with 
columnar-celled  ejiithelium. 

Symptoms. — Polypus  may  exist  for  a  long  time  without  giving  rise 
to  any  definite  symx^toms,  although  the  patient  maj-  experience  a  sense  of 
fulness  in  the  rectum  which  is  not  relieved  by  defecation.  Its  presence, 
however,  is  sooner  or  later  manifested  by  the  discharge  of  mucus  and  blood. 
The  latter  may  be  only  a  few  drops,  or  profuse  bleeding  may  be  present. 
If  the  polyjjus  is  caught  by  the  sphincter,  discomfort  or  pain  is  exiDcrienced. 
The  constant  escape  of  blood  and  mucus  without  pain  should  cause  the  sur- 
geon to  suspect  the  presence  of  polypus.  An  examination  of  the  rectum 
with  the  finger  or  with  a  speculum  will  locate  the  growth.  The  use  of  an 
enema  before  the  examination  is  of  advantage,  as  it  empties  the  rectum  of 
fecal  matter  and  tends  to  bring  the  polypus  nearer  the  anus. 

Treatment. — The  patient  should  be  aniiesthetized,  and,  after  stretching 
the  sphincter,  if  the  polypus  has  a  faiiiy  long  xaedicle  it  comes  into  view  j 
the  use  of  the  speculum  may  be  required  to  expose  it  if  it  has  a  short 
pedicle  or  is  attached  to  a  high  portion  of  the  rectal  wall.  If  the  growth  is 
small  and  well  pedunculated  it  may  be  grasped  with  forcejjs  and  twisted  oif, 
as  the  bleeding  is  not  often  troublesome,  or  its  xtedicle  may  be  divided  and 
the  actual  cautery  or  nitric  acid  applied  to  the  stump.  Ligation  of  the 
pedicle  near  its  origin  from  the  rectal  wall  is, 
however,  the  safest  procedure  before  the  pedicle 
is  divided.  Care  should  be  taken  not  to  make 
so  much  traction  upon  the  pedicle  as  to  invert 
the  rectal  wall  at  its  point  of  attachment,  for  if 
this  were  done  it  might  be  included  in  the  liga- 
ture or  incision.  If  jnultiple  polypi  exist,  the 
same  procedure  is  repeated  for  each  growth. 
When  the  growths  are  sessile  and  involve  a  con- 
siderable portion  of  the  rectal  walls,  they  should 
be  removed  by  curetting,  and  the  surface  left 
should  be  lightly  touched  with  the  actual  cautery 
or  nitric  acid. 

The  after-treatment  consists  in  the  use  of  an 
oiiium  suppository  and  rest  in  bed  for  a  few  days. 
Malignant  Growths  of  the  Rectum. — 
Carcinoma. — These  vary  considerably  in  their 
charactei's,  and  may  present  themselves  as  ejn- 
tlielioma  of  the  squamous  type,  which  has  its 
origin  in  the  skin  or  the  mucous  membrane  of  the  anus  and  spreads  to  the 
rectum  :  columnar-celled  epUlielioina.  sometimes  described  as  malignant  ade- 
noma, which  arises  fi-om  the  mucous  membrane  (Fig.  915)  and  is  the  most 
common  variety  ;  scirrhus,  or  hard  cancer,  which  infiltrates  the  submucous 


Fig.  915. 


ilalignant  adenoma  of  the  rectum. 
(Agnew.) 


SYMPTOMS  OF  CANCER  OF  THE  RECTUM.  1189 

connective-tissue  of  the  rectum ;  colloid,  or  alveolar  cancer,  which  has  its 
origin  in  the  follicles  of  Lieberkiihn,  or  the  rectal  crypts  ;  and  encephaloid, 
which  develops  in  the  glandular  tissue  of  the  mucous  membrane. 

Sarcomata  are  also  met  with,  but  they  are  much  less  frequent  than  the 
various  forms  of  cancer.     Sarcoma  of  the  melanotic  type  has  been  observed. 

Symptoms. — These  vary  greatly  in  individual  cases,  and  often  resemble 
those  of  hemorrhoids,  but  the  most  freqiient  symptom  is  diarrhoea,  which  is 
often  the  earliest  to  attract  attention,  and  which  may  alternate  with  consti- 
pation or  the  escape  of  small,  firm,  fecal  masses  resembling  sheep's  fceces. 
Any  case  of  chronic  diarrhoea  in  the  adult  should  be  looked  upon  with 
suspicion,  and  a  rectal  examination  should  be  made.  Pain  is  sometimes  an 
early  symptom,  but  may  not  be  marked  until  the  disease  is  well  advanced. 
It  is  more  apt  to  be  noticed  early  in  the  disease,  when  the  anus  and  the 
lower  portion  of  the  rectum  are  involved.  It  may  be  severe  in  the  later 
stages  of  the  disease,  when  the  growth  jiresses  upon  the  sacral  plexus,  and 
may  be  confounded  with  sciatica,  or  may  arise  from  obstruction  of  the 
bowel,  in  which  case  it  is  apt  to  be  paroxysmal  and  is  accompanied  with 
efforts  at  defecation. 

Bleeding  may  exist  at  any  stage  of  the  disease,  and  is  seldom  free  except 
in  the  latter  stages.  Its  presence  shows  that  ulceration  of  the  growth  has 
taken  place,  the  escape  of  fseces,  pus,  and  blood  being  a  very  common  symp- 
tom. When  the  disease  is  well  advanced  and  the  sphincter  has  lost  control 
and  the  anus  is  patulous,  or  when  fistulie  exist,  a  thin  fetid  discharge  con- 
stantly escapes,  soiling  the  clothing,  and  producing  often  severe  irritation  of 
the  skin  of  the  anal  region.  Obstruction  due  to  narrowing  of  the  rectum 
may  result  from  the  gro-nth  of  the  neoplasm  into  the  canal  or  from  cicatricial 
contraction  of  the  wall  of  the  gut.  This  symptom  may  appear  early  in  the 
disease,  but  is  most  likely  to  be  a  late  one,  and  is  not  observed  in  every  case. 
"We  have  seen  cases  in  which  the  rectum  and  surrounding  tissues  and  organs 
were  extensively  involved  and  yet  obstruction  was  not  marked.  Tenesmus 
and  straining  are  common  symptoms  as  soon  as  obstruction  occurs.  Com- 
plete obstruction  may  exist,  and  only  occasionally  results  in  fecal  vomiting  ; 
it,  however,  causes  pain  and  abdominal  distention,  and  may  exist  for  some 
days,  when  an  escape  of  thin  fa?ces  occurs  from  the  anus,  or  the  obstruction 
may  be  relieved  by  the  formation  of  a  fistulous  opening  into  the  vagina, 
bladder,  or  rectum,  or  upon  the  skin  in  the  anal  region.  When  the  obstruc- 
tion is  complete  and  not  relieved,  death  results  from  peritonitis  following 
perforation  of  the  gut  at  some  point  above  the  stricture.  Involvement  of 
the  lymphatic  glands  may  occiu-  early  in  the  disease,  and  is  usually  very 
marked.  Pressure  of  the  growth  upon  the  iliac  vein  may  cause  oedema  of 
the  left  leg.  The  duration  of  the  disease  is  usually  fiom  two  to  three  years, 
but  if  obstruction  is  a  marked  symptom  the  disease  may  run  a  shorter  coui-se 
unless  this  condition  is  relieved  by  surgical  interference. 

Diagnosis.— A  digital  examination  should  be  made  in  all  cases  which 
present  any  of  the  symptoms  of  cancer  of  the  rectum,  and  in  the  majority 
of  cases  a  hard  nodular  mass,  a  soft  growth  extending  into  the  rectal  canal, 
or  a  well-marked  strictm-e  can  be  felt.  If  a  digital  examination  is  made 
with  the  patient  standing  and  straining,  a  growth  may  be  felt  by  the  finger 

76 


1190         TEEATMENT  OF  CANCER  OF  THE  RECTUM. 

which  cannot  be  reached  in  the  recumbent  position.  Xo  attempt  should  be 
made  to  force  the  finger  through  the  narrowed  canal  to  ascertain  the  extent 
of  the  growth,  as  such  a  procedure  has  been  followed  by  perforation  of  the 
bowel ;  the  use  of  bougies  for  this  purpose  is  accompanied  by  even  greater 
danger.  At  the  time  of  examination  the  region  of  the  hollow  of  the  sacrum 
should  be  examined  through  the  rectal  wall  for  the  presence  of  enlarged 
glands,  and  attempts  should  be  made  to  ascertain  if  the  rectum  is  movable 
or  is  firmly  fixed  to  surrounding  structures. 

Non-maligimnt  stricture,  or  a  tumor  ijressing  upon  the  rectum,  is  the 
condition  which  is  likely  to  be  confounded  with  cancer  of  the  rectum.  In 
non-malignant  stricture  the  development  of  symptoms  is  very  slow,  and 
upon  examination  the  absence  of  nodular  masses,  so  common  in  cancer,  is 
noted.  In  stricture  of  the  rectum  from  tumors  pressing  upon  the  gut,  upon 
the  introduction  of  the  finger  into  the  rectum  it  will  be  observed  that  the 
mucous  membrane  is  healthy  and  is  freely  movable.  The  peculiar  cachectic 
appearance  which  is  common  to  malignant  disease  soon  develops  in  carci- 
noma of  the  rectum,  particularlj^  if  there  is  free  bleeding,  and  is  not 
observed  in  non-malignant  stricture,  even  of  long  duration. 

Treatment. — This  depends  upon  the  stage  at  which  the  disease  is  seen 
and  the  extent  to  which  it  has  involved  the  rectum  and  surrounding  tissues. 
Many  cases  come  under  the  care  of  the  surgeon  in  which  the  disease  has 
involved  the  tissues  so  extensively  that  no  operative  treatment  is  justifiable. 
In  such  cases  means  must  be  employed  to  render  the  patient's  condition 
comfortable  or  bearable  until  the  fatal  termination  occurs.  Opium,  in  the 
form  of  suppositories,  or  morphine  hypodermically,  sooner  or  later  has  to 
be  resorted  to.  Its  use  is  indicated  as  soon  as  the  pain  is  severe,  but  the 
quantity  employed  should  be  regulated  so  that  the  patient  «hall  not  acquire 
the  opium  habit  early  in  the  disease.  The  diet  should  be  carefully  regulated 
to  diminish  the  quantity  of  the  fecal  matter,  and  the  occasional  use  of  purga- 
tives may  be  required. 

Operative  Treatment. — This  consists  in  excision  of  the  growth,  or 
the  establishment  of  an  artificial  anus  by  the  operation  of  colostomy.  Such 
procedures  as  linear  proctotomy,  curetting  the  growth,  and  the  application 
of  caustics,  result  in  little  benefit,  and  cannot  be  recommended.  The  use 
of  bougies  in  rectal  cancer  is  attended  with  so  much  danger  and  so  little 
benefit  that  they  should  never  be  employed. 

When  operative  treatment  is  decided  upon,  the  choice  of  operation  should 
rest  between  excision  of  the  rectum  and  colostomy.  The  latter  operation 
should  not  be  delayed  until  it  is  performed  to  relieve  intestinal  obstruction, 
but  should  be  employed  before  symptoms  of  obstruction  appear. 

Some  diversity  of  opinion  exists  among  surgeons  as  to  whether  excision 
or  colostomy  is  the  better  operation.  Excision,  if  undertaken  early,  is  fol- 
lowed by  most  encouraging  results,  but  the  immediate  risk  of  the  operation 
is  great,  and  recurrence  often  takes  place  within  a  short  time. 

Excision  of  the  rectum,  in  selected  cases,  is  now  being  more  widely 
employed,  and  should  be  practised  in  limited  movable  growths  unless  there 
are  signs  of  secondary  deposits  in  the  glands  or  in  the  liver,  and  although 
the  results  of  the  operation  are  more  favorable  under  aseptic  precautions, 


EXCISION  OF  THE  RECTUM. 


1 1  m 


Fig.  916. 


Curtis  reportiag  about  twenty  per  cent,  of  cures,  still  a  considerable  mor- 
tality results  from  shock,  hemorrhage,  or  sepsis,  probably  about  fifteen  per 
cent.  In  cases  in  which  obstruction  exists,  left  iliac  colostomy  should  be 
performed,  and  if  done  so  as  to  establish  an  artificial  anus,  through  which 
all  the  fteces  escape,  and  not  merely  to  form  a  lateral  outlet  to  the  bowel, 
permitting  a  portion  of  the  fecal  matter  still  to  find  its  way  into  the  rectum, 
where  its  presence  causes  great  discomfort,  is  an  operation  which  is  often 
followed  by  great  benefit.  A  patient  with  an  artificial  anus  may  often  live 
in  comfort  for  years  and  be  able  to  go 
about  and  attend  to  his  business,  suffer- 
ing little  inconvenience  from  involuntary 
fecal  discharges,  unless  the  bowels  are 
very  loose,  and  at  the  same  time  the 
activity  in  the  growth  of  the  tumor  often 
seems  to  be  diminished  by  the  ablation 
of  the  function  of  the  rectum. 

Colostomy. — This  operation  may  be 
performed  in  the  left  or  the  right  iliac 
region  or  in  the  left  lumbar  region .  In 
the  latter  position  it  is  impossible  to  pre- 
vent part  of  the  fieces  from  still  entering 
the  bowel  below  the  artificial  opening, 
and  therefore  left  iliac  colostomy  is  to  be 
preferred.  (Fig.  916.)  In  exceptional 
cases  the  operation  may  be  done  in  the 
right  iliac  region.  (For  details  of  this 
operation,  see  page  941.; 

Excision  of  the  Rectum,  or  Proctectomy. — The  cases  of  cancer  of 
the  rectum  which  are  considered  most  favorable  for  this  operation  are  those 
in  which  the  disease  does  not  involve  the  rectum  beyond  the  reach  of  the 
finger,  and  in  which  it  involves  the  posterior  rather  than  the  anterior  wall. 
In  the  latter  situation,  involvement  of  the  bladder,  prostate,  urethra,  or 
vagina  may  seriously  complicate  the  oiDcration. 

The  patient  should  have  the  bowels  freely  opened  by  a  laxative  on  the 
morning  of  the  operation,  and  a  few  hours  before  he  is  anesthetized  the 
lower  bowel  should  be  washed  out  with  warm  water  or  a  solution  of  boric 
acid.  The  patient,  having  been  amiesthetized,  is  placed  in  the  lithotomy 
position,  with  the  pelvis  slightly  elevated.  If  the  lower  portion  of  the  rec- 
tum, including  the  anus,  is  involved,  a  circular  incision  should  be  made 
around  the  anus  well  outside  the  limits  of  the  disease,  and  should  be  sup- 
plemented by  an  incision  from  the  posterior  portion  of  the  anus  to  the 
coccyx.  The  dissection  should  theu  be  carried  deeply  into  the  ischio-rectal 
fossa,  the  attachments  of  the  levator  ani  muscle  being  divided.  The  most 
difficult  part  of  the  dissection  is  the  separation  of  the  anterior  portion  of  the 
rectum  from  the  vagina,  urethra,  and  bladder.  This  should  be  accomplished 
with  blunt  scissors  and  the  finger.  It  is  well,  in  the  male,  to  introduce  a 
sound  into  the  bladder,  to  serve  as  a  guide  during  the  dissection.  In  the 
female  the  finger  may  be  placed  in  the  vagina  as  a  guide.    'WTien  the  dissec- 


Eesult  of  left  iliac  colostomy. 


1192  EXCISION   OF  THE  RECTUM. 

tion  has  been  carried  up  to  a  point  above  the  disease,  the  bowel  should  be 
divided  transversely  at  this  point  with  scissors.  If  the  peritoneal  cavity  is 
opened  in  the  dissection,  it  should  be  closed  by  sutures.  Vessels  which 
bleed  freely  during  the  dissection  should  be  clamped  with  haemostatic 
forceps  and  ligated.  The  wound  is  next  irrigated,  and  the  edges  of  the 
bowel  brought  down  and  sutured  to  the  skin,  care  being  taken  to  pass  the 
sutures  deeply,  so  that  no  pockets  shall  be  left  in  which  fluids  may  collect 
and  become  septic.  A  drainage-tube  is  also  introduced  if  the  posterior  por- 
tion of  the  incision  is  closed  by  sutures. 

In  cases  where  the  anus  is  not  involved  in  the  disease  the  incision  should 
be  made  in  the  same  manner,  but  the  sphincter  should  be  divided  posteriorly 
and  turned  aside  with  the  skin.  If  a  portion  of  healthy  mucous  membrane 
is  present,  it  should  be  left.  A  large  rubber  catheter  wrapped  with  iodoform 
gauze  is  passed  into  the  bowel,  and  its  end  left  ijrojecting  from  the  anus  to 
l^ermit  the  escape  of  flatus.  This  tube  is  often  not  well  borne,  and  has 
frequently  to  be  removed  soon  after  the  patient  recovers  from  the  ansesthetic. 
A  gauze  dressing  is  placed  over  the  anal  region  and  secured  by  a  T-bandage. 
The  patient  should  be  placed  upon  a  liquid  diet,  and  the  bowels  kept  quiet 
by  the  use  of  opium.  At  the  end  of  a  week  the  bowels  are  moved  by  a 
laxative  and  the  tube  is  removed. 

To  avoid  the  trouble  which  often  arises  from  fecal  movements  soon  after 
the  operation,  and  to  enable  the  surgeon  better  to  keep  the  wound  aseptic,  a 
preliminary  inguinal  colostomy  is  sometimes  done  on  the  left  side,  and 
excision  of  the  rectum  is  postponed  for  ten  days. 

Kraske's  Operation. — When  cancer  involves  the  rectum  high  up,  even 
as  high  as  the  sigmoid  flexure,  it  is  i^ossible  to  excise  the  growth  by  an  opera- 
tive procedure,  which  has  been  devised  by  Kraske.  This  consists  in  making 
an  incision  from  the  second  sacral  vertebra  to  the  anus,  and  dividing  the 
muscular  attachments  and  ligaments  on  the  left  side  of  the  sacrum  as  far 
its  end.  The  coccyx  should  also  be  excised,  and  a  portion  of  the  left  side 
of  the  sacrum  removed  with  a  gouge.  The  incision  should  next  be  carried 
forward  so  as  to  encircle  the  anus.  This  gives  a  free  exposure  of  the  rectum, 
which  is  then  dissected  loose  from  its  attachments.  The  peritoneal  cavity 
is  opened,  and  the  gut  is  drawn  down  and  amputated  by  a  circular  incision. 
The  edges  of  the  gut  are  next  brought  down  as  far  as  possible  and  sutured 
to  the  tissues  of  the  ischio-rectal  fossa.  A  drainage-tube  should  be  placed 
in  the  peritoneal  cavity,  its  end  projecting  from  the  perineal  wound.  The 
wound  is  packed  with  gauze,  and  a  gauze  dressing  applied. 

Schede  recommends  closing  the  peritoneal  cavity  by  the  application  of 
sutures,  uniting  the  peritoneum  to  the  serous  surface  of  the  sigmoid  flexure. 
He  also  recommends  leaving  the  anus  and  the  lower  portion  of  the  i-ectum 
intact,  if  healthy,  and  suturing  the  lower  rectal  segment  by  two  layers  of 
sutures,  one  passed  through  the  mucous  coat  and  the  other  through  the  other 
coats  of  the  bowel.     Preliminary  colostomy  in  the  left  groin  is  practised. 

Bardenheuer's  Operation. — This  surgeon  in  excising  the  rectum  makes 
an  incision  from  the  posterior  portion  of  the  anus  to  the  middle  of  the 
sacrum.  The  muscles  are  next  separated  from  the  sacrum  and  the  sacro- 
sciatie  ligaments  are  divided.     The  sacrum  is  next  cut  through  transversely 


RECTO- VESICAL  FISTULA.  1193 

at  the  level  of  the  third  sacral  foramen,  the  detached  bone  is  removed,  and 
the  posterior  surface  of  the  rectnm  is  exposed.  The  hand  is  next  introduced 
and  the  rectum  explored  to  locate  the  extent  of  the  disease.  This  explora- 
tion can  be  made  as  high  as  the  sigmoid  flexure.  If  it  is  found  that  the  dis- 
ease involves  the  bowel  above  the  attachments  of  the  levator  ani  muscle, 
excision  of  the  growth  with  circular  suture  of  the  rectum  can  be  practised  ; 
if,  however,  the  growth  extends  to  the  anal  portion  this  should  be  excised 
and  the  upper  lumen  of  the  bowel  drawn  down  and  secured  by  sutures  to 
the  edges  of  the  incision.  A  preliminary  left  inguinal  colostomy  should  be 
done  before  performing  this  operation. 

Recto-Vesical,  Recto-Urethral,  and  Recto-Vaginal  Fistula,— 

These  various  forms  of  fistula  as  congenital  affections  have  already  been 
described,  but  they  may  also  result  from  traumatisms  in  the  female,  as  acci- 
dents of  parturition  and  wounds  received  iu  operations  upon  the  rectum, 
vagina,  bladder,  or  urethra.  Recto-urethral  fistula  occasionally  results 
from  the  operation  of  lithotomy,  or  from  rupture  of  the  urethra  following 
stricture.  But  the  most  frequent  cause  of  these  fistulte  is  malignant  disease 
of  the  rectum,  the  growth  involving  one  of  the  contiguous  organs. 

Treatment. — In  accidental  wounds  of  contiguous  organs  made  in  opera- 
tions upon  the  rectum,  the  wounds  should  be  promptly  closed  by  sutures 
and  in  the  majority  of  cases  rapid  union  occurs,  so  that  no  permanent  fistula 
results.  Where,  however,  a  fistula  persists,  a  plastic  operation  must  be 
undertaken  to  close  the  fistula,  except  in  cases  resulting  from  cancer  of  the 
rectum,  where  no  operation  is  likely  to  be  of  any  service.  A  recto-vaginal 
fistula  in  the  latter  cases  often  is  followed  by  the  relief  of  pain  and  tenesmus 
and  abatement  of  the  symptoms  of  obstruction.  A  recto-vesical  or  recto-, 
urethral  fistula,  on  the  other  hand,  may  cause  so  much  pain  and  discomfort 
that  the  patient's  condition  can  be  improved  by  making  an  artificial  anus  in 
the  left  iliac  region. 


CHAPTER    XLIII. 

VENEREAL  DISEASES. 
By  Heney  E.  Wharton,  M.D. 


Syphilis  is  a  constitutional  disease,  chronic  in  type,  attended  by  lesions 
the  nature  of  which  includes  it  in  the  class  of  infectious  granulomata  with 
leprosy  and  tuberculosis.  It  may  be  hereditary  or  acquired,  and  is  propa- 
gated by  contagion,  the  virus  being  present  in  the  secretion  of  the  initial 
lesion,  the  blood,  and  the  secretions  of  the  lesions  of  the  secondary  and  the 
active  stage  of  the  hereditary  form  of  the  disease.  The  lesions  of  the  ter- 
tiary stage  are  probably  not  contagious,  nor  are  the  normal  secretions,  as  the 
milk,  tears,  etc. ,  unless  contaminated  by  the  blood  or  by  the  discharge  from 
a  syphilitic  lesion.  In  the  acquired  form  of  the  disease  the  method  of  con- 
tagion may  be  immediate, — that  is,  bj^  direct  contact  between  the  infected  and 
infecting  parties,  as  in  sexual  intercourse ;  or  mediate,  where  the  poison  is 
carried  by  something  acting  as  a  vehicle  of  contagion.  The  latter  method 
is  by  no  means  uncommon,  through  the  use  of  table  utensils,  pipes,  glass- 
blowers'  implements,  drinking- vessels,  etc. 

Etiology. — The  nature  of  the  infection  has  not  yet  been  discovered. 
All  the  symptoms  of  syphilis  point  to  its  being  of  bacterial  origin,  and  a 
bacillus  has  been  described  by  Lustgarten,  but  no  germ  has  yet  been  proved 
to  be  the  cause  of  the  disease.  After  the  entrance  of  the  poison  into  the 
system  there  elapses  a  space  of  time,  the  "primary  period  of  incubation," 
during  which  there  are  no  local  or  general  symptoms.  This  period  has  an 
average  length  of  three  weeks,  although  chancre  has  developed  as  early  as 
seven  days  and  as  late  as  ten  weeks  after  inoculation.  At  the  end  of  this 
time  the  local  sore  appears.  Syphilis  is  divided  into  three  stages,  the 
primary,  the  secondary,  and  the  tertiary. 

Chancre,  or  Initial  Lesion. — The  acquired  form  of  syphilis  is  inva- 
riably ushered  in  by  an  initial  lesion  at  the  site  of  the  infection.  There  is 
one  alleged  exception, — that  is,  where  a  mother  is  supiDOsed  to  acquire  the 
disease  from  a  syphilitic  foetus  in  utero,  without  previous  inoculation  from 
the  father,  such  infection  being  proved  bj^  the  subsequent  appearance  of 
constitutional  symjjtoms  ;  but  in  these  cases  there  is  always  the  possibility 
that  the  chancre  has  been  ijresent  and  overlooked. 

A  chancre  is  always  situated  at  the  spot  where  the  virus  gains  admission 
to  the  body,  and,  as  the  most  common  means  of  communication  is  by  sexual 
intercourse,  it  is  in  the  large  majority  of  cases  found  on  the  genitalia. 
Syphilis  is  often  communicated  in  an  innocent  manner,  and  extragenital 
chancre  is,  therefore,  not  uncommon,  constituting  ten  per  cent,  of  the  whole 
number  according  to  Bulkley.  An  abrasion  of  the  surface  is  generally 
necessary,  although  it  is  asserted  that  the  inoculation  can  take  place  on  a 
1194 


PLATE   IV. 


t' 


k^ 


it 


\6 


1.  Chancre  of  the  Up.    2.  Venereal  warts.    3.  Chancre  of  the  thumb.    4.  Chancroids.    5.  Gonorrhoea. 
6.  Chancre. 


CHANCRE. 


1195 


sound  surface,  tlie  virus  peuetrating  the  epithelium  or  travelling  down  a 
hair  or  sebaceous  follicle. 

When  situated  on  the  genitals,  the  favorite  seats  of  chancre  are  the  inner 
layer  of  the  i^repuce  and  the  balanopreputial  furrow.  It  occurs  also  on  the 
glans,  the  prepuce,  the  skin  of  the  penis,  at  the  meatus,  which  it  generally 
surrounds,  although  it  may  occupy  either  lip,  and  in  the  urethra  itself,  where 
it  occasions  a  discharge  which  simulates  gonorrh(]6a.  In  women  it  is  situ- 
ated on  the  labia,  fourchette,  and  clitoris,  rarely  in  the  vagina,  and  on  the 
cervix  uteri.  Extragenital  chancres  may  occur  upon  any  part  of  the  body,  but 
are  most  common  on  the  lip  (Fig.  917  and  Plate  III.,  Fig.  1),  the  tongue,  and 
the  tonsil,  on  the  iinger  (Plate  III.,  Fig.  3)  in  surgeons  and  obstetricians,  and 
on  the  nipple  in  nursing  women.  The  chancre  may  occur  in  one  of  several 
forms.  It  appears  as  the  chancrous  erosion 
(the  most  common  variety),  the  deep  ulcer-  Fig.  917. 

ating  (Hunterian)  chancre,  and  the  dry 
pajjule  (Lancereaux).  The  chancrous  ero- 
sion, the  form  most  commonly  seen,  appears 
as  a  smooth  polished  surface  denuded  of 
epithelium,  dull  red,  seldom  excavated,  but 
sometimes  covered  by  a  thin  greenish  mem- 
brane, and  furnishing  a  scanty  serous  or 
sero-sanguineous  discharge,  contagious  in 
character.  In  the  ulcerating  chancre,  which 
follows  ulceration  of  the  ordinary  variety, 
there  exists  an  excavated  surface  with 
sloping  edges  and  a  gray  base,  the  discharge 
being  sero-purulent.  The  Hunterian  chancre 
is  one  in  which  the  ulcerative  i^rocess  has 
gone  on  to  the  production  of  a  deep  funnel- 
shaped  ulcer,  surrounded  by  much  indura- 
tion, and  with  a  base  often  covered  by  gray- 
ish membrane.  (Plate  III.,  Fig.  6.)  The  dry  chancre  of  the  up. 
papule  occurs  on  a  dry  surface,  and  hence  is 

common  on  the  skin,  where,  owing  to  lack  of  moisture,  it  does  not  ulcerate, 
but  remains  as-  a  papule  with  a  dry  desquamating  surface.  A  constant 
feature  of  the  chancre  is  a  characteristic  induration,  hard  and  circumscribed 
to  the  touch,  very  different  from  the  inflammatory  thickening  around  an 
inflamed  chancroid,  and  due  to  a  round-cell  infiltration  in  and  around  the 
ulcer  and  to  a  layer  of  cedematous  tissue  around  its  base.  It  is  more  pro- 
nounced where  connective  tissue  is  most  abundant,  as  at  the  frenum  and 
behind  the  glans.  Where  the  induration  presents  the  sensation  as  if  a  leaf 
of  parchment  were  placed  beneath  the  ulcer,  the  thickening  is  known  as 
parchment  induration.  It  is  sometimes  described  as  split-pea  induration,  the 
feeling  being  that  of  a  half  of  a  pea,  flat  side  up,  slipped  under  the  skin, 
or,  in  the  Hunterian  variety,  it  may  be  still  more  pronounced,  and  surround 
the  sore.  The  induration  is  not  fully  de^'eloped  for  ten  days  or  two  weeks 
after  the  first  appearance  of  the  chancre,  and  lasts  generally  into  the 
secondary  stage. 


1196  SECONDARY  SYPHILIS. 

Chancre  is  iisually  single,  multiple  chancre  being  due  to  simultaneous 
inoculation  in  several  places,  and  not  to  auto-inoculation. 

Histologically,  a  chancre  consists  of  an  infiltration  of  round  cells,  with 
some  giant  and  epithelioid  cells.  There  are  marked  jjeriarteritis  and  endar- 
teritis, the  walls  of  the  blood-vessels  and  the  perivascular  lymph  spaces 
sharing  in  the  process.  The  cells  are  poorly  nourished  and  show  a  ten- 
dency to  degeneration.  Chancres  are  of  variable  duration,  some  lasting 
but  a  short  time,  and  perhaps  disappearing  unnoticed, — this  is  especially  the 
case  in  women, — while  others  last  well  into  the  secondary  period.  They  may 
become  phagedenic  from  infection  in  debilitated  and  intemperate  subjects. 
Chancres  in  moist  situations  are  in  the  secondary  period  liable  to  become 
converted  into  mucous  patches.  Ee-ulceration  of  the  scar  and  return  of 
induration  are  not  uncommon  later  in  the  constitutional  stage,  and  may  be 
mistaken  for  a  fresh  chancre. 

Mixed  Chancre.- — This  is  the  result  of  a  mixed  infection  with  chancroid 
and  syphilis  in  the  same  spot.  Chancroid  develops,  runs  its  course,  and 
may  or  may  not  be  healed  by  the  end  of  three  weeks,  when  the  chancre 
develops,  and  induration  specific  in  character  begins  to  appear,  followed  by 
constitutional  syphilis. 

Syphilitic  Bubo. — During  the  course  of  chancre,  about  the  time  of 
development  of  induration,  the  inguinal  glands  on  one  or  both  sides  undergo 
a  moderate  enlargement.  Several  glands  may  be  involved,  one  being  usu- 
ally larger  than  the  rest.  The  enlargement  is  slow  and  painless,  and  sup- 
puration only  occurs  in  cases  of  septic  infection  of  the  chancre.  In  extra- 
genital chancres  the  buboes  appear  in  the  glands  draining  the  region  in 
which  they  originate,  as  the  epitrochlear  and  the  axillary  in  case  of  the 
finger,  the  submaxillary  in  case  of  the  lip,  and  the  inguinal  in  case  of  the 
rectum  and  the  lower  portion  of  the  abdomen.  The  lymphatics  themselves 
can  sometimes  be  felt  beneath  the  skin  as  hard  i^ainless  cords. 

During  the  primary  stage  of  syphilis  the  manifestations  of  the  disease  are 
purely  local.  After  the  appearance  of  the  chancre  there  is  a  period  of 
quiescence,  lasting  in  the  average  case  a  little  over  six  weeks,  known  as  the 
period  of  secondary  incubation,  during  which  time  the  virus  (bacterial  or 
otherwise)  is  probably  actively  at  work  in  the  tissues,  and  at  the  end  of  this 
time  the  secondary  constitutional  symptoms  apjiear. 

Secondary  Syphilis. — The  lesions  of  the  secondary  stage  consist 
mainly  of  pathological  manifestations  in  the  skin,  the  mucous  membranes, 
the  blood,  the  lymph-glands,  the  eye,  and  some  of  the  internal  viscera. 
Fever  is  often  present  as  the  first  constitutional  symptom  before  the  erup- 
tion appears.  From  its  preceding  the  eruption  it  is  called  eruptive  feve)-,  and 
may  in  some  cases  precede  each  fresh  crop  of  skin-lesions.  It  is  higher  in 
the  evening,  is  accomj)anied  by  malaise  and  by  osteocopic  pains,  and  after 
a  few  days  disappears  with  the  api^earance  of  the  rash. 

The  lesions  of  the  skin  and  mucous  membranes  are  the  most  prominent 
symptoms  of  the  secondary  stage.  They  are  very  important  from  a  diag- 
nostic stand-point,  both  as  to  the  existence  of  the  disease  and  the  different 
stages  of  its  progress.  The  eruptions  simulate  non-specific  skin  affections, 
and  include  roseola,  papules,  pustules,  tubercles,  and  sometimes  vesicles  and 


SECONDAEY   SYPHILIS. 


1197 


bullfe ;  the  latter  are  not  uncommon  in  congenital  but  are  very  rare  in 
acquired  syphilis.  The  lesions  are  due  to  hypertemia  and  round-cell  infil- 
tration, are  superficial  in  the  early  eruptions,  taking  place  in  the  papillary 
and  Malpighian  layers,  and  in  the  later  stages  in  the  deeper  layers  of  the 
derm.  The  eruptions  are  chronic,  developing  slowly  and  lasting  a  consid- 
erable time.  They  develop  in  successive  crops,  one  coming  before  the  pre- 
ceding one  has  disappeared,  so  that  the  eruption  is  often  polymorphous 
from  the  different  manifestations  being  i^resent  simultaneously.  They  are 
generally  symmetrical  in  the  secondary  stages,  non- inflammatory,  and  there- 
fore usually  unaccompanied  by  itching.  Their  color  is  at  first  like  that  of 
raw  ham,  becoming  copper- colored  as  they  grow  older,  and  leaving  a  char- 
acteristic brown  pigmentation  of  the  skin,  due  to  a  deposit  of  blood-pig- 
ment. The  infiltrated  cells  never  organize,  but  are  absorbed  or  break  down 
and  ulcerate.  Disappearance  withoiat  ulceration  and  scarring  is  the  rule 
with  the  early  secondary  eruptions,  while  those  in  the  late  secondary  and 
tertiary  stages  may  disappear,  but  often  ulcerate,  leaving  white,  shining 
cicatrices.  Ulcerating  lesions  show  thick  black  or  brown  laminated  crusts, 
easily  detached.  Secondary  eruptions  are  generalized  and  contagious,  while 
tertiary  manifestations  show  a  tendency  to  localization,  are  not  symmet- 
rical, and  are  generally  non-contagious.  The  secondary  skin  eruptions  are 
roseola,  papular,  pustular,  vesicular,  and  squamous.  (Fig.  918.)  The 
ulcerating  pustular  forms,  as  impetigo, 

rodens,  ecthyma,  and  rupia,  are  really  Fig.  918. 

on  the  border-line  between  the  second- 
ary and  tertiary  lesions,  partaking  of 
some  of  the  characters  of  each.  Rupia, 
which  is  peculiar  to  syphilis,  classified 
by  some  as  a  late  secondary  and  by 
others  as  a  tertiary  phenomenon,  starts 
as  a  pustule  or  a  bulla,  which  ulcerates, 
the  secretion  drying  into  a  crust,  which 
by  the  addition  of  succeeding  layers  of 
secretion  from  the  ulcer  beneath  forms 
a  typical  blackish-brown,  cone-shaped 
crust,  resting  on  an  ulcerated  base. 
(Fig.  919.) 

The  mucous  membranes  are  very  fre- 
quently affected  in  secondary  syphilis. 
The  sore  throat  accompanying  the 
earliest  eruption  is  due  to  erythema, 
perhaps  in  comjiany  with  mucous 
patches  and  ulcerations.  The  mucous 
patch  is  ijeculiar  to  syphilis,  and  occurs 
around  the  natural  orifices  and  on  the 

skin  in  situations  where  it  is  moist  and  warm,  as  under  the  breasts  and  on 
the  scrotum.  It  is  due  to  a  modification  of  the  eruption  from  the  nature  of 
the  habitat,  and  histologically  consists  of  an  infiltration  of  round  cells  into 
the  deeper  layers  of  the  epiderm,  with  in  some  instances  hypertrophy  of 


Papular  syphilide. 


1198 


SECONDARY  SYPHILIS. 


the  papillae  aud  secondary  changes  in  the  epithelium,  as  thickening  and 
ulceration.  Clinically  it  is  a  small  round  or  oblong  patch  of  rosy  color, 
generally  elevated  and  covered  with  a  whitish  pellicle  composed  of  fibrin 
and  small  round  cells.     The  secretion  is  contagious,  and  is  often  the  source 

whence  infection  is  derived.     The 
Fig.  919.  chancre  is  sometimes  transformed 

directly  into  a  mucous  patch  in 
the  secondary  stage.  Suijerficial 
and  deep  ulcerations  may  occiu-  in 
the  secondary  stage  on  the  fauces, 
the  palate,  the  tonsil,  and  the 
tongue.  Scaly  patches,  smooth, 
white,  shining  spots,  covered  by 
adherent  scales,  are  especially  com- 
mon on  the  inside  of  the  cheek  and 
on  the  tongue  in  smokers.  They 
are  found  late  in  the  secondary  and 
in  the  tertiary  stage.  Alopecia 
is  very  common  in  the  secondary 
stage,  affecting  the  hair,  eyebrows, 
beard,  etc.,  but  is  not  permanent. 
It  may  be  due  to  lowering  of  the 
general  tone  of  the  system  by  the 
syphilitic  virus,  the  nutrition  of 
the  hair-follicles  being  affected 
pari  iHtssu  (as  happens  also  in 
fevers),  or  to  a  localization  of  the 
eruption  on  the  scalp,  causing  a  partial  baldness.  Deep  ulcerating  tertiary 
lesions  of  the  scalp  cause  permanent  baldness. 

With  the  development  of  the  secondary  stage  there  occurs  a  general- 
ized glandular  enlargement  of  the  painless  sluggish  type  observed  in 
the  primary  bubo.  Glandular  enlargement  is  of  value  from  a  diagnostic 
stand-point,  the  glands  most  easily  examined  being  the  post-cervical  group, 
the  axillary,  and  the  epitrochlear  gland  lying  just  above  the  internal  condyle 
of  the  humerus.  The  enlargement  of  the  glands  ajipears  a  little  before  the 
eruption,  and  disappears  to  a  certain  extent  with  the  other  active  symptoms, 
but  in  many  cases  induration  persists  for  a  long  time. 

Analgesia,  localized  and  general,  is  found  in  early  secondary  syphilis, 
being  especially  common  in  females.  Pain  in  the  bones,  especially  at 
night,  and  also  jorovoked  by  pressure,  and  perhaps  accompanied  by  nodular 
swellings,  may  be  observed  in  the  secondary  stage.  General  rheumatoid 
pains  are  complained  of  at  night.  Other  secondary  symptoms  are  jaundice, 
occurring  without  structural  hepatic  changes,  and  nephritis,  which,  while 
less  common  than  in  the  tertiary  stage,  may  be  manifested  by  albuminuria 
and  dropsy,  often  responding  promptly  to  antisyphilitic  treatment.  Iritis 
is  the  most  frequent  eye-lesion  in  the  secondary  stage.  Choroiditis  and 
retinitis  occur  much  less  frequently.  Conjunctivitis  is  sometimes  present, 
and  rarely  keratitis,  which  is  very  frequent  in  the  inherited  disease. 


Rupia. 


TERTIARY   SYPHILIS.  Il!)!» 

In  addition  to  the  above  symptoms,  there  is  a  condition  of  syphilitic 
cachexia,  in  which  the  general  vitality  of  the  individual  i.s  reduced,  and  Ik.' 
becomes  thin,  pale,  and  weak.  An  examination  of  the  blood  shows,  even 
in  the  period  of  secondary  incubation,  a  decrease  in  the  amount  of  hemo- 
globin and  in  the  number  of  red  blood-cells,  with  a  marked  increase  in  the 
number  of  white  cells.  This  becomes  more  marked  before  and  during  the 
eruptive  period.  Under  the  judicious  use  of  mercury  this  anajmia  disap- 
pears. Justus's  test  for  syphilis  rests  on  the  detection  of  a  marked,  rapid, 
but  transient  fall  in  the  percentage  of  hiemoglobin  upon  the  administration 
of  mercury  by  inunction  or  hypodermic  injection.  It  is  not  always  reliable 
in  early  or  latent  cases  where  it  is  most  needed.  Tertiary  ansemia  may 
develop,  but  is  not  proportionately  so  frequent.  Secondary  syphilis  lasts 
from  one  to  three  years.  Tertiary  syphilis  may  develop  at  the  end  of  a 
year,  or  may  be  deferred  for  ten  or  fifteen  years.  In  the  large  majority  of 
well-treated  cases  the  disease  is  cured  in  the  secondary  stage. 

Tertiary  Syphilis. — This  is  irregular  both  in  its  onset  and  in  its 
progress.  It  comes  on  generally  in  the  third  or  fourth  year.  The  lesions 
are  chronic  and  sluggish.  The  surface  lesions  are  unsymmetrical  and  ir- 
regular, and  involve  the  whole  thickness  of  the  skin  and  mucous  membrane, 
as  well  as  the  subcutaneous  and  submucous  tissues.  Internally  there  are 
gummata  in  the  various  organs,  vascular  changes,  and  sclerosis  in  the 
nervous  system  and  elsewhere.  The  skin,  nervous  sj^stem,  bones,  mucous 
membranes,  and  viscera  are  attacked  in  about  this  order  of  frequency.  The 
lesions  are  generally  non-contagious.  The  characteristic  affections  of  the 
skin  are  the  tubercle  and  the  gumma.  The  tubercle  is  a  circumscribed, 
nodular  infiltration  in  the  skin,  not  extending  into  the  subcutaneous  tissue ; 
it  shows  a  tendency  to  be  circinate  in  distribution,  and  is  dry  or  ulcerative. 
On  the  face  the  ulcerative  form  is  common;  and  may  destroy  large  portions 
of  the  nose  and  lips,  owing  to  its  progressive  nature  and  occasional  phage- 
denic properties.  A  gumma  consists  of  a  mass  of  round  cells,  with  giant 
and  epitheloid  cells,  intermingled  with  a  circumscribing  layer  of  condensed 
connective  tissue.  There  is  also  some  new  blood-vessel  formation,  but  in  the 
centre  there  is  a  tendency  to  myxomatous,  fatty,  or  caseous  degeneration. 
A  gumma  starts  as  a  firm  nodule  beneath,  and  at  first  unattached  to,  the 
skin,  single  or  multiple,  and  with  a  tendency  to  soften  and  discharge  through 
the  ulcerated  overlying  skin,  the  gummatous  ulcer  remaining  as  an  indo- 
lent, circumscribed,  circular  sore,  with  thickened  edges,  leaving  after  cica- 
trization a  smooth,  white,  depressed  scar.  It  is  especially  liable  to  become 
serpiginous  on  the  abdomen.  Osseous  and  joint  lesions  occur  both  in 
the  secondary  and  in  the  tertiary  stage,  more  commonly  in  the  latter.  (See 
pages  542  and  612.)  Dactylitis  is  quite  common  in  the  hereditary  form,  and 
is  rare  in  acquired  syphilis,  existing  in  two  forms,  either  (1)  starting  from 
the  subcutaneous  and  fibrous  tissues  of  the  joints,  or  (2)  involving  the  bone 
and  periosteum  primarily.  Syphilis  of  the  testicle  causes  a  hard,  smooth, 
painless  enlargement  of  the  whole  organ,  which  rarely  ulcerates.  Excep- 
tionally localized  gummata  can  be  made  out,  but,  as  a  rule,  the  general  shape 
and  outline  are  preserved.  If  arrested  by  early  treatment  the  function  of 
the  organ  is  preserved.     The  syphilitic  affections  of  the  nervous  system 


1200  INHEEITED   SYPHILIS. 

are  meningitis,  epilepsy,  paraplegia,  hemiplegia  (following  rupture  of  dis- 
eased blood-vessels),  and  gummata  of  the  brain  and  cord.  The  nerve- 
structures  themselves  are  probably  not  affected  primarily  by  syphilis,  their 
involvement  being  secondary  to  connective-tissue  and  blood-vessel  changes. 
To  certain  of  these  conditions,  as  locomotor  ataxia  and  paresis,  the  name 
para- syphilitic  affections  has  been  suggested,  as  they  are  only  indirectly  due 
to  syphilis. 

Inherited  Syphilis. — Syphilis  in  the  secondary  stage  is  very  frequently 
transmitted  to  the  offspring.  Tertiary  syphilis  is  not  generally  transmissi- 
ble. For  syphilis  to  be  transmitted  it  is  probably  necessary  that  the  mother 
should  be  infected, — that  is,  the  father  cannot  transmit  syphilis,  the  mother 
remaining  healthy ;  this  is  denied  by  Kassowitz  and  others,  including 
Taylor.  That  the  mother  is  syphilitic  is  rendered  more  probable  by  the 
fact  that  she  cannot  contract  the  disease  from  her  syphilitic  child  (Colics' s 
law),  although  she  herself  may  seem  perfectly  free  from  the  disease.  If  a 
healthy  woman  acquires  syj)hilis  during  pregnancy  her  child  may  inherit 
the  disease,  especially  if  infection  takes  place  before  the  sixth  month,  as 
pointed  out  by  Eicord.  Later  than  this  the  child  usually  escapes,  although 
in  Chabalier's  case  the  child  contracted  it  during  the  eighth  month.  Abor- 
tions are  very  frequent  in  syphilitic  women,  occurring  about  the  sixth 
month,  associated  with  disease  of  the  placenta  and  the  expulsion  of  a 
macerated  foetus  showing  visceral  lesions  and  perhaps  pemphigus  of  the 
hands  and  feet.  After  several  abortions  the  woman  may  give  birth  to  a 
living  child,  which  usually  shows  no  signs  of  disease  until  the  third  week, 
although  in  some  cases  the  eruption  is  present  from  the  first.  The  infant 
then  shows  signs  of  malnutrition,  becomes  thin  and  wizened,  and  presents  a 
prematurely  old  appearance.  The  early  eruptions  are  superficial  and  gen- 
eralized, and  are  associated  with  visceral  disease,  especially  of  the  liver  and 
lungs,  the  kidney,  spleen,  nervous  system,  and  testicle  being  sometimes  dis- 
eased. The  eruptions  comprise  roseola,  papules,  pustules,  tubercles,  and 
bullae  (pemjjhigus). 

Syphilitic  pemphigus,  rare  in  the  acquired  form,  may  be  present  at 
birth  or  appear  soon   after.      Authorities  agree  that  it  indicates  a  very 

malignant  form  of  the  disease.     It  con- 
^^'^  ^-'^  sists   of  bullfe  which  become  pustular 

and  ulcerate,  the  usual  location  being  on 
the  palms  of  the  hands  and  the  soles  of 
the  feet.  Mucous  patches  are  also  pres- 
ent. With  the  earliest  eruptions  there 
is  an  inflammation  confined  at  first  to  the 
nasal  mucous  membrane,  producing  the 
characteristic  snuffles,  which  later,  by 
ulceration  and  destruction  of  bone  and 
cartilage,  produces  the  sunken  nose  of 
hereditary  syphilis.  (Fig.  920.)  Ulcera- 
tions are  present  around  the  mouth  and 
the  anus,  which  leave  linear  scars,  rluigades,  on  healing.  The  bone-lesions 
consist  of  epiphyseal  and  other  changes.    At  the  epiphyses  there  is  an  osteo- 


Facies  of  hereditai-j'  syphilis. 


TREATMENT  OF  SYPHILIS. 


1201 


Fig.  921. 


chondritis  resulting  in  premature  attempts  at  ossification  and  sometimes 
separation  of  the  epiphysis,  abscess,  and  caries.  Periostitis  of  the  long  and 
flat  bones  results  in  the  formation  of  osteophytes,  which  on  the  skull  are 
grouped  around  the  anterior  fontanelle  as  foui'  nodes  separated  by  the  sutures 
the  "natiform"  appearance  of  Parrot.  Dactylitis  is  quite  common.  The 
prognosis  is  bad,  death  supervening  in  seventy  per  cent,  of  these  cases. 
The  later  the  disease  appears  the  better  is  the  prognosis.  If  the  child  sur- 
vives, the  late  lesions  become  milder  in  nature.  Interstitial  keratitis  is 
a  not  uncommon  and  a  very  typical  symptom.  Iritis,  choroiditis,  and 
retinitis  may  also  be  present.  A  peculiar  condition  of  the  incisor  teeth 
first  described  by  Jonathan  Hutchinson,  is 
of  diagnostic  value  in  connection  with  other 
signs  of  inherited  syphilis.  (Fig.  921.)  Dr. 
Harrison  Allen  has  called  attention  to  the 
fact  that  a  similar  deformity  of  the  teeth 
may  result  from  other  diseases  affecting 
children  during  the  period  of  their  devel- 
opment, and  all  observers  are  aware  of  the 
fact  that  many  cases  presenting  other 
marked  symptoms  of  inherited  syphilis 
often  have  well- developed  teeth.  The  cen- 
tral upper  incisors  of  the  permanent  set  are 
those  involved,  the  deformity  consisting  in 
a  pegging  due  to  a  narrowing  of  the  cut- 
ting edge,  associated  with  a  central  notch 
on  the  free  border.  There  is  often  deafness, 
due  to  otorrhcea.  The  nervous  system  is 
sometimes  involved.  The  subject  of  heredi- 
tary syphilis  very  rarely  contracts  the  dis- 
ease in  later  life,  and  there  are  few,  if  any, 
aiithentic  cases  of  transmission  to  the  third 
generation.  By  Profeta's  immunity  is  meant 
the  immunity  shown  by  children  of  syphilitic  parents  to  syphilis,  even  if 
they  themselves  seem  healthy. 

Treatment.— This  should  be  both  hygienic  and  medicinal.  Every 
means  must  be  taken  to  keep  the  patient  in  good  jjhysical  condition  by 
healthful  surroundings,  good  food,  and  an  avoidance  of  physical  and  mental 
overwork,  thus  allowing  nature  to  assist  in  overcoming  the  disease.  Alco- 
hol, especially  in  excess,  is  injurious,  and,  although  light  beverages  may 
sometimes  be  allowed,  the  use  of  strong  wines  and  liquors  should  be  inter- 
dicted. Tobacco  often  excites  aud  assists  in  keeping  up  mouth  and  thi-oat 
lesions,  and  its  use  should  therefore  be  forbidden.  The  skin  must  be  kept 
in  good  condition,  and  attention  should  be  paid  to  the  teeth.  During  the 
primary  stage,  in  addition  to  the  hygienic  treatment  above  described,  local 
treatment  directed  to  the  chancre  should  be  employed.  Excision  of  the 
chancre  has  been  practised  in  all  its  stages,  in  the  hope, of  aborting  sj'ijhilis. 
but  without  success.  The  sore  should  be  kept  clean  by  the  use  of  mild  anti- 
septic lotions,  and  dusted  with  iodoform,  aristol,  calomel,  or  acetanilid,  iodo- 


Hutchinson's  teeth  with  rhagades  of 
the  lips.  (Museum  of  the  German  Hospital 
of  Philadelphia.) 


1202  TREATMENT  OF  SYPHILIS. 

form  being  the  best.  If  comi)licated  by  chaucroid,  the  mixed  chancre  should 
be  cauterized,  if  necessary,  as  directed  in  treating  chancroid.  Phagedenic 
ulceration  requires  the  same  treatment  as  directed  for  chancroid,  and  in  addi- 
tion is  sometimes  benefited  by  the  internal  administration  of  mercury.  For 
the  primary  adenitis  a  compress  and  spica  bandage  may  be  worn  and  mer- 
curial oiutment  rubbed  in  locally  to  aid  resolution.  If  suiipuration  occurs 
as  a  result  of  pyogenic  infection,  it  must  be  treated  as  a  sujipurating  bubo. 
It  is  seldom  advisable  to  administer  mercury  during  the  primary  stage.  An 
absolute  diagnosis  of  syphilis  cannot  always  be  made  from  the  appearance 
of  the  primary  sore,  and  hence,  if  mercury  be  administered  in  this  stage,  a 
state  of  uncertainty  often  remains  in  the  minds  of  physician  and  patient. 
Again,  if  mercury  be  administered  before  the  secondary  stage,  while  it  may 
postpone  the  appearance  of  the  eruption  and  alter  the  natural  sequence  of 
symptoms,  it  does  not  abort  the  disease. 

After  the  onset  of  the  secondary  stage,  as  manifested  by  the  appearance 
of  the  rash,  the  question  of  medication  becomes  of  primary  importance. 
The  drugs  of  peculiar  antisyphilitic  value  are  mercury  and  iodide  of  potas- 
sium. Mercury  is  of  value  in  all  stages  of  syphilis,  iodide  of  potassium 
especially  in  the  late  secondary  and  tertiary  ijeriods.  Mercury  may  be 
administered  by  the  mouth,  by  inunction,  by  fumigation,  and  hypodermi- 
cally,  the  aim  being  not  to  salivate  the  patient,  but  to  keep  him  sufficiently 
under  the  influence  of  the  drug  to  overcome  the  syphilitic  virus,  for  which 
it  is  almost,  if  not  quite,  a  specific.  The  combination  with  the  iodide  in 
the  form  of  the  mixed  treatment  is  of  especial  value  in  the  late  secondary  and 
tertiary  stages.  The  preparations  of  mercury  suitable  for  internal  use  are 
the  protiodide,  the  bichloride,  calomel,  gray  powder,  and  blue  pill.  The 
protiodide  is  a  favorite  preparation,  and  is  that  preferred  by  Keyes  in  what 
he  calls  his  tonic  treatment  of  syphilis,  which  consists  in  starting  with  a 
small  dose  (one-sixth  of  a  grain  of  the  protiodide)  three  times  a  day,  and 
gradually  inci'easing  the  quantity  until  tenderness  of  the  teeth  and  gums,  or 
diarrhcea,  shows  that  a  marked  constitutional  effect  is  produced.  The  quan- 
tity necessary  to  do  this  is  called  the  full  dose :  the  half  of  this  is  the  tonic 
dose,  and  is  to  be  administered  steadily  for  many  months  ;  the  difference 
between  it  and  the  full  dose  is  called  the  reserve  dose,  and  is  added  to  the 
regular  quantity  when  indicated  by  a  fresh  outbreak  of  syphilitic  lesions. 
Keyes  asserts  that  under  this  method  of  administering  mercury  the  number 
of  red  blood- corjjuscles  is  increased,  the  general  health  improved,  and  the 
disease  often  cured  in  the  secondary  stage.  Other  writers  consider  such  a 
course  entirely  too  mild,  and  are  guided  in  their  dose  by  the  effect  produced 
on  the  rash  and  other  symptoms,  increasing  the  quantity  until  its  effect  is 
shown  by  the  disappearance  of  the  eruption  and  glandular  enlargements, 
and  the  improvement  in  the  patient's  general  health,  keeping  the  quantity 
below  the  point  necessary  to  salivate  or  cause  gastroenteric  symptoms. 
The  combination  of  opium  with  the  mercury  will  often  enable  the  patient 
to  increase  his  dose  beyond  that  otherwise  possible.  When  the  necessity  of 
vigorously  attacking  syphilitic  lesions  demands  it,  inunctions  are  a  very 
efficacious  means  of  treatment,  and  may  be  used  as  a  routine  or  in  combina- 
tion with  internal  ti'eatment  when  it  is  desired  rapidly  to  impress  the  sys- 


TREATMENT  OF  SYPHILIS.  1203 

tern  or  to  attack  a  generalized  eruption.  It  is  often  a  useful  plan  to  institute 
a  short  course  of  inunctions  after  several  months  of  internal  medication. 
Mercurial  ointment  is  the  best  preparation,  from  3ss  to  3i  being  rubbed  in 
daily  in  different  parts  of  the  body  in  succession,  in  combination  with  hot 
baths,  to  favor  absorption,  "the  great  inconveniences  of  the  method  are 
its  dirtiness  and  the  difficulty  in  following  it  out  with  secrecy  at  the  patient's 
home.  Fumigation  is  practised  by  introducing  the  fumes  of  mercury, 
obtained  by  heating  calomel  or  cinnabar  over  a  lamp,  mixed  with  steam, 
under  a  frame  covered  with  blankets,  or  other  device,  in  which  the  patient, 
stripped  of  his  clothing,  is  seated,  bis  head  remaining  outside.  After  an 
exposure  of  twenty  or  thirty  minutes  to  the  fumes,  the  patient  either  goes  to 
bed  or  wraps  up,  to  avoid  rapid  cooling  of  the  surface,  at  the  same  time 
avoiding-  rubbing  off  the  coating  of  mercury  deposited  on  the  skin.  This 
method  is  useful  as  an  adjunct  to  other  modes  of  treatment. 

Hypodermic  injections  of  calomel,  gray  oil,  yellow  oxide  of  mercury, 
corrosive  sublimate,  and  other  preparations  of  mercury,  have  recently 
attained  much  popularity  in  the  treatment  of  syphilis,  and  extravagant 
claims  have  been  made  as  to  the  ease  and  rapidity  of  cure  by  this  method. 
The  injections  are  made  into  the  subcutaneous  tissue,  and  even  the  muscles, 
the  back  and  buttocks  being  favorite  sites,  but,  while  often  effective,  are 
painfial,  and,  especially  when  using  the  insoluble  preparations,  as  calomel, 
are  liable  to  be  followed  by  abscesses  at  the  sites  of  the  injections.  When  a 
rapid  effect  is  necessary,  as  in  syphilis  of  the  brain,  spinal  cord,  and  eye, 
and  when  the  stomach  is  rebellious,  and  other  means,  as  inunctions  and 
fumigations,  are  impracticable,  hypodermic  medication  should  be  employed. 
The  insoluble  preparations  are  given  suspended  in  some  medium  like 
glycerin  or  liquid  vaseline.  Calomel  may  be  given  in  one-grain  doses, 
repeated  every  week  or  two,  and  bichloride  of  mercury  in  one-sixth  to 
one-tenth  grain  doses  every  day  or  every  other  day.  Scrupialous  attention 
must  be  paid  to  asepsis  in  preparing  and  giving  the  injection,  and  a  careful 
watch  kept  for  signs  of  salivation. 

Late  in  the  secondary  stage,  or  earlier  in  those  cases  of  precocious  syphilis 
which  are  marked  by  the  early  appearance  of  gummata  and  nervous  syphilis, 
iodide  of  potassium  or  iodide  of  sodium  becomes  of  use,  and  in  the  tertiary 
stage  is  of  great  benefit  both  alone  and  in  combination  with  mercury. 
Starting  with  ten-grain  doses,  it  may  be  pushed  until  one  or  two  ounces  a 
day  are  being  taken,  when  the  nervous  or  other  symptoms  demand  it. 
Excessive,  long-continued  use  of  the  iodides  causes  a  condition  known  as 
iodism.  The  iodide  may  be  given  in  plain  water,  wine  of  pepsin,  Vichy 
water,  or  milk  well  diluted,  two  or  three  hours  after  eating.  The  combina- 
tion of  bichloride  of  mercury,  iodide  of  potassium,  and  compound  syrup  of 
sarsaparilla  is  a  i^opular  one,  as  is  also  that  of  biniodide  of  mercury  and 
iodide  of  potassium.  In  hereditary  syphilis,  inunctions  may  be  adminis- 
tered by  smearing  mercurial  ointment  on  the  binder,  or  calomel,  gray 
powder,  or  bichloride  of  mercury  may  be  prescribed  internally.  Later, 
the  iodides  are  useful  in  combination  with  mercury  and  alone.  If  a  syphi- 
litic woman  becomes  pregnant,  she  should  be  kept  under  medication,  in 
the  endeavor  to  secure  a  healthy  child.     Similarly,  if  a  pregnant  woman 


1204  CHANCROID. 

acquires  syphilis,  she  should  be  thoroughly  treated,  and  if  the  diagnosis 
be  clear  from  the  appearance  of  the  chancre  it  is  better  to  begin  treat- 
ment at  once,  without  waiting  for  the  secondaries  to  appear. 

Local  Treatment  of  Secondary  and  Tertiary  Eruptions.— The 
advantage  of  treating  generalized  eruptions  by  fumigations  and  inunctions 
in  combination  with  internal  medication  has  already  been  emphasized. 
Localized  secondary  and  tertiary  eruptions  should  be  treated  locally  with 
mercurial  ointment,  ammoniate  of  mercury  ointment,  oleate  of  mercury,  etc. 
A  solution  of  bichloride  of  mercury  from  two  to  four  grains  to  the  ounce 
may  be  applied  with  advantage.  Ulcerating  lesions  demand  removal  of 
crusts  and  stimulating  applications,  as  iodoform,  black  wash,  or  dilute  oint- 
ment of  nitrate  of  mercury,  the  iodoform  being  especially  happy  in  its 
results.  In  the  treatment  of  serpiginous  ulcers  the  following  ointment, 
ungt.  hydrarg.,  3iii;  ac.  salicylici,  gr.  xii ;  ungt.  adhesivi,  3iv,  spread 
upon  kid  and  applied  to  the  surface  of  the  ulcer  and  the  surrounding  indu- 
rated tissues,  will  be  found  most  satisfactory.  The  di-essing  should  be 
renewed  at  intervals  of  twenty-four  or  forty-eight  hours.  Mucous  patches 
on  the  skin  should  be  kept  clean,  stimulated,  and  dusted  with  iodoform, 
calomel,  or  other  powder.  When  present  in  the  mouth,  an  antiseptic  gargle 
may  be  prescribed,  and  the  ulcers  themselves  touched  with  acid  nitrate  of 
mercury,  pure  or  diluted,  nitrate  of  silver,  sulphate  of  copper,  or  a  solution 
of  chromic  acid,  gr.  x,  to  water,    si. 

CHAISrCKOID,    OE  SIMPLE   VENEREAL   ULCER. 

Chancroid,  or  soft  chancre,  as  it  is  sometimes  called,  is  an  ulcer  com- 
monly found  on  the  genitalia,  contagious  in  nature,  and  generally  of  venereal 
origin.  Unlike  chancre,  with  which  uj)  to  comparatively  recent  times  it 
was  confused,  it  is  a  local  affection,  never  being  followed  by  constitutional 
symptoms.  Its  exact  cause  has  not  yet  been  fully  demonstrated.  It  is  con- 
sidered by  some  authors  to  be  a  specific  lesion  caused  by  a  special  bacterium, 
and  a  streptobacillus  has  been  described  by  Ducrey  and  Unna  as  occurring 
in  the  pus  and  tissues  of  the  ulcer,  which  they  believe  to  be  the  cause  of  the 
affection.  Other  investigators  regard  it  as  non-specific,  and  assert  that  it 
can  arise  as  the  result  of  irritation,  uncleanliness,  and  pus-infection  acting 
on  simple  lesions,  causing  them  to  take  on  the  peculiar  features  of  chancroid. 
(Bumstead,  Finger,  Taylor.)  It  has  been  successfully  inoculated  in  the 
lower  animals. 

Chancroid  is  most  frequently  observed  among  the  lower  classes,  and  is, 
therefore,  more  frequently  encountered  in  hospital  than  in  private  practice, 
in  which  latter  chancre  is  the  more  common  lesion.  The  most  common  seat 
of  the  ulcer  is  at  the  side  of  the  frenum  and  in  the  sulcus  behind  the  glans  ; 
it  is  also  found  on  the  inner  and  outer  layers  of  the  prepuce,  on  the  glans, 
around  the  meatus,  and  on  the  penis  above  the  prepuce,  and  by  auto- 
inoculation  on  the  scrotum  and  thighs,  and  is  sometimes  encountered  in  the 
urethra.  In  women  it  affects  the  labia,  fourehette,  clitoris,  vestibule,  rarely 
the  vagina  itself,  and  the  os  uteri.  The  discharge  running  down  over  the 
perineum  inoculates  that  region  and  the  anus,  the  latter  situation  in  the 
male  being  generally  inoculated  in  the  practice  of  sodomy.     Chancroid  has 


COMPLICATIONS  OF  CHANCROID.  1205 

no  period  of  incubation.  As  soon  as  the  germs  penetrate  the  epithelial 
layer,  or  immediately  in  those  cases  in  which  infection  takes  place  through 
an  existing  abrasion,  the  inflammatory  process  begins,  and  by  the  second  or 
third  day  the  part  becomes  the  seat  of  a  pustule  surrounded  by  an  inflam- 
matory area.  The  pustule  soon  breaks  down,  producing  the  typical  chan- 
croidal ulcer.  The  lesion  is  often  unnoticed  until  the  ulcerative  stage  is 
reached. 

The  appearance  of  the  chancroidal  ulcer  is  characteristic.  It  is  round, 
oval,  or  of  irregular  shape,  with  a  punched-out  appearance,  due  to  the 
sharply  cut  or  undermined  edges,  in  marked  contrast  to  the  sloping  edges 
and  floor  of  a  chancre.  The  floor  is  covered  with  a  grayish-yellow  deposit 
of  membrane,  beneath  which  is  the  uneven  surface  of  the  ulcer.  (Plate  III., 
Fig.  4.)  .  There  is  a  thin,  brownish,  unhealthy  pus  secreted,  which  is  auto- 
inoculable, — that  is,  capable  of  producing  identical  lesions  on  the  same 
individual  wherever  inoculated.  There  are  multiple  ulcers  as  a  result  of 
this  property  in  a  majority  of  cases.  On  compressing  the  base  of  the  sore 
between  the  fingers  there  is  an  absence  of  the  characteristic  circumscribed 
induration  of  the  chancre,  but  there  may  be  a  diffuse  inflammatory  oedema. 
The  ulceration  is  progressive,  especially  on  the  mucous  membranes,  and 
may  involve  considerable  destruction  of  tissue.  There  is  usually  some  pain 
felt  in  cases  of  chancroid,  and  it  may  be  very  severe  in  rapidly  advancing 
and  fthagedenic  cases,  which  is  in  contrast  to  the  painless  chancre.  In  un- 
treated cases  the  advancing  stage  lasts  for  a  week  or  two,  being  succeeded 
by  a  stationary  period  of  the  same  duration,  after  which  the  process  of 
healing  begins,  being  marked  by  a  change  in  the  character  of  the  secretion, 
which  becomes  more  healthy,  and  by  the  disapj)earance  of  the  pseudo- 
membrane  and  the  springing  irp  of  granulations.  The  edges  lose  their 
punched-out  appearance  and  become  the  starting-points  for  cicatrization. 
At  any  stage  the  ulcer  may  lapse  into  its  former  virulent  condition. 

Complications. — Phagedena  is  the  most  serious  complication  of  chan- 
croid. It  consists  in  a  marked  increase  in  the  tissue-destroying  properties 
of  the  ulcer.  It  is  predisposed  to  by  factors  lessening  the  resistance  of  the 
tissues  to  infection,  as  unsanitary  surroundings  with  a  lowered  condition  of 
strength,  due  to  alcoholic  excesses,  scurvy,  diabetes,  etc ,  and  often  in  con- 
junction with  local  irritation  and  uncleanliness. 

Phagedena  is  of  two  kinds, — gangrenous,  or  sloughing,  and  serpiginous.  In 
the  first  variety  the  ulcer  becomes  the  seat  of  a  gangrenous  process,  indi- 
cated by  swelling,  pain,  a  scanty  sanious  discharge,  a  dusky  color  of  the 
parts,  and  the  rapid  formation  of  a  slough,  involving  the  entire  chancroidal 
surface  and  perhaps  destroying  the  entire  prepuce  or  glaus.  In  the  ser- 
piginous variety  the  ulcer  extends  rapidly  or  slowly,  destroying  the  tissues 
in  its  course,  perhaps  denuding  the  penis  and  exposing  the  testes  in  its 
ravages.  There  is  marked  constitutional  involvement.  In  the  chronic  ser- 
piginous variety,  which  most  frequently  has  its  origin  in  a  chancroidal 
bubo,  the  process  lasts  for  months  or  even  years,  the  ulcer  healing  at 
parts  as  the  ulceration  advances  over  the  abdomen  or  down  the  thigh.  It 
may  cause  death  by  exhaiistion,  or  by  peritonitis  from  perforation  of  the 
abdominal  wall,  or  by  hemorrhage  if  large  vessels  are  eroded. 

77 


1206  DLIGXOSIS  OF  CHANCROID. 

Inflammatory  phimosis  is  a  frequent  complication  of  chancroids  situ- 
ated beneath  the  prepuce,  which,  by  retention  of  the  discharge  and  inter- 
fei-ence  with  dressing,  favors  phagedena  and  bubo.  The  concealment  of 
the  lesion  renders  diagnosis  difficult,  especially  from  chancre  and  gonorrhoea. 
The  history  of  the  case,  the  acuteness  of  the  inflammation,  and  the  character 
of  the  discharge  are  points  of  most  importance  in  the  diagnosis. 

Paraphimosis  may  be  the  result  of  the  same  inflammatory  condition  of 
the  prepuce.  Lymphangitis  appears  as  hard,  red,  knotty  cords  under  the 
skin  of  the  penis,  painful,  and  sometimes  associated  with  .redness  and  oedema 
of  the  whole  organ.  Abscess  may  develop,  followed  by  a  secondary  chan- 
croid, which  develops  at  its  site. 

Bubo.' — This  is  the  most  common  complication  of  chancroid,  its  fre- 
quency being  variously  estimated  at  from  ten  to  thirty  per  cent.  It  is 
more  frequently  encountered  in  hospital  than  in  private  practice.  It  may 
develop  at  any  stage  of  the  disease,  and  has  been  known  to  appear  after 
healing  of  the  sore  had  taken  jjlace.  It  is  favored  by  improper  treatment, 
irritation,  and  neglect  of  cleanliness.  It  commonly  appears  in  the  groin 
on  the  side  corresponding  to  the  ulcer,  the  process  being  carried  to  the 
inguinal  glands  by  the  lymphatics  of  that  side,  but  if  the  sore  is  at  the 
freniim,  where  the  lymphatics  cross,  it  may  occui'  on  both  sides.  Chancroids 
at  the  frenum  are  jDeculiarly  apt  to  be  complicated  by  bubo,  from  the  rich- 
ness of  the  lymphatic  suj)ply  in  this  locality.  The  glands  affected  are  those 
along  the  line  of  Poupart's  ligament.  The  resulting  bubo  is  usually  classi- 
fied as  simple  or  virulent  (chancroidal),  the  former  being  identical  with  that 
complicating  gonorrhoea  or  an  ordinary  infected  wound  and  not  necessarily 
going  on  to  suppuration,  while  the  latter  is  allied  in  virulency  to  the  chan- 
croid causing  it,  and  develops  after  oj)ening  into  a  secondary  chancroid. 
It  is  claimed,  however,  by  Sti-auss  that  the  pus  of  even  the  virulent  bubo 
is  free  from  micro-organisms  before  opening,  and  that  the  development  of 
chancroidal  properties  is  due  to  secondary  infection.  This  may  be  true  in 
many  cases,  but  chancroidal  bubo  is  more  rapid  in  its  course  and  more 
severe  in  its  symptoms  than  other  forms.  One  or  more  glands  may  be 
affected,  the  swelling  being  inflammatory  instead  of  the  painless  swelling  of 
the  polyganglionic  bubo  of  syphilis,  and  in  the  case  of  virulent  bubo  rapidly 
goes  on  to  suppuration,  the  abscess-cavity  after  opening  being  lined  with  a 
gray  slough  and  presenting  irregular  edges,  with  in  some  cases  (whether  as 
a  result  of  secondary  inoculation  or  not)  an  auto-inoculable  secretion.  In 
strumous  subjects  there  is  a  tendency  to  an  indolent  inflammation  of  a  num- 
ber of  glands,  forming  a  large  swelling,  perhaps  suppurating,  and  resulting 
in  the  formation  of  numerous  fistulre,  with  periglandular  suppuration  and  a 
long-standing  discharge.  Chancroidal  bubo,  as  already  mentioned,  may  be 
a  starting-point  for  serpiginoiis  ulceration. 

Diagnosis. — Chancroid  must  be  separated  from  other  ulcers  found  on  the 
genitalia,  those  with  which  it  is  most  likely  to  be  confused  being  the  chancre, 
herpetic  ulceration,  ulcerative  balanitis,  and  mucous  patches.  From  chancre 
it  may  be  differentiated  by  the  rapid  onset  after  exposure,  the  punched-out 
appearance  of  the  ulcers,  which  are  usuallj^  multiple,  the  aiito-inoculable 
secretion,  the  absence  of  cartilaginous  induration,  and  the  non-development 


TREATMENT  OF  CHANCROID.  1207 

of  constitutional  symptoms.  Herpetic  ulceration  may  be  an  idiojjatbic  pro- 
cess, or,  like  balanitis,  result  from  irritation  and  nn cleanliness,  the  lesions 
being  shallow  and  irregular,  not  auto-inoculable  or  destructive,  and  not  apt 
to  be  complicated  by  bubo.  Mucous  patches  do  not  have  the  characteristic 
appearance  of  chancroid,  and  are  associated  with  signs  of  general  syphilis. 
In  any  case  of  doubt  as  to  the  diagnosis  of  chancroid,  aiato-inoculation  will 
be  the  crucial  test. 

Treatment. — In  the  ordinary  case  of  chancroid,  the  firet  thing  to  be 
considered  is  the  question  of  converting  it  into  a  simple  ulcer,  thus  destroy- 
ing its  power  of  auto- inoculation  and  lessening  the  chances  of  bubo.  It 
was  formerly  the  universal  practice  to  cauterize  chancroids  freely,  but  at 
present  the  results  following  the  antiseptic  treatment  of  such  sores  have 
been  so  satisfactory  that  destructive  cauterization  is  reserved  for  special 
cases.  In  well-to-do  patients  who  are  careful  as  to  cleanliness,  unless 
phagedena  occurs,  cauterization  is  seldom  required,  while  in  dispensary 
practice  it  is  often  safer  to  employ  it,  as  these  patients  are  careless  as  regards 
the  care  of  the  sore.  Cleansing  of  the  ulcers  with  peroxide  of  hydrogen, 
and  their  daily  irrigation  with  a  1  to  500  or  1  to  1000  bichloride  solution, 
followed  by  the  application  of  powdered  iodoform,  aristol,  iodol,  or  ace- 
tanilid,  or  the  use  of  au  ointment  of  iodoform  or  aristol,  oi ;  ungt.  petrolat., 
3  i,  will  usually  be  followed  by  satisfactory  healing  of  the  ulcers.  If  wet 
dressings  are  preferred,  the  ulcers  may  be  dressed  with  lint  saturated  in  1 
to  60  carbolic  solution,  or  1  to  5000  bichloride  solution,  or  in  a  solution  of 
calomel,  gr.  x  ;  lime  water,  5  i. 

Chancroid  of  the  meatus  or  in  the  urethra  itself  should  not  be  cauterized, 
and  healing  chancroids,  of  course,  do  not  require  it.  Very  much  inflamed 
chancroids  demand  elevation  and  rest  of  the  part,  with  the  local  use  of  lead 
water  and  laudanum.  Where  the  surfaces  affected  are  in  contact,  as  under 
the  prepuce,  and  on  the  labia  in  women,  they  must  be  kept  separated  by 
liat  or  cotton  covered  with  an  ointment  of  iodoform  or  aristol.  Cauteriza- 
tion with  nitric  acid  or  the  actual  cautery  is  reserved  for  cases  in  which  the 
ulcers  increase  in  size  and  depth  in  spite  of  the  former  treatment,  or  in 
which  phagedena  develops  ;  here,  after  drying  the  surface  of  the  ulcer  with 
absorbent  cotton,  it  may  be  covered  for  a  few  minutes  with  cotton  saturated 
with  a  four  per  cent,  solution  of  cocaine,  and  after  removing  this  the  sur- 
face should  be  freely  cauterized  with  nitric  acid  or  with  the  actual  cautery  ; 
the  latter  agent  is  the  most  satisfactory,  but  is  so  alarming  to  the  patient 
that  it  cannot  often  be  employed  unless  an  anesthetic  is  administered.  After 
cauterization,  some  of  the  antiseptic  dressings  previously  mentioned  should 
be  employed.  Chancroids  beneath  the  prepuce,  if  cauterized,  are  liable  to 
be  attended  with  much  oedema;  hence  after  the  application  the  patient 
should  be  kept  at  rest,  if  possible,  and  measures  taken  to  avoid  inflamma- 
tory phimosis. 

Inflammatory  phimosis  is  treated  by  rest  and  elevation  of  the  penis,  with 
the  external  application  of  lead  water  and  laudanum,  and  syringing  with 
antiseptics  and  astringents  should  be  tried.  If  these  fail  and  there  is  any 
doubt  as  to  the  extent  of  the  lesion,  or  if  there  are  signs  of  threatening 
gangrene,  it  is  better  to  slit  up  the  prepuce  by  a  dorsal  incision  and  thor- 


1208  GONOEEHOEA. 

oughly  expose  the  sore.  A  formal  cireuiQcision  is  generally  inadvisable, 
owing  to  the  liability  to  infection  of  the  edges  of  the  wound  with  chan- 
croidal matter,  but  if  the  lesion  be  situated  on  the  margin  of  the  prepuce  a 
V-shaped  piece  may  be  excised  with  advantage.  Chancroid  of  the  meatus 
demands  irrigation  and  an  iodoform  dressing,  and  the  same  measures  are 
useful  in  case  the  urethra  is  infected  higher  up. 

Phagedena  demands  careful  attention  to  the  health,  tonics  and  stimulants 
being  used,  and  opium  freely  administered  to  relieve  pain.  Potassio- 
tartrate  of  iron  in  twenty-grain  doses  was  recommended  by  Eicord.  Locally, 
thorough  curetting,  followed  by  cauterization  and  the  use  of  iodoform,  and 
every  means  to  encourage  granulation,  must  be  used.  Any  reappearance  of 
the  process  demands  a  repetition  of  the  same  treatment.  If,  owing  to  the 
patient's  condition  or  the  proximity  of  important  structures,  as  large  vessels, 
the  above  treatment  is  inadvisable,  the  prolonged  application  of  hot  water  by 
intermittent  or  continuous  baths,  local  or  general,  is  of  the  greatest  value, 
as  is  spraying  of  the  lesion  with  hot  antiseptic  solutions. 

Bubo  in  the  early  stage  is  treated  by  rest,  pressure,  and  some  form  of 
counterirritation.  If  the  case  be  seen  early  tincture  of  iodine  may  be 
painted  over  the  surrounding  region.  If  the  patient  is  forced  to  be  about, 
the  application  to  the  part  of  mercury  and  belladonna  ointment  on  lint, 
with  a  well-fitting  spica  bandage,  will  be  of  service.  As  a  means  of  abort- 
ing bubo  the  injection  into  the  gland  of  from  ten  to  forty  minims  of  a  1  to 
60  solution  of  carbolic  acid  has  been  recommended,  and  Welander  uses 
benzoate  of  mercury,  1.0 ;  sodium  chloride,  0.3 ;  and  distilled  water,  100, 
for  the  same  puri^ose.  If  suppuration  occurs,  the  pus  may  be  evacuated, 
and  the  abscess-cavity  irrigated,  dusted  wdth  iodoform,  and  packed  loosely 
with  iodoform  gauze.  If  any  enlarged  glands  not  yet  broken  down  are 
found  in  the  cavity,  they  must  be  dissected  out,  as  they  are  involved  in  the 
suppurative  process.  Care  must  be  exercised  in  removing  those  deeply 
seated  to  avoid  injuring  the  femoral  vessels,  to  which  they  may  have  become 
adherent.  If  the  abscess-cavity  becomes  transformed  into  a  chancroidal 
ulcer,  it  will  demand  the  treatment  applicable  for  chancroid,  possibly 
including  cauterization.  Chronically  enlarged  glands  that  do  not  yield  to 
milder  treatment  will  demand  extirpation,  as  well  as  those  constituting  the 
strumous  bubo  found  in  scrofulous  cases  and  complicated  by  sinuses  and 
prolonged  suppuration.  The  treatment  for  serpiginous  ulceration  has 
already  been  described.  Lymphangitis  requires  rest,  elevation  of  the  penis, 
and  sedative  applications.  Abscesses  should  be  opened,  and  when  develop- 
ing into  chancroidal  ulcers  should  be  treated  as  if  they  were  primary  sores. 

GONORKHCEA. 

Gonorrhoea  is  an  inflammation  of  the  mucous  membrane  of  the  genitalia, 
but  is  occasionally  present  in  the  mucous  membrane  of  other  portions  of 
the  body,  as  the  rectum,  the  conjunctiva,  and,  rarely,  the  mouth.  Specific 
gonorrhoea  is  due  to  a  micro-organism,  the  gonococcus  of  Neisser.  (Plate  I., 
Fig.  4.)  The  bacterium,  which  is  found  in  the  discharge,  is  a  kidney-shaped 
coccus,  .commonly  arranged  in  pairs,  with  the  flattened  edges  separated  by 
a  narrow  interval,  and  generally  an  inhabitant  of  the  pus-cells  or  attached 


PATHOLOGY   OF  GONORRHaCA.  120!) 

to  epithelial  cells,  a  few  being  observed  free.  It  is  stained  by  the  afjiieous 
aniline  dyes,  bnt  is  decolorized  by  Gram's  method.  A  watery  solution  of 
gentian  violet  is  most  convenient  for  its  detection.  There  are  other  organ- 
isms found  in  the  normal  and  inflamed  urethra  which  may  be  mistaken  for 
the  gouococcus,  among  them  the  so-called  pseudo-gouococcus,  which  must 
be  remembered  as  x^ossible  sources  of  error.  Urethritis  is  also  sometimes 
excited  by  causes  other  than  the  gonococcus,  as  by  violent  prolonged  coitus, 
especially  in  combination  with  alcoholic  stimulation  and  the  presence  in  the 
woman  of  an  acrid  leucorrhceal  or  menstrual  discharge  ;  by  the  use  of 
instruments ;  by  the  iiassage  of  a  calculus ;  by  masturbation ;  by  certain 
drugs  taken  internally,  as  cantharides,  and  by  strong  injections.  The 
staphylococcus,  streptococcus,  and  bacillus  coli  communis  have  been  noted 
as  causative  agents  in  the  iiroduction  of  urethritis.  Urethral  discharges  are 
sometimes  present  in  syphilis  from  the  existence  of  chancre  or  mucous 
patches  in  the  urethra,  and  may  also  occur  as  a  result  of  tubercular  ulcer- 
ation. As  predisposing  causes  of  gonorrhoea  may  be  mentioned  phimosis, 
a  large  meatus,  hypospadias,  and  urethral  lesions  from  previous  attacks, 
such  as  chronic  thickenings  and  ulcerations.  Prolonged  copulation  and 
alcoholic  excess  are  factors,  by  exciting  irritation  and  thus  rendering  the 
tissues  less  resistant  to  invasion.  The  presence  of  the  gonococcus  in  inflam- 
matory discharges  in  cases  where  no  specific  infection  can  be  found  in  the 
other  partner  in  the  sexual  act  has  led  certain  observers,  as  Taylor,  to  sug- 
gest that  the  gonococcus  may  be  an  inhabitant  of  the  normal  urethra  which 
is  capable  under  favoring  circumstances  of  becoming  virulent.  The  pos- 
sibility of  error  should  act  as  a  warning  against  the  too  hasty  expression  of 
an  opinion  as  to  the  spe-nflc  nature  of  any  case. 

Pathology. — The  infection  of  the  urethra  occurs  almost  invariably 
during  the  sexual  act,  although  mediate  contagion,  in  which  towels,  etc.,  act 
as  carriers  of  infection,  is,  of  course,  possible.  Gonorrhoeal  urethritis  has 
frequently  been  observed  in  male  children,  and  even  infants.  The  gono- 
coccus having  gained  admission  to  the  urethra,  there  elapses  a  period  of 
incubation  varying  from  two  to  fourteen  days,  the  majority  of  cases  devel- 
ing  in  the  first  week.  In  very  susceptible  persons,  especially  those  with 
lesions  of  the  urethra  remaining  uncured  from  previous  attacks,  symptoms 
may  show  themselves  within  forty-eight  hours.  Non-specific  urethritis  has  no 
true  period  of  incubation,  and  may  come  on  in  the  course  of  a  few  hours. 

During  the  incubation  stage  the  gonoeocci  are  multiplying  and  pene- 
trating between  the  epithelial  cells,  beginning  at  the  fossa  navicularis  and 
travelling  backward.  The  diplococcus  finds  its  way  between  the  epithelial 
cells  to  the  superficial  layers  of  the  subepithelial  connective  tissue,  where 
it  excites  a  violent  inflammatory  reaction,  consisting  in  the  migration  of 
leucocytes  and  serum  from  the  dilated  capillaries  and  a  lifting  up  and  exfoli- 
ation of  the  epithelium.  In  the  subepithelial  tissue  the  process  of  bacterial 
growth  goes  on  attended  by  round-cell  infiltration  and  bacterial  invasion 
of  the  pus-cells  coincident  with  the  purulent  stage  of  the  disease.  The 
process  of  elimination  and  repair  takes  place  by  a  conversion  of  the  epi- 
thelium from  a  columnar  to  a  squamous  type,  which  the  gonoeocci  cannot 
penetrate. 


1210  SYMPTOMS  OF   GONOBRHCEA. 

Symptoms. — The  first  symptom  noted  at  the  end  of  the  period  of  incu- 
bation is  a  slight  tickling  or  itching  sensation  referred  to,  or  immediately 
behind,  the  meatus,  with  a  little  burning  dui-ing  or  after  urination,  accom- 
panied by  a  slight  mucous  discharge,  perhaps  gluing  the  lips  of  the  meatus 
together.  The  lips  of  the  meatus  soon  swell,  becoming  slightly  reddened, 
and  often  everted.  The  discharge  increases,  and,  while  at  first  consisting  of 
epithelial  cells  with  gonococci  attached  and  a  few  pus-cells,  soon  becomes 
milky,  and  after  a  few  days  decidedly  purulent  and  thick  yellow  or  yellow- 
ish green.  (Plate  III.,  Fig.  5.)  The  disease  reaches  its  height  from  the 
seventh  to  the  tenth  day.  There  is  then  profuse  discharge,  ardor  wince,  or 
burning  in  urination,  the  glans  is  reddened,  sometimes  swollen,  and  oedema 
of  the  prepuce,  with  consequent  phimosis  or  j)araphimosis,  is  not  uncom- 
mon. The  whole  organ  may  become  swollen,  and,  as  the  disease  spreads 
backward  along  the  urethra,  the  corpus  spongiosum  becomes  involved  by 
extension,  and  is  painful  and  tender.  With  the  ardor  urinse  there  is  a 
change  iu  the  size  and  shape  of  the  stream,  from  the  swelling  of  the  mucous 
membrane  making  it  smaller,  and  often  twisted  or  forked,  simulating  stric- 
ture. Eetention  of  urine  may  follow  imf)licatiou  of  the  prostate.  There  is 
generally  increased  sexual  feeling,  and  frequent  seminal  emissions  are  not 
uncommon.  Chordee  is  a  very  distressing  symptom,  and  is  due  to  an 
extension  of  the  inflammatory  process  to  the  meshes  of  the  corpus  spongi- 
osum. Erection  coming  on,  the  cor^jus  spongiosum  can  take  part  only 
imperfectly  in  the  process,  and  the  organ  assumes  a  bent  or  twisted  shape, 
severe  pain  being  produced  by  the  stretching  of  the  inflamed  tissues. 
Chordee  occurs  especially  at  night  after  the  patient  is  warm  iu  bed,  and  may 
cause  great  suffering  and  loss  of  sleep. 

These  inflammatory  symptoms  remain  at  their  height  from  one  to  three 
weeks,  at  the  end  of  which  time  they  gradually  disappear,  the  pain  ceasing, 
the  sexual  symptoms  abating,  and  the  discharge  becoming  thin  and  milky, 
then  watery,  and  ceasing  after  lingering  as  a  mucous  drop,  which  can  be 
pressed  out,  or  is  noticed  at  the  meatus  especially  in  the  morning.  The 
disease  may  be  prolonged  much  beyond  its  usual  limits  by  violent  exercise, 
the  use  of  alcoholic  beverages  and  stimulating  foods,  and  sexual  excitement 
of  any  kind.  The  average  duration  of  a  successfully  treated  case  is  from 
four  to  eight  weeks.  Constitutional  symptoms  are  not  common,  although 
there  may  be  slight  depression  and  malaise  or,  rarely,  slight  fever. 

It  was  formerly  believed  that  the  i)osterior  urethra  generally  escaped, 
the  inflammation  being  checked  in  its  backward  x^rogress  by  the  compressor 
urethrae  muscle,  but  this  has  recently  been  shown  to  be  incorrect.  Infection 
probably  takes  place  in  from  eighty  to  ninety  per  cent,  of  cases.  The 
symptoms  of  posterior  urethritis  are  a  decrease  in  the  amount  of  dis- 
charge, increased  frequency  of  urination,  and  deep-seated  burning  pain  in 
the  perineum  at  the  end  of  the  act,  sometimes  also  referred  to  the  glans. 
Urination  is  often  urgent  and  accompanied  by  tenesmus,  being  repeated 
every  few  minutes,  and  perhaps  followed  by  the  passage  of  blood  from  the 
inflamed  mucous  membrane,  or  there  may  be  temporary  retention.  Consti- 
tutional symptoms  are  usually  absent,  but  erections  and  seminal  emissions 
follow  irritation  of  the  region  around  the  orifices  of  the  ejaculatory  ducts, 


TREATMENT  OF  GOKORRHCEA.  1211 

and  extension  to  the  seminal  vesicles  and  epididymis  is  liable  to  occur. 
Thompson's  two-glass  test  is  a  convenient  method  for  the  detection  of  pos- 
terior urethral  inflammation.  The  pus  ft-om  the  posterior  urethra  ha.s  a 
tendency,  when  present  in  any  amount,  to  flow  back  into  the  bladder.  If 
the  i^atient  passes  his  urine  into  two  glasses,  that  in  the  first  will  l)e  cloudy 
from  the  pus  washed  out  of  the  urethra,  while  cloudiness  in  the  second, 
excluding  bladder  and  kidney  diseases,  will  indicate  iDOsterior  urethral 
inflammation. 

The  first  attack  of  gonori-hoea  is  the  most  severe,  but  is  the  one  most 
likely  to  be  followed  by  complete  recovery.  If  instead  of  the  discharge 
disappearing  it  becomes  chronic,  we  have  the  condition  known  as  chronic 
urethritis,  or  gleet,  due  to  a  variety  of  pathological  changes,  which  will  be 
described  later. 

Treatment. — The  treatment  of  gonorrhoja  embraces  hygienic  and 
medicinal  measures.  A  patient  presenting  himself  for  treatment  must  be 
directed  to  abstain  absolutely  from  alcoholic  beverages.  Sexual  intercourse 
must  be  interdicted  as  well,  as  must  all  associations  tending  to  sexual  excite- 
ment. Physical  exercise  is  to  be  restrained  as  far  as  possible,  the  nearest 
practicable  approach  to  absolute  rest  being  made.  Plain  diet,  with  avoid- 
ance of  highly  seasoned  food  and  with  the  use  of  plenty  of  water,  should  be 
directed  ;  a  milk  diet  is  the  best.  A  suspensory  bandage  should  be  worn, 
as  it  diminishes  the  risk  of  epididymitis.  The  patient  must  be  cautioned  as 
to  the  contagious  nature  of  the  discharge  and  as  to  the  attention  necessary 
to  the  disposition  of  towels  and  dressings,  to  avoid  infecting  his  own  con- 
junctiva or  that  of  other  persons  with  whom  he  is  brought  in  contact. 

A  dressing  should  l;>t^  applied  to  receive  the  discharge.  Some  form  of 
gonorrhoea-bag  may  be  worn,  or  if  the  prepuce  is  long  it  may  be  retracted 
and  a  piece  of  lint  or  a  little  absorbent  cotton  be  wrapped  around  the  glans 
and  retained  by  pulling  forward  the  prepuce,  or,  if  short,  a  piece  of  lint  or 
muslin  may  be  perforated  for  the  penis  and  then  dropped  around  the  meatus. 
The  dressings  must  not  occlude  the  meatus  or  retain  the  secretion  in  immedi- 
ate contact  with  the  glans.  If  there  is  much  ardor  uriuie,  it  may  be  relieved 
by  immersion  of  the  penis  in  hot  water  during  urination,  and  the  immersion 
may  be  practised  in  any  case  two  or  three  times  a  day  to  relieve  the  conges- 
tion.    Hot  baths  are  also  conducive  to  comfort  especially  before  retiring. 

Many  attempts  have  been  made  to  discover  a  successful  abortive  treat- 
ment for  gonorrhoea.  Nitrate  of  silver  in  strong  solution  has  had  many 
advocates,  but  has  proved  disappointing  and  dangerous.  It  should  be 
remembered  that  the  use  of  strong  astriugent  or  antiseptic  solutions  used 
as  means  of  aborting  the  disease  may  aggravate  the  condition  and  produce 
cystitis,  prostatic  congestion,  abscess,  or  epididymitis.  Any  abortive  treat- 
ment can  be  of  service  only  during  the  first  day  or  two,  before  the  micro- 
organisms have  gained  a  foothold  in  the  subepithelial  layer.  The  use  of 
one  of  the  non- irritating  silver  salts,  as  argonin  or  protargol.  or  the  method 
of  anterior  irrigation,  which  is  useful  in  all  stages  of  anterior  urethritis,  is 
probably  the  least  objectionable.  Irrigation  may  be  practised  by  passing  a 
catheter  four  or  five  inches  into  the  urethra— that  is,  to  the  compressor 
urethra  muscle— and  attaching  to  it  a  fountain  syringe  containing  a  weak 


1212  TREATMENT  OF  GONORRHCEA. 

solution  of  permanganate  of  potassium,  bichloride  of  mercury,  or  nitrate  of 
silver,  -with  whicli  the  urethra  should  be  irrigated  two  or  three  times  a  day, 
from  one  to  two  quarts  of  the  solution  being  used.  A  hot  solution  of  per- 
manganate of  potassium,  beginning  with  1  to  6000  and  increasing  to  1  to  2000, 
is  the  most  satisfactory.  Or  the  patient  may  be  directed  to  use  the  same 
solution  himself  with  an  ordinary  syringe,  using  a  number  of  syringefuls 
three  times  a  day. 

Internally,  an  alkaline  mixture  is  useful  by  rendering  the  urine  less  irri- 
tating and  decreasing  the  ardor  urinte.  Citrate  of  potassium  alone,  in  ten- 
grain  doses,  or  in  combination  with  extractum  hyoscyami  fluidum  (one  to 
five  minims),  can  be  given  three  times  a  day,  or  powders  of  potassium  bicar- 
bonate and  potassium  citrate,  each  five  grains,  may  be  dissolved  in  a  glass 
of  water  and  taken  every  three  hours  during  the  day.  Bicarbonate  of 
sodium,  in  doses  of  ten  grains  every  three  hours,  is  useful  for  the  same  pur- 
pose. There  are  some  drugs,  such  as  copaiba,  cubebs,  and  oil  of  sandal- 
wood, which,  acting  during  elimination  by  the  urine,  exert  a  curative  influ- 
ence on  the  urethral  membrane.  Some  surgeons  use  these  in  the  declining 
stages  only,  but  others  start  them  early  and  give  increasing  doses  during 
the  acute  stage.  Balsam  of  copaiba,  in  from  ten-  to  twenty-minim  doses,  in 
capsules,  or  in  combination  with  an  alkali,  may  be  administered  three  times 
daily.  It  has  a  tendency  at  times  to  disorder  the  stomach,  and  its  use  may 
be  followed  by  a  copaiba  rash  on  the  skin.  Sandal-wood  oil  is  given  in  a 
similar  manner  and  in  the  same  dose.  Cnbebs,  copaiba,  or  oil  of  sandal- 
wood, in  doses  of  from  ten  to  twenty  minims,  may  be  administered  in  a 
capsule  combined  with  salol  five  grains  and  pepsin  two  grains.  The  fol- 
lowing mixture  is  recommended  by  Keyes :  Potassii  citratis,  5ii  to  3vi; 
bals.  copaibse,  3iii  to  3vi ;  ext.  hyoscyami  fl.,  5ss  to  3ii ;  syr.  acacise,  ,?iss ; 
aq.  menth.  pip.,  q.  s.  ad  ,^iii.  Sig. — A  teaspoonful  in  water  three  times 
a  day. 

When  chordee  is  present,  the  patient  should  take  a  hot  bath  before 
retiring,  and  sleep  on  his  side  on  a  hard  bed  with  light  covering.  Bromide 
of  potassium  is  a  useful  agent,  and  monobromide  of  camphor  and  lupnlin 
may  be  emjjloyed  with  advantage.  Opium  with  camphor  in  the  following 
suppository,  to  be  used  at  bedtime,  is  most  useful :  Pulv.  opii,  gr.  i ;  pulv. 
camphorse,  gr.  iii ;  ol.  theobrom.,  q.  s.  When  erection  comes  on,  cold 
should  be  applied  in  some  form.  The  patient  should  be  warned  against 
breaking  the  chordee,  as  this  i^rocedure  is  apt  to  result  in  traumatic  stricture. 

Injections. — During  the  incipient  and  acute  stages  of  the  disease  injec- 
tions are  generally  omitted,  bat  if  used  should  consist  of  mild  antiseptic  and 
sedative  washes  or  irrigations  by  the  method  previously  described,  such  as 
warm  boric  acid  solution,  gr.  v,  to  water,  fsi,  bichloride  of  mercury  solution 
1  to  20,000.  permanganate  of  potassium  1  to  2000,  a  solution  of  sulphocar- 
bolate  of  zinc,  gr.  ss,  to  water,  fsi,  or  peroxide  of  hydrogen  diluted  one-half 
or  one-fourth. 

Protargol  in  solution  varying  from  0.4  to  1.5  per  cent,  has  been  found  a 
rapid  means  of  eliminating  the  gonococcus  and  hastening  the  cure.  It  can 
be  used  at  any  stage.  Injections  are  given  from  three  to  six  times  a  day, 
beginning  with  the  weak  solution  and  holding  the  injection  in  the  urethra 


TREATMENT  OF   CI0N0]{R1I(EA.  1213 

for  several  minutes.  Argoniu,  an  albuminoid  preparation  of  silver,  is  also 
non-irritating,  and  may  be  used  by  injection  or  irrigation  in  a  1  to  200  or  1 
to  500  solution. 

In  the  later  stage  of  the  disease  the  treatment  by  injection  becomes  of 
great  importance.  The  character  of  the  discharge,  which  changes  from  a 
greenish  yellow  to  a  grayish  white,  must  be  watched,  and  fui'nishes  the 
signal  for  treatment.  Astringents  are  now  of  great  value.  Sulphate  of 
zinc  and  sulphocarbolate  of  zinc  (1  to  .5  gT.  to  water  .5i),  acetate  of  zinc  (2  to 
12  gr.  to  wat«r  gi),  nitrate  of  silver  1  to  4000,  and  sulphate  of  copper  (1  to 
5  gr.  to  water  3i)  are  the  most  generally  applicable.  The  following  formulae 
will  be  found  useful :  ac.  carbolici,  zinci  sulphocarbolat.,  aluminis,  aa  gr.  v  ; 
glycerini,  f  gss ;  aquse,  q.  s.  ad  f  giv.  Or,  zinc,  sulph.,  gr.  xv  ;  plumbi  acetat., 
gr.  XXX  ;  tr.  opii,  foil ;  aquse,  q.  s.  ad  f gvi. 

It  is  well  to  begin  with  the  milder  solutions,  and  if  an  injection  causes 
pain  it  must  be  diluted.  The  patient  should  urinate  before  using  it,  so  as 
to  wash  out  the  urethra  and  permit  the  full  local  action  of  the  injection. 
The  syringe  should  hold  from  two  to  three  drachms,  and  the  patient  should 
be  instructed  in  the  method  of  using  it.  Sitting  on  the  edge  of  a  chair,  or 
standing  with  the  feet  separated,  holding  the  syringe  in  the  right  hand,  the 
nozzle  should  be  gently  introduced  and  the  meatus  compressed  laterally  with 
the  fingers  of  the  left  hand,  so  as  to  prevent  escape  of  the  fluid.  The  con- 
tents should  be  gently  thrown  in  until  the  urethra  is  distended  ;  the  syringe 
is  then  withdrawn,  and  after  one  or  two  minutes  the  fluid  is  allowed  to 
escape.     The  injections  may  be  given  three  or  four  times  daily. 

Treatment  of  Posterior  Urethritis. — When  there  is  present  a  high 
grade  of  posterior  urethritis,  as  shown  by  frequent  and  imperative  urina- 
tion, hsematuria,  and  a  diminution  or  cessation  of  the  discharge,  injections 
should  be  discontinued,  and  the  patient  put  to  bed  and  given  a  very  light 
diet,  consisting  largely  of  milk.  The  bowels  should  be  kept  open  by 
laxatives  and  the  patient  encouraged  to  drink  freely  of  water.  If  anti- 
blennorrhagics  are  being  administered,  they  should  be  stopiied,  and  urinary 
sedatives  substituted,  as  boric  acid,  salol,  and  hyoscyamus,  the  latter  either 
by  the  mouth  or,  where  there  is  much  tenesmus,  in  suppository  combined 
with  opium.  After  the  very  acute  stage  has  been  passed,  irrigations  of  the 
deep  urethra  with  weak  solutions  of  permanganate  of  potassium  or  nitrate 
of  silver  are  useful.  These  may  be  administered  by  passing  a  soft  catheter 
into  the  prostatic  urethra  and  then  attaching  it  to  the  reservoir  containing 
the  solution,  which  is  allowed  to  run  into  the  bladder  until  that  viscus  is 
filled  ;  the  catheter  is  then  withdrawn,  irrigating  the  urethra  in  its  passage, 
and  the  patient  voids  the  solution  contained  in  his  bladder,  thus  bringing 
it  in  immediate  relation  with  all  parts  of  the  urethra.  In  the  later  stages 
copaiba  and  oil  of  sandal-wood  may  be  again  administered,  and  if  the  dis- 
ease becomes  chronic,  irrigations  and  local  installations  of  nitrate  of  silver 
will  be  useful,  as  well  as  the  other  measures  mentioned  in  the  treatment  of 
chronic  urethritis.  Tonics  and  other  agents  to  overcome  the  sexual  neu- 
rasthenia associated  with  chronic  posterior  urethritis  may  be  called  for. 

Complications.— Retention  of  Urine. — Tliis  may  be  spasmodic,  or 
follow  involvement  of  the  prostate,  or  be  the  result  of  previous  stricture. 


1214  COMPLICATIONS  OF  GONORRHOEA. 

A  hot  sitz-bath,  mucilagiuous  drinks,  hot  applications  over  the  bladder  and 
perineum,  and  the  free  use  of  opium,  with  perhaps  leeching  to  the  peri- 
neum, will  generally  relieve  the  patient  without  the  use  of  a  catheter,  which 
should  not  be  passed  until  other  expedients  fail,  and  then  a  soft  instrument 
should  be  used. 

Balanitis  and  Balanoposthitis.— These  are  due  to  the  extension  of  the 
inflammation  to  the  surface  of  the  gians  penis  and  the  inner  layer  of  the 
prepuce.  They  are  predisposed  to  by  uncleanliness  and  a  long  aud  tight 
prepuce,  and  are  liable  to  be  complicated  by  an  inflammatory  phimosis. 
The  symptoms  are  burning  and  itching,  with  redness  aud  purulent  secretion, 
and  finally  superficial  ulceration.  Treatment. — This  consists  in  cleanli- 
ness, with  the  use  of  a  dusting  i^owder,  and  in  some  cases  the  injection 
under  the  prepuce  of  a  niti-ate  of  silver  solution  (gr.  x  to  xx  to  water  ffi). 

Phimosis. — This  is  due  to  infiltration  of  lymph  into  the  prepuce,  and 
must  be  diagnosed  from  that  due  to  other  inflammatory  causes,  as  chancre 
and  chancroid.  The  history  of  the  case,  and  the  absence  of  external  signs 
of  chancre  or  chancroid,  with  the  presence  of  ardor  urinse,  of  chordee,  and 
perhaps  of  gonococci  in  the  pus,  are  diagnostic  points.  Irrigation  of  the 
subpreputial  space,  followed  by  stripping  of  the  urethra,  will  .be  followed 
by  the  appearance  of  pus  if  the  phimosis  is  secondary  to  a  urethritis,  but 
not  if  it  is  simple  or  due  to  chancre  or  chancroid.  It  should  be  treated  by 
injections  beneath  the  prepuce  of  hot  bichloride  (1  to  10,000  to  1  to  30,000), 
weak  carbolic  solution,  or  lead  water  and  laudanum,  combined  with  eleva- 
tion of  the  penis  and  rest  in  bed. 

Paraphimosis. — This  is  due  to  inflammatory  swelling  after  retraction, 
aud  should  be  promptly  reduced,  and  the  part  dressed  with  a  sedative  lotion, 
such  as  lead  water  aud  laudanum.  Inflammation  of  the  preputial  follicles 
going  on  to  the  formation  of  abscess  is  sometimes  noted,  and  may  require 
incision  or  extirpation.  Follicular  inflammation  of  one  of  the  lacunce  of 
Morgagni  appears  as  a  little  sensitive  swelling  under  the  skin,  and  is  due  to 
the  occlusion  of  the  mouth  of  the  follicle.  If  pus  forms,  it  may  discharge 
externally  or  into  the  ui-ethra,  perhaps  resulting  in  a  urethral  fistula. 
Treatment. — This  consists  in  enucleation,  or  in  excision  of  a  portion  of 
the  wall  of  the  follicle.  It  may  result  in  periurethral  abscess  by  spreading 
in  the  connective  tissue,  when  prompt  incision  should  be  resorted  to.  Peri- 
urethral Abscess. — This  may  develop  on  one  or  both  sides  of  the  frenum, 
at  the  bulb,  or  between  these  two  points.  It  is  most  serious  at  the  bulb, 
from  involvement  of  the  perineum.  It  may  rupture  into  the  urethra  or 
externally,  or  may  result  in  the  formation  of  a  fistula,  or  may  burrow  and 
cause  retention  of  urine.  Treatment.— It  is  to  be  treated  by  rest  in  bed 
and  the  application  of  anodyne  fomentations,  with  prompt  evacuation  of 
the  pus. 

Cowperitis. — Inflammation  of  Cowper's  glands  is  not  a  very  frequent 
complication.  It  develops  from  the  third  to  the  fourth  week  or  later,  and  is 
due  to  extension  of  the  gonorrhceal  process  through  the  ducts  from  the  bulb. 
It  is  generally  unilateral,  the  left  gland  being  most  frequently  affected,  and 
begins  as  a  painful  swelling  on  one  side  of  the  perineum,  which  increases  in 
size,  and  finally  shows  the  signs  of  pus-formation,  with  ruptui-e  into  the 


COMPLICATIONS  OF  GONORRHOEA.  1215 

perineum  or  urethra.  Troublesome  fistultB  may  result,  and  perhaps  reten- 
tion of  urine,  or  rarely  urinary  infiltration.  As  the  result  of  imperfect 
resolution  there  may  persist  an  induration  as  the  site  for  futui-e  outbreaks  of 
inflammation.  Treatment. — This  consists  in  rest,  with  the  administration 
of  a  laxative,  and  locally  leeching,  followed  by  anodyne  applications,  as 
poultices,  or  lead  water  and  laudanum,  and  an  incision  as  soon  as  pus  has 
formed. 

Lymphangitis  and  Perilymphangitis.— These  are  occasionally  pres- 
ent during  the  height  of  the  inflammation,  and  are  indicated  by  hard  cord- 
like swellings  under  the  skin  on  the  dorsal  surface  of  the  penis,  and  often 
by  red  lines.  Abscess  exceptionally  occurs  in  their  course.  Treatment. — 
This  consists  in  applications  of  warm  anodyne  fomentations,  and  incision  if 
pus  forms. 

Gonorrhoeal  Bubo. — Sometimes  the  inguinal  glands  become  inflamed 
in  the  course  of  gonorrhoea,  resulting  in  bubo,  which  is  rather  rare,  and, 
unlike  chancroidal  bubo,  is  not  prone  to  suppuration.  Eest,  anodyne  lotions, 
and  resolvent  ointments  will  generally  r&sult  in  resolution.  If  suppui-ation 
takes  place,  the  treatment  should  be  the  same  as  for  the  inflammatory  bubo 
following  chancroid. 

Epididymitis. — This  is  the  most  frequent  complication  of  gonori-hcea, 
occurring  in  from  six  to  twelve  per  cent,  of  cases.  It  is  due  to  the  infection 
travelling  from  the  prostatic  urethra  backward  through  the  ejaculatory  ducts 
and  vas  deferens  to  the  epididymis.  The  testicle  may  also  be  involved,  in 
which  case  it  is  known  as  ejndidymo-orcMtis.  It  is  predisposed  to  by  violent 
exercise  and  sexual  and  alcoholic  indulgence.  Its  most  common  time  for 
development  is  usually  given  as  from  the  third  to  the  sixth  week,  but  it  has 
been  shown  by  the  investigations  of  Bergh,  verified  by  Untei'berger  and 
Taylor,  that  more  than  one-half  of  the  cases  develop  in  the  first  three 
weeks,  and  a  somewhat  less  number  in  the  next  three.  It  may  occur  much 
later,  owing  to  fresh  outbreaks  of  a  chronic  urethritis.  One  testicle  is 
involved  at  a  time,  although  the  other  may  be  subsequently  aflected.  The 
onset  is  often  preceded  by  an  aching  pain  in  the  groin  and  pelvis,  running 
along  the  cord,  or  by  acute  pain  above  the  pubes  at  the  edge  of  the  rectus 
muscle,  indicating  inflammation  of  the  seminal  vesicle  on  that  side.  The 
discharge  generally  ceases  at  the  beginning  of  the  attack,  which  may  be 
acute  or  subacute,  the  first  attack  being  the  most  severe.  The  epididymis 
swells  rapidly  and  partly  surrounds  the  testicle,  and  from  implication  of  the 
tunica  vaginalis  an  acute  hydrocele  is  usually  present ;  the  scrotum  becomes 
cedematous  and  inflamed,  and  the  first  portion  of  the  vas  deferens  is  often 
enlarged  and  tender.  Pain  is  very  severe,  is  increased  on  motion  and  press- 
ure, and  involvement  of  the  cord  in  the  canal  causes  extreme  pain  and 
signs  of  strangulation.  The  irregular  character  of  the  swelling,  with  the 
history,  the  rapid  onset,  and  the  mildness  of  the  constitutional  symptoms, 
will  separate  it  from  orchitis.  In  untreated  cases  after  from  three  to  five 
days  the  symptoms  decrease  in  severity.  The  most  common  resulting  lesion 
is  a  persistent  induration,  due  to  inflammatory  exudate  in  and  around  the 
tubules  of  the  epididymis,  especially  at  the  globus  minor,  with  consequent 
sterility  so  far  as  the  involved  testicle  is  concerned. 


1216  COMPLICATIONS  OF  GONOERHCEA. 

Treatment. — A  suspensory  bandage  worn  during  the  course  of  urethritis 
diminishes  the  tendency  to  epididymitis.  Patients  with  posterior  urethritis 
should  be  warned  of  their  liability  to  an  attack,  and  premonitory  symptoms 
should  be  an  indication  for  rest  in  bed.  At  the  onset  of  the  attack,  rest  in 
bed,  with  light  diet  and  a  preliminary  purge,  are  advisable.  The  pain  is 
much  relieved  by  supporting  the  testicles  on  a  pillow  between  the  thighs, 
or  by  suspension  by  some  form  of  handkerchief  bandage  fastened  around 
the  waist.  As  local  applications  in  the  acute  stage,  lead  water  and  lauda- 
num, or  some  form  of  narcotizing  i^oultice,  as  a  combination  of  tobacco, 
digitalis,  or  hyoscyamus  with  flaxseed,  applied  hot,  are  the  most  useful. 
Guaiacol  has  been  recommended,  either  painted  on  the  ^crotum  or  aijplied 
as  a  paste  with  vaseline  in  the  proportion  of  one  part  of  guaiacol  to  six 
parts  of  vaseline.  Counterirritation  in  the  declining  stage  may  be  prac- 
tised by  the  use  of  the  actual  cautery  or  of  strong  solutions  of  silver  nitrate 
over  the  affected  side.  For  the  remaining  swelling,  strapping  (page  153), 
and  for  the  induration  in  the  globus  minor,  mercurial,  belladonna,  and  iodine 
ointments,  are  recommended.  Mercury  internally  sometimes  seems  to  aid  in 
removing  the  exudate.  As  a  rule,  urethral  injections  are  to  be  discontinued, 
although  the  instillation  of  silver  nitrate  (gr.  i.  to  viii.  to  water  f  oi)  into 
the  piostatic  urethra  is  recommended  by  Boeck  and  Alexander. 

Gonorrhoeal  Septicsemia. — This  occurs  as  a  complication  of  urethral, 
vaginal,  and  conjunctival  gonorrhoea,  being  much  commoner  in  men  than 
in  women.  It  attacks  the  joints,  the  sheaths  of  tendons,  the  burste,  the 
nerves,  the  eye,  the  meninges  of  the  cord  and  the  brain,  and  the  endocardium 
and  pericardium,  in  about  the  order  of  frequency  set  down,  and  occurs  in 
about  two  per  cent,  of  cases  of  gonorrhoea.  (For  gonorrhoeal  arthritis,  see 
page  611.) 

Prostatitis. — This  is  due  to  an  extension  of  the  inflammation  from  the 
posterior  urethra,  and  may  consist  simply  in  congestion  of  the  prostate,  or 
may  go  on  to  actual  inflammatiou  and  suppuration.  It  is  indicated  by  heat 
and  throbbing  in  the  perineum,  a  sense  of  fulness  in  the  rectum,  increased 
frequency  of  urination,  and  perhaps  rectal  and  vesical  tenesmus.  Pain  is 
felt  in  the  perineum,  urethra,  testicles,  and  down  into  the  thighs,  and  fever 
is  usually  present.  Congestion  generally  disappears  in  about  ten  days,  but 
if  suppuration  occurs,  the  above  symptoms  are  much  aggravated,  and  sweats 
and  rigors  may  occur.  The  resulting  abscess,  which  may  hold  from  one 
drachm  up  to  sevei'al  ounces  of  pus,  will  most  commonly  point  in  the  urethra, 
but  may  open  into  the  rectum,  the  perineum,  the  ischiorectal  fossa,  the 
bladder,  or  the  peritoneum.  The  j)rognosis  in  small  abscesses  is  usually 
favorable,  but  prostatic  abscess  may  result  in  pyajmia,  peritonitis,  or  fistula, 
and  the  inflammation  may  extend  to  the  seminal  vesicles  and  epididymis. 

Treatment. — This  consists  In  confinement  to  bed,  with  light  diet,  and 
attention  to  the  bowels  is  necessary.  Opium,  bromides,  citrate  of  potassium, 
and  hyoscyamus  are  useful  internally.  Leeches  to  the  perineum,  followed 
by  a  hot  sitz-bath,  and  hot  or  cold  applications  to  the  perineum  and  the 
rectum,  according  to  the  relief  given,  are  to  be  used.  If  retention  occurs, 
careful  catheterization  may  be  required.  Urethral  treatment  should  be  sus- 
pended.    If  the  abscess  points  into  the  urethra,  the  passage  of  the  catheter 


CHRONIC   URETHRITIS.  1217 

to  empty  the  bladder  will  geneially  rupture  it.  Suprapubic  as])iration  and 
suprapubic  cystotomy,  with  puncture  of  the  abscess,  have  also  been  recom- 
mended in  these  cases.  If  it  points  towards  the  perineum  or  the  rectum,  a 
perineal  incision  should  be  employed.  (See  page  1092.)  Foijyrostalic  abscess 
may  simulate  prostatic  abscess,  and  demands  the  same  treatment.  Chronic 
prostatitis  is  described  under  Diseases  of  the  Prostate. 

Gonorrhoeal  Cystitis. — This  occurs  as  an  extension  of  intlammatiou 
from  the  posterior  urethra,  and  rarely  involves  the  entire  surface,  being 
generally  confined  to  the  neck  of  the  bladder.  Its  symptoms  are  those  of 
posterior  urethritis,  with  vesical  tenesmus  especially  pronounced.  In  the 
chronic  stage  the  symjjtonis  abate  in  severity.  There  is  increased  ft-equency 
of  micturition,  with  pain  following,  and  often  htematuria  from  a  villous 
condition  of  the  mucous  membrane.  Eesidual  urine  is  present,  and  finally 
alkaline  fermentation.  The  pelvis  of  the  kidney  may  become  secondarily 
involved  through  the  ureter.  Treatment. — This  in  the  acute  stage  consists 
in  the  stopping  of  injections,  rest  in  bed,  light  diet,  alkaline  diluent  drinks, 
and  local  applications,  either  hot  or  cold.  In  subacute  and  chronic  cases 
the  antiblennorrhagics  act  well.  Irrigation  of  the  bladder  should  be  prac- 
tised with  boric  acid  or  Thiersch's  mild  solution,  or  with  a  weak  solution  of 
j)ermanganate  of  potassium  or  of  nitrate  of  silver,  or  with  a  bichloride 
solution  (1  to  30,000).  Perineal  drainage  may  be  necessary  as  a  last 
resort. 

Vesiculitis. — Inflammation  of  the  seminal  vesicles  as  a  consequence  of 
gonorrhoea  may  be  acute  or  chronic.  Lloyd  claims  that  it  is  a  very  frequent 
unrecognized  complication  of  gonorrhoea.  It  comes  on  in  the  third  or  fourth 
week,  and  is  often  assoiiated  with  epididymitis.  In  the  acute  stage  the 
symptoms  resemble  those  of  posterior  urethritis  and  prostatitis,  from  which 
it  must  be  excluded  by  rectal  examination.  The  subacute  and  chronic 
forms  are  more  common,  the  most  important  symptoms  being  sexual  de- 
rangements, such  as  exaggerated  sexual  desire,  delayed  ejaculation,  seminal 
emissions,  mental  depression,  and  sometimes  a  purulent  discharge.  Eectal 
examination  shows  distention  of  the  seminal  vesicles.  Treatment. — This 
in  acute  cases  is  sedative,  and  if  pus  forms  it  should  be  evacuated.  In 
chronic  cases,  tonic  treatment,  the  cure  of  the  posterior  urethritis,  if  it  is 
present,  and  stripping  or  milking  the  vesicles  through  the  rectum,  as  recom- 
mended by  Fuller,  are  indicated. 

Chronic  Urethritis.— Gleet.— If  instead  of  the  discharge  ceasing 
it  persists  and  becomes  chronic,  we  have  to  deal  with  chronic  urethritis,  or 
gleet.  It  is  due  to  a  persistence  of  inflammation  in  some  portion  of  the 
urethra  in  the  form  of  congested,  ulcerated,  granular,  or  papillomatous 
areas,  with  a  submucous  infiltration  as  a  primary  cause.  It  is  due  also 
to  stricture  already  formed,  or  to  inflammation  lingering  in  the  follicles,  and 
sometimes  in  Oowper's  glands.  It  may  be  attended  by  a  profuse  discharge, 
or  only  a  drop  may  be  noticed  in  the  morning,  or  the  only  indication  may 
be  the  presence  of  fine  threads  in  the  urine,  called  dai)  threads,  which  consist 
of  the  scabs  from  patches  of  ulceration,  and  if  examined  under  the  micro- 
scope are  seen  to  consist  of  epithelial  and  pus  cells  embedded  in  mucus, 
sometimes  containing  gonococci.     The  bulb  is  a  favorite  seat  for  the  locali- 


1218  GONORRHCEA  IN  THE  FEMALE. 

zation  of  the  process,  which  may,  however,  affect  any  portion.  In  the  pos- 
terior urethra  lesions  may  be  attended  by  no  discharge,  but  there  may  be 
sexual  and  neurasthenic  symptoms,  frequent  and  painful  micturition,  and 
attacks  of  epididymitis.  In  the  anterior  urethra  the  position  of  the  ulcera- 
tion or  stricture  may  be  determined  by  the  use  of  a  bulbous  bougie  or 
the  endoscope.  Chronic  urethritis  may  develoj)  into  an  acute  attack  by 
violation  of  the  rules  of  urethral  hygiene,  as  alcoholism,  venery,  and  violent 
exercise.  It  is  probably  contagious  so  long  as  gonococci  are  present,  espe- 
cially in  purulent  cases. 

Treatment. — Internally  the  antiblennorrhagics  are  useful.  Irrigation 
of  the  urethra  with  a  solution  of  sulphate  of  zinc,  alum,  and  carbolic  acid  of 
each  1  to  500  is  used  by  Ultzmann.  The  solution  is  thrown  into  the  bladder 
and  then  voided.  This  is  followed  after  a  couple  of  weeks  by  hot  solutions 
of  permanganate  of  potassium  or  silver  nitrate ;  the  latter  is  esj)ecially 
useful  in  chronic  cases.  Any  portion  of  the  canal  may  be  irrigated  with 
the  same  solution.  When  the  disease  is  localized,  a  few  drops  of  a  solution 
of  sulphate  of  copper  or  nitrate  of  silver,  the  latter  varying  in  strength 
fi'om  1  to  2000  up  to  twenty  grains  to  the  ounce,  may  be  deposited  on  the 
diseased  area.  A  special  syringe  is  necessary,  and  either  Taylor's  or  Ultz- 
mann's  (Fig.  922)  may  be  used.  Applications  may  also  be  made  through 
the  urethroscope,  strong  solutions  of  silver,  iodine,  sulphate  of  copper,  and 


ritziriann"s  syringe. 

glycerole  of  tannin  being  the  most  valuable.  In  the  anterior  urethra  the 
milder  solutions  thrown  in  with  the  ordinary  syringe  will  answer  in  many 
cases.  If  no  severe  urethral  lesion  can  be  detected,  the  passage  of  a  large 
steel  sound  every  few  days  will  often  effect  a  cure,  and  is  advised  by  Otis 
as  a  preliminary  and  coincident  measure  in  any  case,  as  it  accomplishes  the 
absorption  of  the  submucous  deposit,  which  he  regards  as  the  important 
primary  cause  of  the  trouble.  Care  should  be  taken,  however,  in  emj)loying 
sounds,  that  the  urethra  is  gradually  accustomed  to  their  use,  as  they  some- 
times do  much  harm  when  used  otherwise.  The  same  precaution  should  be 
observed  in  the  use  of  the  urethroscope. 

Gonorrhoea  in  the  Female. — Gonorrhoea  in  the  female  occurs  less 
frequently  than  in  the  male,  and  does  not  run  so  definite  a  course,  but  is 
attended  by  equally  or  more  severe  and  lasting  complications.  It  attacks 
the  vulva,  ui-ethra,  vagina,  uterus,  tubes,  ovaries,  and  j^eritoneum,  and  is 
very  liable  to  become  chronic  in  some  portion  of  the  genital  tract.  Its  most 
common  sites  are  the  urethra  and  the  cervix  uteri.  There  are  non-specific 
inflammations  of  the  female  genitals  due  to  a  variety  of  causes,  as  in  the 
male,  in  which  the  gonococcus  is  not  a  causative  agent.  They  include 
uncleanliness,    traumatism,    masturbation,  and  the   presence  of  parasites 


TREATMENT   OF  GONORRHCEA   IN  THE  FEMALE.  1219 

(ascarides).  The  vulvovaginitis  of  children  may  be  non-specific,  arising 
from  these  causes,  or  may  be  a  genuine  gonorrhosal  infection  from  mediate 
or  immediate  contagion,  and  sometimes  occurs  as  an  epidemic  in  children's 
asylums,  usually  from  the  common  use  of  towels,  sponges,  and  bed-linen. 

Inflammation  of  the  vulva  may  be  primary  or  secondary.  It  is  marked 
by  heat  and  burning,  and  examination  shows  swelling  of  the  labia  majora 
and  labia  minora,  with  first  a  mucopurulent  and  later  a  purulent  discharge, 
accompanied  by  superficial  excoriation  of  the  mucous  membrane.  It  may 
extend  to  the  urethra  and  vagina,  and  be  complicated  by  bubo  aud  abscess 
of  the  vulvovaginal  glands.  Gonorrhceal  bubo  is  rare,  as  in  the  case  of  the 
male,  and  is  not  usually  attended  by  suppuration.  Inflammation  of  the 
vulvo- vaginal  glands  may  be  localized  in  the  ducts  or  extend  to  the  glands, 
in  the  latter  case  sometimes  going  on  to  the  formation  of  an  abscess,  with 
the  usual  signs  of  inflammation,  and  swelling  of  the  labium  majus  on  the 
same  side.  It  may  become  chronic,  with  persistent  induration  of  the  gland, 
and  sometimes  remains  a  source  of  contagion  in  such  cases. 

The  urethra  is  the  most  frequent  seat  of  gonorrhcea  in  the  female,  aud 
inflammation  of  the  urethi-a  is  usually  indicative  of  venereal  contagion.  The 
symptoms  are  increased  frequency  of  micturition,  with  ardor  lu-inse,  and  a 
discharge  purulent  in  character.  It  is  liable  to  become  chronic,  in  which 
case  stripping  of  the  canal  from  behind  forward  will  show  the  presence  of 
pus.  The  process  may  also  be  localized  and  persistent  in  Skene's  glands, 
and  in  the  follicles  around  the  urethra.  Gonorrhceal  vaginitis,  formerly 
considered  very  common,  is  now  known  to  be  comparatively  infrequent.  It 
is  observed  in  young  women  and  girls,  in  whom  the  mucous  membrane  of 
the  vagina  is  softer  and  less  resistant.  There  is  a  deep-seated  burning  pain, 
and  inspection  shows  at  first  a  dry,  red,  glazed  membrane,  soon  covered 
with  a  muco-pm'ulent,  later  a  purulent,  discharge,  accompanied  by  swelling 
and  erosion  of  the  mucous  membrane  of  the  orifice.  There  may  be  rectal 
aud  vesical  symjitoms,  from  the  proximity  of  the  inflammation,  with  reflex 
pain  in  the  lumbar  and  abdominal  regions.  It  may  become  chronic  and 
cause  a  granular  condition  of  the  mucous  membrane. 

Infection  of  the  os  uteri  is  most  frequent  next  to  infection  of  the  urethra. 
It  is  marked  by  redness  and  swelling  of  the  os  aud  the  membrane  lining  the 
cervical  canal,  with  mucopurulent  or  purulent  discharge,  and  redness  and 
erosion  of  the  surrounding  mucous  membrane.  It  has  a  tendency  to  become 
chronic  in  the  IS'abothiau  glands,  and  may  secondarily  infect  the  vagina. 
In  the  chronic  stage  it  may  be  impossible  to  separate  it  from  the  discharge 
of  a  simple  endocervicitis  or  endometritis.  Invasion  of  the  mucous  mem- 
brane of  the  uterus  and  tubes,  with  involvement  of  the  ovaries  aud  peri- 
toneum, is  very  common  and  causes  a  variety  of  symptoms,  including  dis- 
orders of  menstruation,  backache,  pain  in  the  groins,  mental  depression, 
occasional  outbursts  of  peritonitis,  and  sterility  in  most  cases. 

Treatment.— In  acute  cases  it  is  well  to  insist  on  rest  in  bed,  with  very 
light,  even  milk,  diet,  with  a  preliminary  purge.  In  vulvar  inflammation, 
hot  baths  and  thorough  cleansing  with  hot  alkaline  solutions  of  bicarbonate 
of  sodium  or  borax  may  be  employed,  after  which  a  dusting  powder  may 
be  used,  or  the  labia  may  be  separated  by  pieces  of  lint  satui-ated  with 


1220  CONDYLOMATA. 

lead  water  aud  laudanum.  Silver  nitrate  is  useful  in  the  declining  stage. 
Involvement  of  the  vulvo- vaginal  glands  demands  sedative  applications  and 
an  incision  if  pus  forms.  The  chronic  induration  is  best  remedied  by  excision. 
In  the  urethral  form  the  same  measures  that  were  employed  in  the  male  to 
render  the  urine  alkaline  and  unirritatiug  are  useful ;  antiblennorrhagics, 
also,  can  be  used  with  advantage.  In  the  later  stage  irrigation  is  of  value, 
and  in  chronic  cases  applications  of  nitrate  of  silver  are  indicated. 

Vaginitis. — In  the  early  stages  irrigation  with  alkaline  solutions  and 
hot  water,  with,  in  the  later  stages,  as  the  inflammation  declines,  solutions 
of  bichloride  of  mercury  1  to  10,000  or  1  to  20,000,  acetate  of  lead,  acetate 
and  sulphate  of  zinc,  tampons  containing  subnitrate  of  bismuth,  glycerin, 
aud  tannin,  and  suppositories  of  alum  and  tannic  acid,  are  useful.  Nitrate 
of  silver  in  thirty  grains  to  the  ounce  solution  may  be  carefully  applied  to 
the  vaginal  surface  also,  and  the  application  repeated  at  intervals  of  a  few 
days  if  necessary.  In  endocervicitis  the  greatest  care  is  called  for  to  pre- 
vent infection  of  the  pelvic  structures.  Irrigations  and  the  application  of 
strong  solutions  of  nitrate  of  silver  or  chloride  of  iron,  with  gentle  curette- 
ment,  may  be  necessary. 

Gonorrhoea!  Salpingitis,  or  Pyosalpinx. — This  is  a  frequent  and 
serious  comi^licatiou  of  gonorrhoea,  and  may  exist  as  an  acute  or  as  a  chronic 
affection  and  may  complicate  vulvo- vaginitis  even  in  children.  Symptoms. 
— In  the  acute  form  the  patient  suffers  from  pain  on  one  or  both  sides  of 
the  pelvis,  the  temperature  is  usually  elevated,  the  pulse  is  rapid,  and  a 
rigor  or  chill  may  occur.  In  the  chronic  form  there  is,  as  a  rule,  little  con- 
stitutional disturbance,  the  principal  symptoms  being  painful  menstruation, 
sometimes  pain  in  defecation  and  in  coition,  and  a  profuse  leucorrhoeal  dis- 
charge. In  both  forms  of  the  affection  more  or  less  enlargement  and  indura- 
tion of  the  tubes  can  be  discovered  by  a  vaginal  examination.  Treatment. — 
This  consists  in  rest  in  bed,  hot  external  applications,  hot  vaginal  douches, 
and  opium  if  the  pain  is  severe.  If  the  symptoms  do  not  subside  in  a  few 
days  under  this  treatment,  and  the  induration  does  not  diminish,  laparotomy 
should  be  performed  and  the  diseased  tubes  removed. 

CONDYLOMATA. 

Condylomata,  or  Venereal  Warts. — Moist  or  dry  papillary  over- 
growths springing  from  the  mucous  membrane  of  the  genitals  are  commonly 
known  as  venereal  warts,  but  these  growths  may  occur  independently  of 
any  venereal  affection,  although  they  are  quite  often  associated  with  it. 
The  irritating  discharges  from  gonorrhoea,  chancroid,  or  the  primary  or 
secondary  lesions  of  syphilis  are  often  the  cause  of  these  papillary  growths 
(Plate  III.,  Fig.  2),  but  they  are  also  not  infrequently  caused  by  the  dis- 
charge from  a  simple  balanoposthitis  or  an  irritating  vaginal  discharge,  often 
observed  in  children  and  in  persons  entirely  free  from  venereal  taint. 
They  consist  of  small  or  large,  discrete  or  confluent,  moist  or  dry  papillary 
growths,  which  are  exceedingly  vascular,  and  are  made  up  largely  of  con- 
nective-tissue elements,  the  papillae  being  much  hypertrophied  and  covered 
with  a  mucous  layer  ;  in  certain  localities  the  horny  layer  may  be  found 
well  developed.     The  favorite  site  for  these  growths  in  the  male  are  the 


VENEREAL  AVARTS. 


1221 


internal  surface  of  the  pi-epuce,  the  furrow  behind  the  corona  glandis,  the 
surface  of  the  glaiis  penis,  and  tlie  edge  of  the  meatus  ;  in  the  female  they 
appear  upon  the  labia,  in  the  vagina,  and  about  the  anus.  (Fig.  923.) 
Heat  and  moisture,  conditions  which  exist  in  these  localities,  are  elements 
favorable  for  the  development  of  vegetations.  Phimosis  often  acts  as  a  pre- 
disposing cause  in  the  production  of  these  growths,  the  concealed  condition 
of  the  parts  rendering  the  rejnoval  of  the  natural  secretions,  or  the  dis- 
charges due  to  venereal  disease,  difficult  or  impossible. 

When  these  growths  occur  upon  the  glans  penis  or  the  inner  surface  of 
the  prepuce,  they  exist  as  elevated  masses,  granular  in  ajjpearance,  which 


Cundvloiuata  in  the  female. 


may  be  pedunculated  or  sessile ;  when  situated  upon  the  body  of  the  penis 
or  upon  the  edge  of  the  prepuce,  they  are  apt  to  be  conical  in  shape  and 
often  show  a  predominance  of  the  horny  layer.  In  the  neighborhood  of  the 
anus  they  appear  as  elevated  granular  masses  flattened  by  pressure,  while 
on  the  female  genitals  they  are  frequently  seen  as  large  masses  resembling 
cauliflower  growths. 

As  regards  the  contagiousness  of  these  growths,  much  difference  of 
opinion  exists  ;  some  authorities  consider  them  extremely  so,  the  contagious 
property  residing  in  the  secretions  from  the  growths  themselves,  while 
others  beli%ve  them  incapable  of  being  transmitted  in  this  way.  If  one 
growth  is  present  upou  the  genitals,  others  are  apt  soon  to  develop,  and 
there  are  many  well- authenticated  cases  on  record  in  whi(!h  persons  having 
intercourse  with  women  suffering  from  genital  vegetations  have  developed 
these  growths,  but  in  these  cases  the  irritating  discharge  which  produces  the 
growth  in  the  female  is  quite  competent  to  produce  similar  growths  in  the 
man  exposed  to  it.     The  discharges  from  growths  appearing  upou  active 

78 


1222  TREATMENT  OF  VENEREAL  WARTS. 

secondary  lesions,  such  as  mucous  patches,  may  give  rise  to  the  initial  lesion 
of  syphilis. 

Treatment. — Venereal  warts  frequently  disappear,  if  the  exciting  cause, 
such  as  an  irritating  discharge,  is  removed  and  the  parts  are  kept  clean  and 
dry,  for  moisture  is  an  important  factor  in  their  production.  Cleanliness 
and  the  use  of  drying  powders,  such  as  oxide  of  zinc,  boric  acid,  and  lyco- 
podium,  will  often  be  followed  by  their  disappearance.  In  cases  of  dissemi- 
nated  warts,  particularly  those  of  the  horny  variety,  painting  them  with  the 
following  solution  will  usually  promptly  cause  their  removal :  ext.  cannabis 
indicse,  gr.  x ;  ac.  salicylic,  gr.  x ;  collodion,  3  ss.  If,  however,  the  masses 
are  large,  their  removal  is  best  accomplished  by  excision  or  cauterization. 
They  may  be  excised  with  the  knife  or  scissors  ;  an  objection  to  this  method 
is  the  free  bleeding  which  occurs,  but  this  can  soon  be  controlled  by 
pressure,  after  which  the  surface  from  which  the  growths  have  been 
removed  should  be  touched  with  carbolic  or  nitric  acid  and  dusted  with 
powdered  iodoform  or  aristol.  When  excision  is  objected  to,  cauteri- 
zation with  the  actual  cautery,  or  with  nitric  or  chromic  acid,  may  be 
employed.  Growths  complicated  with  phimosis  require  splitting  of  the 
prepuce  or  circumcision  before  they  can  be  successfully  exposed  for  treat- 
ment. The  growths  which  occur  during  pregnancy  should  be  treated  by 
disinfectant  and  antiseptic  lotions,  and,  as  a  rule,  should  not  be  subjected 
to  operative  treatment,  as  they  often  disappear  spontaneously  after  labor. 


NDEX. 


Abdomen,  contusions  of,  899. 
injuries  of,  899. 
wounds     of,     diagnosis     of, 
900. 

penetrating,   899. 

symptoms  of,  900. 

treatment  of,   901. 
Abdominal  aorta,  aneurism  of, 

375. 
hysterectomy    in    cancer    of 
uterus,    1141. 

for      fibroid      tumors     of 
uterus,   1136. 
myomectomy,   1131. 
operations,     after-treatment 
of,  909. 

ciosure  of  wound  in,  908. 

drainage  in,  908. 

extraperitoneal  method  In, 
909. 

peritoneal     adhesions     in, 
906. 

treatment  of   pedicles   in, 
906. 

Trendelenburg's     position 
in,  905. 
surgery,  technique  of,  903. 
tumors,  diagnosis  of,  963  et 

seq. 
wall,  inflammation  of,  909. 

tumors  of.  910. 

wounds  of,  899. 
Abscess,   21. 
alveolar,  776. 
of  antrum.  776. 
of  anus,  1162. 
atheromatous,  353. 
of  auditory  meatus,   follicu- 
lar, 892. 
of  brain,  729. 
of      breast,       subcutaneous, 

863. 
cerebral,  729. 
of  face,  743. 
incision  in,  30. 
in  hip-disease,  626,  630. 
of  joint,  609. 
labial,  1116. 
of  larynx,  814. 
of  liTer,  919. 
lymphatic,  319. 
mediastinal,  839. 
of  neck,  790. 
ovarian,  1147. 
of  palate,  786. 
palmar,  417. 
perinephritic,  1049. 
perirectal,  1167. 
of  prostate,  1092. 
rectal.  1168. 
retromammary,  863. 
retropharyngeal,  790. 

in     tuberculosis     of     the 
spine,  548. 
spinal,  treatment  of,  553. 
of  spleen,  962. 
subphrenic,  917. 
of  testicle,  metastatic,  1080. 
of   tongue.    767. 
of  tonsil,  796. 
treatment  of,  28. 
tuberculous,  65. 
A.  C.  B.  mixture.  214. 
Acetabulum,  fractures  of.  484. 
Acetate  of  aluminum,  115. 


Acid,  boric,  116. 

carbolic,  114. 

salicylic,  117. 
Acinous  carcinoma,  310. 
Acromegaly,  522. 
Acromial  end  of  clavicle,  dis- 
locations of.  572. 
Acromlo-clavicular        articula- 
tions, tuberculosis  of,  640. 
Acromion   process   of   scapula, 

fracture  of,  451. 
Actinomycosis,  59. 

of  bone,  546. 

of  Jaw,  778. 

of  tongue,  771. 

treatment  of,  61. 
Actol,  117. 
.Actual  cautery,  156. 
Acupuncture  in  aneurism,  369. 
Adenitis,  cervical,  tuberculous, 

791. 
Adenoid    polypus    of    rectum, 

1187. 
Adenoids  of  pharynx,  798. 
Adenoma,  302. 

treatment  of,  304. 

of  uterus,  1132. 
Adenomata  of  palate,  787. 
Adrenalin    in    arterial    hemor- 
rhage. 334. 
Aerobic  micro-organisms,  2. 
Age,    effect    of    operations    on, 
86. 

in  etiology  of  tumors,  269. 

in  operations,   86. 
Air  embolism,  340. 

entrance  of,  into  veins,  340. 
Airol,   115. 
Air-passages,  foreign  bodies  in, 

819. 
Albuminous  periostitis,  528. 
Alcoholism,  efEect  of,  on  opera- 
tions, 88. 

in  operations,  87. 
Aluminum,  acetate  of,  115. 
Alveolar  abscess,  776. 

sarcoma,  296. 
Alveolus,  excision  of,  660. 
Amazia,   860. 

Ambulant    treatment    in    frac- 
tures of  the  femur,  496. 
of    fractures    of    the    leg, 
505. 
Amenorrhoea,  1101. 
Ammonium     sulphate     catgut, 

127. 
Amputations,  216. 

after-treatment  of,  225. 

in  aneurism,  369. 

at  ankle-joint,  247. 
Pirogoff's,  248. 
Roux's,  249. 
Syme's,  247. 

of  the  arm,  238. 
circular,  238. 
modified  circular,  239. 
oval,  239. 
Teale's,  239. 
transfixion,  239. 

of    cervix    in    carcinoma   of 
uterus.  1142. 

circular,  219. 

complications  after,  226. 

in  compound  fractures,  512. 

conditions  requiring.  216. 

consecutive.  229. 

details  of,  224. 


Amputations  at  the  elbow,  236. 

anterior  flap,  236. 

elliptical,  236. 

lateral  flap,  237. 
elliptical,  221. 

Esmarch's  hemostatic  appa- 
ratus in.  217. 
of  fingers,  231. 

atypical,  234. 
flap  method,  220. 
of  the  foot,  245. 

Chopart's.  247. 

Hey's,  246. 

Lisfranc's,  246. 

Pirogoff's,   248. 

Tripier's,  247. 
of  forearm.  235. 

circular,  236. 

modified  circular,  236. 

oval,  236. 

Teale's,   236. 
gangrene  after,  226. 
in  gunshot  fractures.  190. 
of  hand,  atypical,  234. 

carpo-metacarpal,  234. 
hemorrhage  in,  226. 
in  hip-disease,  632. 
above  the  hip-joint,  257. 
at  hip-joint,  254. 

antero-posterior  flap,  255. 

circular,  255. 

Guthrie's,   255. 

oval,  255. 

Wyeth's  bloodless  method, 

infection  after,  227. 
instruments  for,  216. 
interscapulo-thoracic,  242. 
at  knee-joint,  252. 

anterior  flap,  252. 

circular,  253. 

Garden's,  253. 

elliptical.  253. 

Gritti's.  253. 

oval,  253. 
of  the  leg.  250. 

Bier's  osteoplastic,  251. 

circular,  250. 

external  flap,  250. 

modified  circular,  250. 

rectangular  flap,  251. 

SSdillot's,   250. 

Teale's,  251. 
of    little    finger    and    meta- 
carpal bone.  233. 
medio-tarsal,  247. 
of  metacarpal  bones,  232. 
metacarpo-phalangeal.  231. 
of  metatarsal  bones.  244. 
metatarso-phalangeal,  243. 
methods  of.  219. 
modified     circular     method, 

221. 
mortality  after,  227. 
multiple,  229. 
osteoplastic.  Bier's.  221. 
oval  method  in.  221. 
of  penis.  1073. 
period  of.  222. 
periosteal  flaps  in,  223. 
prosthetic     apparatus     for, 

shock 'in,  236. 
in  shock.  223. 
above      the      shoulder-Joint, 

242. 
at  the  shoulder-joint,  239. 

1223 


1224 


INDEX. 


Amputations   at  the  shoulder- 
joint,  Dupuytren's,  241. 

Larrey's,  240. 

Listranc's,  241. 

oval,   240. 

Spence's,  241. 
simultaneous,  229. 
subastragaloid,  247. 
synchronous,  229. 
tarso-metatarsal,  246. 
Teale's  method,  221. 
of  the  thigh,  253. 

circular,   253. 

modified  circular,  254. 

transfixion,  254. 
of    thumb    and    metacarpal 

bone,  233. 
of  the  toes,  243. 
transfixion  method  in,  220. 
of  the  wrist,  235. 
Anastomosis,  intestinal,  943. 
Anatomical  tubercle,  180. 
Anaerobic  micro-organisms,  3. 
Anaesthesia,  201. 
from  cold,  201. 
from  ether,  201. 
for  ethyl  chloride,  201. 
from  eucaine  hydrochlorate, 

203. 
general,   205. 

after-efiiects  of,  215. 

preparation      of      patient 
for,   206. 
from  guaiacol,  203. 
from  holocaine,  203. 
from  hypnotism,  214. 
infiltration,    203. 
neural,  204. 
paralysis    of    nerves    after, 

215. 
in  reduction  of  dislocations, 

564. 
regional,  204. 
from  rhigolene,  201. 
Anesthetics,  201. 
choice  of,  205. 
Avel's  operation  in  aneurism, 

365. 
Aneurism,  357. 

of  abdominal  aorta,  375. 
acupuncture,  369. 
amputation  in,  369. 
by  anastomosis,  351. 
Anel's  operation  in,  365. 
Antvllian  operation  in,  367. 
aortic,  370. 
arteriovenous,  354. 
axillary,  374. 
brachial,   374. 

Brasdor's  operation  in,  366. 
cirsoid,  351. 
common  carotid,  371. 
compression  in,  363. 

digital,   364. 

distal,  364. 

instrumental,  364. 

proximal,   363. 

rapid,  364. 

of  sac  in,  364. 
diagnosis   of,    362. 
dissecting,  358. 
excision  of  sac  in,  367. 
external  carotid,  372. 
femoral,  376. 
flexion  in,  365. 
fusiform,   357. 
galvanism  in,  368. 
galvano-puncture  in,  368. 
gluteal,  376. 

Hunteriau  operation  in,  365. 
iliac,   375. 

inflammation  in,  361. 
innominate,  371. 
instrumental  compression  in, 

364. 
internal  carotid,  372. 
introduction        of        foreign 
bodies  in,  369. 

of  wire  in.  368. 
ligation  in,  365. 
Macewen's       operation      in, 

369. 


Aneurism,      manipulation     in, 

369. 
needle,   380. 
needling  in,  369. 
old  operation  in,  367. 
orbital.  372. 
of  palate,  787. 
pathology  of,  359. 
plantar,  378. 
popliteal,  377. 
pressure  symptoms  in,  362. 
pudic,   376. 
radial,  374. 

Eeid's  method  in,  365. 
renal,  376. 
return    of    pulsation    after 

ligation  in,  366. 
rupture  of  sac  in,  361. 
sacculated.   358. 
of  scalp,  703. 
sciatic,  376. 
secondary  hemorrhage  after 

ligation  in,  367. 
sloughing  of  sac  after  liga- 
tion in,  367. 
subclavian,  373. 
suppuration     of     sac     after 

ligation  in,  367. 
symptoms  of,  360. 
tibial,  378. 
traumatic,  355. 

circumscribed,   356. 

diffused.  355,  356. 

treatment  of.  356. 
treatment  of,  362. 

medical,  363. 

surgical,   363. 
tubular,  357. 
ulnar,  374. 
varicose,  355. 

Wardrop's  operation  in,  366. 
Aneurismal  varix,  354. 

treatment  of,  354. 
Angioma,  288. 

of  blood-vessels,  288. 
of  breast,  881. 
plexiform,  351. 
of  scalp,  701. 
treatment  of,  290. 
Animals,   bites  of,   181. 
Ankle,  dislocations  of,  602. 

compound,  604. 
Ankle-joint,      amputation     at, 

247. 
diseases  of,  635. 
excision  of,  656. 
synovitis  of,  acute,  635. 
tuberculous      arthritis      of, 

635. 
Ankylosis,  679. 

after  fracture,  520. 
of  jaw,  783. 
of  joints,  617. 

treatment  of,  617. 
Anomalous  dislocations  of  the 

hip.  596. 
Anteflexion  of  uterus,  1124. 

operations  for,  1130. 
Anterior      spinal       curvature, 

672. 
thoracotomy,   846. 
tibial  curvatures,  677. 
Anteversion  of  uterus.  1124. 

operation  for,  1130. 
Anthrax,  55. 

treatment  of,  56. 
Antipyrin    in    arterial    hemor- 
rhage, 334. 
Antisepsis,  112. 
Antiseptic     dressings,     impro- 
vised, 131. 

in  inflammation,  27. 
method,  118. 

operation,  details  of,  124. 
treatment         of         infected 

wounds,   124. 
Antiseptics,  chemical.   11. 
Antrum,  abscess  of,  776. 
epithelioma  of,  781. 
myoma  of.  781. 
sarcoma  of,   781. 
tumors  of,   781. 


Antyllian    operation    in   aneu- 
rism, 367. 
Anus,  abscess  of,  1162. 
artificial,  258. 
burns  and  scalds  of,  1157. 
diphtheria  of,  1165. 
diseases  of,  1162. 
epithelioma  of,  1165. 
examination  of,  1160. 
fissure  of,  1162. 
pruritus  of,  1162. 
structure  of,   1165. 
syphilitic  affections  of,  1164. 
ulcer  of,   irritable,  1162. 
vegetations  of,  1164. 
warts  of,   1164. 
wounds  of,   1156. 
Aorta,     abdominal,     aneurism 

of,  375. 
Aortic  aneurism.  370. 
Appendicitis,   943. 
with  abscess,  945. 
acute  perforative,  949. 
treatment  of,  949. 
chronic,  950. 

treatment  of,  950. 
diagnosis  of,  946. 
McBurney's  incision  in,  904. 
prognosis  of,  947. 
simple,   944. 

treatment  of,  945. 
treatment  of,  947. 
Appendix,  colic  of,  944. 

vermiform,  diseases  of,  943. 
Approximation  sutures,  164. 
Aristol,  115. 

Arm,  amputation  of,  238. 
and  chest  bandage,  142. 
spiral   reversed   bandage  of, 
138. 
Arrow  wounds,  178. 
Arterial       hemorrhage,       326. 
See,    also.    Hemorrhage, 
arterial, 
elastic      constriction      In, 
330. 
varix,   Sol. 
Arteries,  contusions  of,  322. 
treatment  of,  322. 
injuries  of,  322. 
laceration  of,  323. 
ligation  of,  376. 
suture  of,  333. 
wounds  of.     See  under  each 
artery, 
gunshot,  324. 
incised,   324. 
punctured,  323. 
Arteriovenous  aneurism,  354. 
Arteritis,  352. 

acute  plastic,  352. 
chronic,  353. 
embolic,  353. 
obliterating,  353. 
suppurative,  352. 
syphilitic,  354. 
tuberculous,  354. 
Artery  forceps,  332. 

gunshot  wound  of,  gangrene 

from,  325. 
rupture      of,      in      fracture, 

520. 
and       vein,        simultaneous 
wound  of,  337. 
Arthrectomy.  660. 
Arthritis,  609. 
acute,   609. 
of    ankle-joint,    tuberculous, 

635. 
deformans.  613. 
gonorrhoeal,  611. 
gouty,   613. 

of  hip-joint,  septic,  622. 
of     knee-ioint,     suppurative 

acute,  632. 

neuropathic,  614. 

rheumatic,   612. 

chronic,  613. 

of      special      joints.        See 

under  each  joint, 
suppurative,  acute,  609. 
treatment  of,   610. 


INDEX. 


1225 


Arthritis,   syphilitic,   612. 
tuberculous,   618. 
treatment  of,  620. 
operative,  621. 
Arthrodesis,  686. 
Arthropathy,   spinal,   614. 
Arthrospores,  3. 
Artificial  arms,  258. 
legs,  258. 
respiration,  161. 

direct  method  of.  161. 
Howard's  method,  161. 
Laborde's  method,  163. 
Silvester's  method,  162. 
Asepsis,   112. 

Aseptic       dressings,        impro- 
vised, 130,  131. 
fever,  96. 
method,  118. 

operation,   clothing  for,  122. 
details  of,  123. 
materials  for,   125. 
preparation      of      patient 
for,   122. 
of  room  for,  123. 
treatment         of         infected 
wounds,    124. 
Aspirator,  157. 
Aspiration.  157. 

of      bladder      in      stricture, 
1014. 
Astragalus,  dislocation  of,  606. 
compound,  606. 
excision  of.   656. 

in  club-toot,  690. 
fracture  of,   508. 
Astringents,      mechanical,      in 

inflammation,  28. 
Atheroma,  effect  of,  on  opera- 
tions, 88. 
in  operations,  88. 
Atheromatous  abscess,  353. 
Atresia  of  cervix  uteri,  1102. 
of  hymen,  1102. 
of  urethra,   997. 
Atrophic     scirrhus     carcinoma 

of  breast,   875. 
Atrophy  of  bone,   522. 
of  muscles.    412. 
of  skull,   699. 
Auditory    canal,    exostoses   of, 
893. 
foreign  bodies  in,  893. 
polypi  of,  893. 
meatus,  abscesses  of,  follicu- 
lar, 892. 
cellulitis  of.  892. 
cysts  of,  sebaceous,  892. 
epithelioma  of,  892. 
furuncle  of,  892. 
tumors  of,  892. 
wounds  of.  892. 
Anger's    operation    in    ingrow- 
ing toe-nail,  688. 
Auricle,   congenital  defects  of, 
889. 
frost  bite  of,  890. 
inflammation  of,  892. 
prominent,  892. 
supernumerary,  889. 
tumors  of.  890. 
wounds  of,  889.    ■ 
Auto-transfusion,  160. 
Avulsion  of  limbs,  175. 

of  the  scalp.  175,  698. 
Axillary  aneurism,   374. 
artery,  ligation  of.  386. 
rupture  of,   in  dislocation 

of  humerus.  580. 
wounds  of.  338. 
vein,   rupture  of,  in  disloca- 
tion of  humerus,  580. 
wounds  of,  341. 


Bacillus  aerogenes  capsulatua, 
53. 


anthracis,   55. 
coli  communis,  13. 
diphtherite,  13. 
leprae,  67. 


Bacillus  mallei,  57. 

o»dematis  aeroblcus,  53. 

pyocyaneus,   13. 

tetani,  68. 

tuberculosis,  61. 

typhi   abdominalis,   13. 
Back,  inflammation  of,  852. 

injuries  of,  848. 

tumors  of,   852. 
Bacteria,  cultivation  of,  5. 

description  of,  1. 

effect  of  oxygen  on,  2. 

effects  of,  6. 

elimination  of,  6. 

growth  of,  3. 

habitat  of,  2. 

immunity  to,   9. 

infection  by,   5. 

inflammation  from,  15. 

inoculation  of.  5. 

parasitic  nature  of,  3. 

resistance  to,   7. 

staining  of.  12. 

varieties  of.  12. 
Balanitis  in  gonorrhoea,  1214. 
Balanoposthitls,   1069. 

in  gonorrhcea,  1214. 
Bandage,  arm  and  chest,  142. 

Barton's,  131. 

compound,  134. 

Desault's,  141. 

double  T-.  134. 

elastic  webbing,  147. 

figure-of-eight,      of       elbow, 
139. 
of  knee,    143. 

flannel,   146. 

of  foot,   French,   144. 

handkerchief,  135. 

of  heel,  145. 

many-tailed,  135. 

oblique,  of  jaw,  137. 

plaster-of-Paris,  147. 
removal  of,  150. 

recurrent,  of  head,   137. 
of  stump,   145. 

rubber,  146. 

of  Scultetus,  135. 

silicate  of  potassium,  151. 
of  sodium.  151. 

single  T-,   134. 

spica,  of  foot,  144. 

of  groin,  ascending,  142. 

double.   142. 
of  shoulder,  140. 
of  thumb,  138. 

spiral,  of  flnger,  138. 
reversed,  133. 
of  arm,  138. 
of  leg,   145. 

starched.   151. 

sterilized.  131. 

varieties  of,  132. 

Velpeau's,  140. 
Bandaging.  132. 
Barton's  bandage,  136. 
Baths,  153. 
Bayonet   wounds,   178. 
Bed-sore,   109. 
Benign  tumors.  266. 
Beta-naphtol.    115. 
Biceps     tendon,     rupture     of, 

414. 
Bichloride  cotton,  131. 

gauze.  130. 

of  mercury,   113. 

of  palladium  catgut,  128. 
Bier's  osteoplastic  amputation, 

221. 
Biliary  ducts,  diseases  of,  921. 
Binder's     board     splints,     151, 

436. 
Bis-axillary  cravat,  136. 
Bites  of  animals.   181. 
Bladder,      aspiration     of,      in 
stricture,  1014. 

diverticula  of,  1018. 

exstropUv  of.  1016. 

fistula  of.   1021. 

foreign  bodies  in,  1021. 

hernia  of.  1018. 

inflammation  of,  1021. 


Bladder,    injury   of.    In   opera- 
tions for  hernia.  987. 
malformation  of,  1016. 
neuroses  of.  1043. 
paralysis  of,  1043. 
rupture  of,   1019. 
spasm  of,  1043. 
sterilization  of,  121. 
tuberculosis  of.  1024. 
tumors  of,   1040. 

treatment  of,  1042. 
wounds       of,       perforating, 

1020. 
Blood,  transfusion  of,  160. 
Bloodletting,  158. 
Blood-vessels,  angioma  of,  288. 
gunshot  wounds  of,  188. 
repair  of,  82. 
Bone,  actinomycosis  of,  546. 
atrophy  of,    .'j22. 
caries  of.  539. 
chips,  Senn's,  664. 
diseases  of,  521. 
of  foot,  dislocations  of,  006, 

607. 
fragments,    replacement    ot, 

663. 
grafting.  664. 
hyperaemia  of,  525. 
hypertrophy  of,  521. 
incised  wounds  of,  424. 
injuries  of,  424. 
necrosis  of,  526. 
operations  upon,  642,  661. 
plastic      operations      upon, 

663. 
plates,  Senn's,  664. 
repair  of,  80. 
resection  of,  642. 
sarcoma  of.  299. 
syphilitic  diseases  of,  542. 
tumors  of,  526. 
Boric  acid,  116. 
Bougies,  sterilization  of,  120. 
Bow-legs,   675. 

osteoclasis  in,  676. 
osteotomy      in,      cuneiform, 
676. 

linear.  676. 
treatment  of,  675. 
Brachial  aneurism,  374. 
artery,  ligation  of,  387. 

wounds  of.  338. 
plexus,  operations  on,  408. 
Brain,  abscess  of,  729. 

symptoms  of,  730. 

treatment  of,  731. 
compression  of,  718. 
concussion  of,  716. 
contusion  of,  721. 
inflammation  of,  726. 
injuries  of,  716. 

treatment  of.  722. 
laceration  of,  722. 
membranes   of,    injuries   of, 

716. 
motor  centres  of,  739. 
operations  upon.  738. 
sinuses  of,  phlebitis  of,  728. 
tissue,    escape    of,    in    frac- 
tures of  the  skull,  712. 
wounds  of,  721. 
Bran-bags  in  fracture,  437. 
Branchial  cysts,  272. 
Brasdor's    operation    in    aneu- 
rism, 366. 
Breast,   abscess  of,   retromam- 
mary,  863. 

subcutaneous,  863. 
angioma  of,  SSI. 
anomalies  of.  860. 
carcinoma  of.  871. 

atrophic.  875. 

colloid,  871. 

encephaloid.   873. 

removal  of.  876. 

scirrhus,  874. 

treatment  of,  876. 
cvstoadenoma     of.      diffuse, 
"  866. 
cysts  of.  880. 

retention,  SSO. 


1226 


INDEX. 


Breast,   endothelioma   of,   294, 
871. 

fibroadenoma  of,   866. 

hypertrophy  of,   860. 

inflammation  of,  861. 

injuries  of,  861. 

lipoma   of,   881. 
.    male,  diseases  of,  881. 
■     myxoma  of,  871. 

sarcoma  of,   869. 

sinuses  of.   chronic,   862. 

surgery  of,  860. 

syphilis  of,  865. 

tuberculosis  of,  864. 

tumors  of,   866. 
fibroid,  881. 
Brisement    forc6   in   club-foot, 

690. 
Broad    ligaments,    tumors    of, 

solid,  1149.  ■ 
Bronchus,    foreign    bodies    in, 

820. 
Brush-burn,  176. 
Bubo,  chancroidal,  1206. 

in  gonorrhiEa,  1215. 

syphilitic,    1196. 
Bubonocele,  071. 
Bullet  wounds,  186. 

explosive  effect  in,  187. 
treatment  of,  187. 
Bunion,  423. 
Buried  sutures,  165. 
Burns,  190. 

of  anus,   1157. 

of  conjunctiva,  885. 

constitutional      effects      of, 
191. 

of  cornea,  885. 

of  face,  t42. 

of  larynx,  809. 

mortality  in,  191. 

powder,  184. 

shock  in,   191. 

of  tongue,  760. 

treatment  of,  191. 

X-ray.    196. 
Bursa,    hernial   protrusion   of, 
423. 

prepatellar,  disease  of,  422. 

of  tubercle  of  tibia,  bursitis 
of,   423. 
Bursse,  injuries  of,  421. 

of  neck,  793. 

wounds  of.  421. 
Bursitis,  421. 

chronic,  421. 

non-suppurative,  421. 

of  olecranon  bursa,  423. 

of  OS  calcis  bursa,  423. 

of  popliteal    bursa,    423. 

of  prepatellar   bursa,    422. 

of  quadriceps  extensor  bursa, 
423. 

of  subdeltoid  bursa,  423. 

of      subligamentous      bursa, 
423. 

suppurative,  421. 

syphilitic,  422. 
Button  suture,  167. 


C. 

Caesarian  section,  1142. 
Calculus,  renal.  1055. 

salivary,  795. 

ureteral,  1063. 

urethral,  996. 

vesical.  1030. 
in  female,  1040. 
Callus,  absorption  of,  518. 

affections  of.  518. 

exuberant,  518. 

fracture  of,  519. 

tumors  of.   519. 
Cancer,  contagion  of,  270. 

of  rectum,  1188. 
Capillarv  hemorrhage.  326. 

treatment  of.  335. 
Caput  succedaneum,  697. 
Carbolic  acid.   114. 
Carbolized  gauze,  130. 


Carbuncle,  45. 
of  neck,  789. 
treatment  of,  46. 
Carcinoma,  306. 
acinous,  310. 
of  breast,  871. 

clinical  history  of,  871. 
colloid,   871. 
treatment -of,  876. 
colloid,   311. 
of  face,  749. 
of  intestines,  938. 
of  jaw,  779. 
of  kidney.  1054. 
of  lip,   749. 

treatment  of,  750. 
melanotic,  309. 
metastasis  of,  307. 
pathology  of.  306. 
of  rectum.  1188. 
diagnosis  of.   1189. 
treatment  of.  1190. 
of  stomach,  930. 
of  testicle,  1082. 
of  tongue,    772. 

treatment  of.  773. 
treatment  of,  313. 
tubular,   309. 
of  uterus,  1138. 

amputation   of   cervix   in, 

1142. 
diagnosis  of,  1139. 
hysterectomy   in,   1140   et 

seq. 
treatment  of,  1139. 
Cardiac  disease  in  operations, 

88. 
Caries  of  bone.  539. 

sicca  of  shoulder-joint.  638. 
Carotid  aneurism.  371. 

artery,  common,  ligation  of, 
381. 
wounds  of.  337. 
external,   ligation  of,  382. 

wounds  of,  337. 
internal,  ligation  of,   382. 
wounds  of.  337. 
Carpal    bones,    dislocation    of, 
589. 
fracture  of,  479. 
Carpo-metacarpal    amputation 

of  hand,  234. 
Castration.  1083. 

for     hypertrophy     of     pros- 
tate,  1028. 
Cataract,  traumatic,  883. 
Catarrhal  inflammation,  43. 

prostatitis.  1090. 
Catgut,  alcohol.  127. 

ammonium  sulphate,  127. 
bichloride  of  palladium,  128. 
boiled.    127. 
chromicized.  128. 
chromic  acid,   128. 
cumol.   127. 
formalin,  127. 
ligatures,  127. 
sutures.   127. 
Von    Eergmann's,    127. 
Catheterization  in  the  female. 
1009. 
retrograde,  1014. 
Catheters.      sterilization       of, 

120. 
Caustics,   gangrene   from,    108. 

in  hemorrhoids,  1177. 
Cauterization  in  arterial  hem- 
orrhage, 331. 
Cautery,  actual,  156. 
Cellulitis.   47. 

of  auditorv  meatus,  892. 
diabetic,  106. 
of  neck,  789. 

treatment  of,  789. 
pelvic,  1119. 
treatment  of.  47. 
Cerebral  abscess,  729. 
hemorrhage,  723. 
diagnosis  of.  724. 
symptoms  of,  724. 
treatment  of.  724. 
localization.  739. 


Cerebro-spinal  fluid,  escape  of, 
in      fracture     of     base     of 
skull,  712. 
Cerumen,  impacted,  893. 
Cervical  plexus,  operations  on, 
408. 
rib.  793. 
Cervix  uteri,  atresia  of,  1102. 
deformities  of,  1102. 
erosion  of.   1117. 
hypertropliic       elongation 

of,  1102. 
inflammation  of,  1117. 
laceration  of,  1110. 

treatment  of.  1111. 
stricture  of,  1102. 
Chancre,  1194. 

extragenital.   1195. 
mixed,   1196. 
of  tongue.  769. 
Chancroid.   1204. 
diagnosis  of.   1206. 
phagedena  in,   1205. 
treatment  of.  1207. 
Chancroidal  bubo,  1206. 
Charcot's  disease.   614. 
Cheeks,  injuries  of,  760. 
Chemotaxis,  IS. 
Chest,  concussion  of,  833. 
contusions  of,  833. 

with    rupture    of   viscera, 
833. 
operations  upon,  842. 
surgery  of,  833. 
wounds  of,  834. 
gunshot,  837. 

penetrating,  837. 
non-penetrating,  834. 
penetrating,  834. 
Chilblain.  193. 

treatment  of,  193. 
Children,    fracture   of   clavicle 

in,  449. 
Chloride  of  sodium,  117. 

of  zinc,  116. 
Chloroform,  212. 

administration   of.    212. 
ansesthesia,    accidents    dur- 
ing, 213. 
and  ether.  214. 
and  oxygen.  213. 
Cholangitis,  921. 
Cholecystectomy,  925. 
Cholecystendyses.  925. 
Cholecystenterostomy,  925. 
Cholecystitis,  921. 
Choleeystostomy,  923. 
Cholecystotomy,  925. 
Choledochotomv,   926. 
Cholelithiasis,  922. 

treatment  of.  923. 
Chondritis  of  larynx,  813. 
Chondroma,  285. 

treatment  of.  287. 
Chromacized  catgut,  128. 
Chromic-acid  catgut,  128. 
Chronic  arteritis,  353. 
appendicitis,  950 
inflammation.    23. 
urethritis,    1217. 
Cicatrix,  contracting.  198. 
treatment   of,  199. 
depressed.  197. 

treatment  of.  198. 
diseases  of,  196. 
epithelioma  of,  197. 
painful.  196. 
weak,  196. 
Circular  amputation,  219. 
Circumcision,  1065. 
Circumpatellar  suture  in  frac- 
ture of  patella,  500. 
Cirsoid  aneurism,  351. 
Clamp   and   cautery  in  hemor- 
rhoids,   1178. 
Clavicle,  acromial  end  of,  dis- 
locations of,  572. 
dislocation  of.  570. 
fracture  of.   445. 
resection  of,  649. 
separation   of  epiphyses   of, 
450. 


INDEX. 


1227 


Clavicle,   sternal    end    of,    dis- 
locations of,  570. 
Cleft  palate,  783. 

treatment  of,  784. 
Club-foot,  689. 

brisement  forc6  in,  690. 
excision    of    astragalus    in, 

690,  692. 
tarsectomy  In,  691,  692. 
tenotomy  in,  690,  692. 
transplantation    of    tendons 

in,   691. 
treatment  of,  689. 
Club-band,   683. 
Coaptation  sutures.  164. 
Cocaine  bydrochlorate,  202. 
Coccygodynia,   482. 
Coccyx,  dislocation  of,  591. 
excision  of,   657. 
fractures  of,  4S2. 
Cold,  anffistbesia  from,  201. 
effects  of,  193. 

treatment  of,  193. 
gangrene  from,   108. 
water  dressings,  155. 
Colles's     fracture     of     radius, 
472. 
reversed,  475. 
Colloid  carcinoma,  311. 

of  breast,  871. 
Colostomy,   1191. 
iliac,  941. 
lumbar,  941. 
Colporrhaphy,  941. 
Comminuted  fracture,  427. 
Common      carotid      aneurism, 

371. 
Complete  dislocation,  561. 

fracture,  426. 
Complicated    dislocation,    562, 
565. 
fracture,  428. 
Composite  odontomata,  276. 
Compound  bandages,  134. 
dislocation,   562,  565. 
of  elbow,   586. 
of  humerus,   581. 
fracture,  427,  511. 

of  the  humerus,  466. 
separations     of     epiphyses 
432. 
of  the  lower  epiphysis  of 
the  humerus,  467. 
Compresses  in  arterial  hemor- 
rhage, 330. 
Compression,   158. 

in  arterial  hemorrhage,  329. 
of  brain,  718. 

symptoms  of,  719. 
treatment  of,  721. 
of  spinal  cord,   857. 
of  nerves,  399. 
Concussion  of  brain,  716. 
diagnosis  of.  718. 
symptoms  of,  717. 
treatment  of,  718. 
of  chest,  833. 
of  eyeball,  882. 
of  spinal  cord,  856. 
Condyloid     fractures     of     the 

humerus,  464. 
Condylomata,  1220. 
Congenital  deformities  of  face, 
743. 
dislocation,  562. 
of  hip,   681. 
of  humerus.  581. 
of  the  linee,  601. 
of  lower  jaw,  569. 
elephantiasis       of       nerves, 

279. 
fistula  of  ear,  889. 
hernia,   970. 
malformations  of  anus  and 

rectum,   1158. 
sinuses  of  neck,  793. 
tumor   of   sterno-cleido-mas- 
toid,   410. 
Conical  stump,  228. 
Conjunctiva,  burns  of,  885. 
foreign  bodies  in.  885. 
treatment  of,  886. 


Conjunctiva,  scalds  of,  885. 
Consecutive  amputations,  229. 

dislocation.  562. 

hemorrhage,  326. 
Contagion  of  cancer,  270. 
Continued  suture,   165. 
Contraction  of  fasciae.  413. 

of  joints,  685. 

of  muscles,  412. 
Contused  wounds,  175. 
Contusions,  170. 

of  abdomen,  899. 

of  arteries.  322. 

of  the  brain.  721. 

of  chest,  833. 

of  eyeball,   882. 

of  joints,   557. 

of  nerves,  398. 

of  spinal  cord,  856. 

treatment  of,  171. 

of  veins,  339. 
Coracoid  epiphysis  of  scapula, 
separation  of,  452. 

process  of  scapula,  fracture 
of,  451. 
of  ulna,  fracture  of.  478. 
Cord,      spinal.        See      Spinal 

cord. 
Cornea,  burns  of,  885. 

foreign  bodies  in,  885. 
treatment  of,  886. 

scalds  of,  885. 

wounds  of,  884. 
Corrosive      sublimate      gauze, 

130. 
Costal    cartilages,    dislocation 
of.  569. 
fracture  of,  443. 
Cotting's     operation     in      in- 
growing toe-nail.  688. 
Cotton,  bichloride,  131. 

gloves.    119. 

sterilized,    131. 
Counterirritation,  155. 

from  actual  cautery,  156. 

from  hot  water,  156. 

from      Paqueiin's      cautery, 
156. 

from  tincture  of  iodine.  156. 

from  turpentine.   156. 
Cowper's  glands,  inflammation 
of,  1093,  1214. 
tumors  of,  1093. 
Coxalgia,  623. 
Coxa  vara,  681. 
Crepitus  in  fracture,  431. 
Crystalline     lens,     dislocation 

of.  882. 
Cumol  catgut,   127. 
Cupping.  158. 

dry.  158. 

wet,  159. 
Curvature  of  spine,  668. 
Cutthroat  wounds,   788. 
Cyrtometer.  Wilson's,  741. 
Cystitis,  1021. 

drainage  in,  1023. 

in  gonorrhcea,  1217. 

treatment  of,  1022. 
Cystoadenoma   of   breast,    dif- 
fuse, 866. 
Cvstocele,   1105. 

treatment  of.  1107. 
Cystoscope,  1042. 
Cystoscopy,  1042. 
Cysts,   315. 

of  Bartholinl.  1120. 

branchial,  272. 

of  breast,  880. 
lymphatic,  880. 

dentigerous,'  276. 
.  dermoid  of  scalp,  701. 

epithelial,  traumatic,  268. 

of  face,  751. 

of  joints.  616. 

of  liver,  hydatid.  919. 

of  mouth,  dermoid,  762. 

mucous.  316. 

of  ovary.  1147. 

of  palate.  787. 

of  pancreas,  961. 

pathology  of,  315. 


Cysts,  retention,  310. 
sebaceous,  315. 

of  auditory  meatus,  892. 

of  scalp,   700. 

treatment  of.  315. 
of  testicle,  1081. 
thyroglossal,  274. 


D. 

Dactylitis,      syphilitic.      1199, 

1201. 
Death  after  operations,   85. 
Decortication     of     the     lung, 

845. 
Decubltis,   109. 
Deflected  septum.  752. 
Deformed    union    in    fracture, 
517. 
treatment  of.  518. 
Deformity  in  fracture.  430. 
Deformities  of  jaws,  782. 
Dela.ved     union     in     fracture, 

513. 
Delirium,   traumatic,   97. 
tremens,  97. 

in  fracture.  520. 
symptoms  of,   98. 
treatment  of,  98. 
Dentigerous  cyst,  276. 
Dermatitis,  44. 
of  face.  742. 
treatment  of.  45. 
Dermoid  cyst  of  mouth,   764. 
of  ovary,   1149. 
I  of  scalp.   701. 

thyroids,    272. 
I       tumors,   270. 
Desault's  bandage.   141. 
Diabetes,   effect   of.    on   opera- 
tions,  88. 
in  operations,  88. 
j  Diabetic  cellulitis,   106. 
;      gangrene,   105. 
Diapedesis.  18. 

Diaphragm,  congenital  defects 
of.  839. 
rupture  of.  839. 
'       wounds  of.  839. 
Diaphragmatic  hernia,   976. 
Diastasis.   561. 
j       of  pelvic  bones,   591. 
1       of    sutures     of     the     skull. 
706. 
Diet  after  operations,  85. 
Digital      compression     in      ar- 
I      terial   hemorrhage,   329. 
Dilatation  of  stomach.   930. 
Diphtheria  of  anus.  1165. 
Diphtheritic   laryngitis,   812. 
Diseases  of  bone.  521. 

of  cicatrices.  196. 
Disinfection,  methods  of,  117. 
Dislocations,   561. 

of  acromial   end  of  clavicle, 

572. 
of  the  ankle,  602. 
compound,   604. 
treatment  of.  605. 
of  astragalus,   606. 
of    body    of    sternum    from 

manubrium.    569. 
of  bones  of   forearm.   581. 

lateral,  585. 
of  carpal  bones,  589. 
causes  of,  562. 
of  clavicle,   570. 
of  coccyx,   591. 
complete.   561. 
complicated.  562.  565. 
compound,  562.  565. 
treatment  of.  565. 
congenital,  562. 
consecutive.   562. 
of  costal  cartilages,  569. 
of  crystalline  lens,  882. 
of  elbow.  581. 
compound.   586. 
old,   586. 
of  ensiform  process,  569. 
of  the  fibula,  602. 


1228 


INDEX. 


Dislocations  of  foot,   604. 
in  fracture,  431. 
habitual,  562,  566. 
of    head    of    femur    In    hip- 
disease,   623. 
of  radius,   582. 
of  the  hip,  591. 
of    humerus,     complications 
In,   580. 
compound,  581. 
congenital,  581. 
diagnosis  of,   576. 
fracture    of    neck    of,    in, 

581. 
old,  580. 

subclavicular,   575. 
subcoracoid,   575. 
subspinous,   578. 
supracoracoid,    579. 
symptoms  of,   576. 
treatment  of,  576. 
incomplete,  561. 
of  inferior  angle  of  scapula, 
573. 
radio-ulnar      articulation, 
587. 
irreducible,   562,   566. 
of  the  knee.  599. 
compound,   601. 
of  lower  jaw,  566. 
bilateral,   567. 
unilateral,  567. 
treatment  of,  568. 
medio-carpal,   589. 
of  metacarpus,  589. 
of  metacarpal  bones,  589. 

of  thumb,  589. 
of  metatarsal  bones,  607. 
of  nerves,  400. 
old,  562. 
of  OS  calcis,   607. 

magnum,  589. 
of  patella,   597. 
pathological,  562. 
of  pelvic  bones,  591. 
of  penis,  1068. 
of     phalanges     of     fingers, 
590. 
compound,   590. 
of  toes,   607. 
of  pisiform  bone,  589. 
primitive,  562. 
radio-humeral,   582. 
of  radius  and  ulna,   584. 

divergent,  586. 
recent,  562. 
reduction  of,  564. 
anaesthesia  in,  564. 
by  extension  and  counter- 
extension,  565. 
manipulation  in,   564. 
of  ribs,  569. 
secondary,   562. 
of  semilunar  bone,  589. 

cartilages,  601. 
of  shoulder-Joint.   574. 

subglenoid.    574. 
of  spine,  848. 
of   sternal    end    of   clavicle, 

570. 
of  sternum,  569. 
symptoms   of,    563. 
of  tendons,    416. 
of  testicle,   1079. 
traumatic,  562. 
treatment  of,  564. 
of  ulna  from  radius,  583. 
of  vertebrae.  848. 
of  the  wrist,  587. 
compound,   588. 
Dissecting  aneurism,  358. 
Dissection  wounds,  178. 

treatment  of,  179. 
Diverticula  of  bladder,   1018. 
intestinal   obstruction  from, 

952. 
of  oesophagus.   802. 
of  urethra,  1001. 
Dorsalis     pedis     artery,    liga- 
tion  of,   394. 
Double  ligature,   168. 
lip,    751. 


Drainage  In  abdominal  opera- 
tions,  908. 
in  hypertrophy  of  prostate, 

1028. 
tubes,   128. 
Dressings,    antiseptic,     impro- 
vised,  131. 
aseptic,  improvised,  131. 
cold  water,  155. 
fixed,  147. 
gauze,   129. 
plaster-of-Paris,  fenestrated, 

149. 
of  stumps,   225. 
Dry  cupping,  158. 
gangrene,   102. 
'  Duodenum,   ulcer  of,   937. 
!  Dupuytren's     finger     contrac- 
tion,  685. 
Dysenteric  proctitis,  1166. 
Dysmenorrhoea,  1101. 


Ear,     congenital     defects     of, 
889. 
diseases  of,  889. 
fistula  of,  congenital,  889. 
middle,  catarrh  of,   chronic, 
895. 
inflammation  of,  895. 
Elastic      constriction      in      ar- 
terial hemorrhage,   330. 
ligatures.   169. 
webbing  bandage,  147. 
Elbow,   amputations  at,  236. 
dislocations  of,   581. 
compound,  586. 
old.   586. 
figure-of-eight     bandage     of, 

139. 
joint,  diseases  of,  638. 
excision  of.   645. 
synovitis  of,   acute.   638. 
Electrolysis     in     hemorrhoids, 

1180. 
Electricity,  injuries  from,  194. 

treatment  of,  195. 
Elephantiasis,  317. 
Graecorum,   67. 
of  scrotum,   1076. 
of  vulva,   1123. 
Elliptical   amputation.    221. 
Embolic  arteritis,   353. 

gangrene,  103. 
Embolism.   34,   344. 
air,  340. 
fat.   99. 

in  fracture,  520. 
Emphysema,  836. 

after  tracheotomy,  825. 
Emphysematous  gangrene,    53. 
Empyema,   841. 
Encephalitis,   729. 
Encephalocele,  726. 
Encephaloid       carcinoma       of 

breast.   873. 
Encysted  hernia,  971. 

rectum,    1181. 
Endarteritis,   353. 
Endometritis,  1116. 
Endothelioma,   293. 
of  breast,  294,  871. 
of  mucous  membrane,   293. 
of  ovary.  294. 
of  skin.  293. 
treatment  of,   294. 
Ensiform    process,    dislocation 

of,   569. 
Enterectomy.  941. 
Enterocele,  976. 
Entero-epiplocele.   976. 
Enterostomy,  940. 
Enterotomy,  940. 
Enuresis,  1044. 

Epicondylar    epiphysis    of    hu- 
merus, external,  sepa- 
ration of,  468. 
internal,   separation  of, 


Epididymitis,   1215. 


Epilepsy,  732. 
focal,  732. 

treatment  of,   733. 
local,  732. 
Epileptiform  neuralgia,  397. 
Epiphysis  of   clavicle,   separa- 
tion of,  450. 
coracoid,  of  scapula,  separa- 
tion of,  452. 
external  epicondylar,  of  hu- 
merus, separation  of,  468. 
of  femur,   lower,   separation 
of,  495. 
upper,  separation  of,  484. 
of  fibula,  separation  of,  506. 
of  foot,   separation   of,    508. 
of      great      trochanter      of 
femur,       separation       of, 
485. 
of     humerus,     lower,     com- 
pound, separation  of, 
467. 
separation  of,  467. 
upper,  separation  of,  455. 
internal       epicondylar,       of 
humerus,    separation     of, 
468. 
of   metacarpal    bones,    sepa- 
ration of,  480. 
of     phalanges     of     fingers, 

separation  of,  480. 
of  radius,  lower,  separation 
of,  475. 
upper,  separation  of,  471. 
separations  of,  432. 
compound,    432. 
treatment  of,  434. 
of    tibia,    lower,    separation 
of,  504. 
upper,       separation        of, 
504. 
of  tubercle  of  tibia,  separa- 
tion of,  504. 
of    ulna,    lower,    separation 
of,  478. 
Epiphysitis,    acute,   535. 
Epiplocele.   976. 
Epispadias,   998. 

treatment  of,   999. 
Epistaxis,    754. 

Epithelial      cyst,      traumatic, 
268. 
cystic  tumors,  275. 
Epithelioma,   309. 
of  antrum,    781. 
of  anus,   1165. 
of  auditory  meatus,  892. 
of  cicatrices.  197. 
of  gums,   779. 
of  larynx,  816. 
of  mouth,  763. 
of  palate,  787. 
of  penis,  1071. 
of  scalp,  702. 
of  skull,   702. 
of  vagina,   1122. 
of  vulva,    1122. 
Epithelium,  repair  of,  79. 
Epulis,  778. 

Ergot,  gangrene  from,  104. 
Erosion,   660. 
Erysipelas,  49. 
facial,  50. 

inoculation  in  sarcoma,  302. 
phlegmonous.  49. 
treatment  of,  51. 
Erysipelatoid         lymphangitis, 

51. 
Estlander's    operation,    thoro- 

coplasty,  844. 
Ether,   201,   208. 

administration  of,  208. 
after-effects  of,  211. 
ansesthesia,    accidents    dur- 
ing,  210. 
first  insensibility  from,  210. 
and  nitrous  oxide  gas,  211. 
and  oxygen,  211. 
Etherization,      accidents     dur- 
ing,  210. 
Ethmoidal      sinuses, 
of,   758. 


1229 


Ethyl  bromide,   214. 

chloride,  201. 
Eucaine  hydrochlorate,  203. 
Excision     in     compound     frac- 
tures, 512. 
of    head    of    femur    in    hip- 
disease.   631. 
of  hemorrhoids,  1179. 
of  joints,   642. 
of  larynx,   818. 
of  the  rectum,  1191. 
of  sac  in  aneurism,  367. 
of      special      joints.         See 

under  each  joint, 
subperiosteal,  643. 
of  varicose   veins,    350. 
Exophthalmic  goitre,   806. 
Exophthalmos,   traumatic,  888. 
Exostosis,    523. 

of  auditory  canal.  893. 
treatment  of,   524. 
Explosive      effect      in      bullet 

wounds,    187. 
Exstrophy  of  bladder,   1016. 

treatment  of,  1017. 
Extension    and    counterexten- 
sion    in    reduction    of    dislo- 
cation, 565. 
External      carotid      aneurism, 
372. 
popliteal    nerve,    operations 

on,  409. 
urethrotomy,   1012. 
Extradural  hemorrhage,  723. 
Extraperitoneal      hsematocele, 
1153. 
method  in  abdominal  opera- 
tions, 909. 
Extra-uterine  pregnancy,  1154. 

treatment  of.   1155. 
Eye,  injuries  of,  882. 
Eyeball,  concussion  of,  882. 
contusion  of,   882. 
wounds  of.  884. 
penetrating,  884. 
Eyelids,  injuries  of,   887. 


Face,  abscess  of,  743. 
burns  of,  742. 
carcinoma  of,  749. 
cellulitis  of,  743. 
congenital      deformities    of, 

743. 
cysts  of.  751. 
dermatitis  of,  742. 
erysipelas  of,  743. 
foreign  bodies  in.  742. 
furuncles  of.  742. 
osteitis  of  bones  of,  743. 
tumors  of.  747. 
wounds  of,  742. 
Facial  artery,  ligation  of,  383. 
erysipelas,  50. 
nerve,  operations  on,  407. 
tetanus,  72. 
Facultative    anaerobic    micro- 
organisms, 3. 
Fallopian    tubes,    removal    of, 
1145. 
tumors  of.   1146. 
Fasci£e,   contraction  of,  413. 
gunshot  wounds  of,  188. 
wounds  of,  412. 
Fat  embolism,  99. 

treatment  of,  100. 
Fecal  fistula,  938. 

treatment  of,  939. 
Impaction,     intestinal       ob- 
struction  from,   951. 
Feet,   sterilization  of,    122. 
Felon,    420. 
deep.  420. 
superficial,   420. 
Felt  splints.   436. 
Female    genitals,    diseases    of, 
1096. 
examination  of,   1096. 
foreign  bodies  in,  1104. 
injuries  of,  1103. 


Female    genitals,     tumors    of, 

diagnosis  of,  1099. 
Femoral  aneurism,  376. 
artery,  ligation  of,  392. 

wounds  of,  339. 
hernia,  973. 

radical  cure  of,  987. 
vein,   wounds  of,   342. 
Femur,    condyles   of,    fracture 
of,  496. 
epiphysis      of      great     tro- 
chanter of,  separation  of, 
485. 
fractures  of,  484. 
compound,   497. 
great     trochanter    of,    frac- 
ture of.   490. 
lower   epiphysis   of,   separa- 
tion of,  495. 
neck  of,  fracture  of,  485. 
shaft  of,  fracture  of,  492. 
supracondyloid  fractures  of, 

495. 
upper    epiphysis   of,   separa- 
tion of,  484. 
extremity  of,  fractures  of, 

484. 
third  of,  fracture  of,  491. 
Fenestrated    plaster    dressing, 

149. 
Fever,  aseptic,  96. 
inflammatory,  96. 
traumatic.   95. 
urethral,  1006. 
Fibroadenoma   of   breast,    866. 
encapsulated,  867. 
intracanalicular,  867. 
treatment  of.   869. 
Fibroid     polypus     of     rectum, 
1187. 
tumors  of  breast,   881. 
of    uterus,    treatment    of, 
1134. 
Fibroma,  277. 
of  gums,  778. 
molluscum,  278. 
of  scalp,  702. 
of  sheath  of  nerves,  279. 
Fibromata,   treatment  of,  280. 
Fibromyoma  of  uterus,  1132. 
diagnosis  of,   1133. 
treatment  of,  1134. 
Flbromyomata       of       vagina, 

1122. 
Fibrous  odontome,  276. 

tumors.  277. 
Fibula,  dislocations  of,  602. 
epiphyses  of,   separation  of, 

506. 
fractures  of,  506. 
lower    end    of,    fracture   of, 

507. 
resection  of,   655. 
shaft  of,  fracture  of,  507. 
upper   end   of,    fracture   of, 
506. 
Figure-of-eight       bandage     of 
elbow,  139. 
of  knee.  143. 
Fingers,  amputation  of,  231. 
atypical  amputation  of,  234. 
deformities  of,  683. 
fractures    of    phalanges    of, 

480. 
phalanges     of,     dislocations 

of,  590. 
spiral  bandage  of.  138. 
supernumerary,  683. 
webbed,  683. 
Fissure  of  anus,  1162. 

treatment  of,   1163. 
Fissured  fracture,  427. 
Fistula.  41. 
in  ano.   1170. 
complete,   1170. 
external.  1170. 
horseshoe-shaped,   1170. 
internal,   1170. 
treatment  of,  1171. 
fecal,  938. 
gastric,  936. 
of  larynx,   827. 


Fistula,   lymphatic,  318. 
recto-urethral,  1193. 
recto-vaginal,   1193. 
recto-veslcal,  1103. 
salivary,  793. 
of  trachea,  827. 
treatment  of,  41. 
ureteral,   1062. 
urethral,  1015. 
■  urinary,   1021. 

vesico-vaglnal,  1112. 
Fixed  dressings,   147. 
Flat-foot,  693. 

treatment  of,  694. 
knot,  164. 
Flannel  bandage,   146. 
Floating  kidney,  1045. 
Fluctuation     in     suppuration, 

29. 
Focal   epilepsy.   733. 
Foetal      Inclusion     theory     of 

tumors,  267. 
Follicular  cyst  of  ovary,  1147. 

odontomata,  275. 
Fomentations,  hot,  155. 
Foot,  amputations  of,  245. 
bones  of.  fracture  of,  508. 
dislocations  of.  604. 

bones  of,  606.  607. 
epiphyses  of,   separation  of, 

508. 
French  bandage  of,  144. 
osteoplastic      resection      of, 

249. 
perforating  ulcer  of,  41. 
spica  bandage  of,  144, 
Forced  respiration.  162. 
Forceps,  artery,   332. 
Forearm,   amputation   of.   235. 
dislocation      of      bones      of, 

.581. 
fracture  of  bones  of,   468. 
greenstick        fracture        of 
bones  of,  470. 
Foreign     bodies     in     the    air- 
passages,   819. 
treatment  of.  821. 
in  auditory  canal,  893. 
In  bladder.   1021. 
in  bronchi,  820. 
in  conjunctiva,    885. 
in  cornea,    885. 
in  crystallized   lens,   886. 
globe,  886. 
heart.  838. 
intestinal  obstruction 

from,  951. 
in  nose.  755. 
in  rectum.  1157. 
in  stomach,   927. 
in  urethra,   996. 
in  wounds,,  173. 
treatment  of,  174. 
Formalin,  IIC. 
catgut.  127. 
Fractional  sterilization,   11. 
Fracture-bed.  435. 
Fracture-box,  430. 
Fracture-rack.  437. 
Fractures,  425. 

of  acetabulum.  484. 
of  acromion       process       of 
scapula,  451. 
treatment  of,  451. 
age  in,  425. 

of   anatomical    neck   of   hu- 
merus, 453. 
compound,  454. 
treatment  of.  454. 
of  angles  of  scapula.  450. 
angular      displacement      in, 

429. 
ankylosis  after.   520. 
of   articular   process   of  hu- 
merus, 464> 
of  astragalus,  508. 

compound,   509. 
by  avulsion,  428. 
of  body  of  scapula.  450. 
of  bones  of  foot,  508. 
compound,   510. 
of  forearm,  468. 


1230 


INDEX. 


Fractures  o£  bones  of  forearm, 
treatment  of,  469. 

of  leg,  501. 

ambulant  treatment  of, 

505. 
compound,   505. 
treatment  of,  501. 

of  skull,  711. 

hemorrhage   in,   711. 
injury     of     nerves     In, 
712. 
bran-bags  in,  437. 
of  callus,   519. 
of  carpal  bones,  479. 

compound,  479. 
causes  of,  426. 
of  the  clavicle,  445. 

in  children,  449. 

treatment  of,  446. 
of  the  coccyx,  482. 
Colles's,   472. 
comminuted,  427. 
complete,  426. 
complicated,   428. 
complications  after,  520. 
compound,  427,  511. 

amputation  in,  512. 

dressing  of,  512. 

excision  in,   512. 

treatment  of,   511. 
compresses  in,  437. 
of  condyles  of  femur,  496. 
of       coracoid       process     of 

scapula,   451. 
of  the  costal  cartilage,  443. 
crepitus  in,   431. 
deformed   union   in,    517. 
deformity   in,   480. 
delayed   union   in,   513. 
delirium  tremens  in,  520. 
depression  in,  430. 
diagnosis  of,  431. 
direction  of,  428. 
discoloration   in,    431. 
dislocation  in.  429. 

of  spine,   849. 
embolism,  520. 
examination  of,   431. 
of   external    condyle   of   hu- 
merus, 465. 

maleolus,   508. 
of  the  femur,  484. 

ambulant     treatment     of, 
496. 

compound,  497. 
of  the  fibula,  506. 
fissured,  427. 
gangrene  after,  520. 
of       great       trochanter     of 

femur,  490. 
greenstick,  426. 
gunshot,   189. 

amputation   in.    190. 

treatment  of,  189. 
of  head  of  radius,   471. 

of  humerus,  453. 
of  the  humerus,  452. 

supracondyloid,  461. 
treatment  of,   462. 
of  hyoid  bone,  441. 
of  ilium,  482. 
impacted,  428. 
impressed,   426. 
incomplete,   426. 
of    internal    condyle    of    hu- 
merus,   464. 
of     internal     epicond^le    of 

humerus,  465. 
of  the  ischium.  4S3. 
junk-bags  in,  437. 
lateral       displacement       in, 

429. 
longitudinal,   428. 

displacement  in,  429. 
loss  of  function  in,   430. 
of  lower  end  of  fibula.  507. 
treatment  of,  507. 
of  radius,  472. 

treatment    of,    473. 
of  tibia,  504,  505. 

extremity     of       humerus, 
treatment  of,  465. 


Fractures  of  lower  jaw,  440. 
treatment  of,  441. 
oblique,   428. 

of  olecranon  process,  476. 
open,  427. 
of  OS  calcls,  509. 

pubis,   483. 
massage  in,  434. 
of  malar  bone,  439. 
of  metacarpal  bones,  479. 

compound,  479. 
of  metatarsal  bones,  510. 
multiple,  427. 
muscular  spasm  in,  430. 

wasting  after,  520. 
of  nasal  bones,  437. 
compound,   438. 
treatment  of,  438. 
of  neck  of  femur,  485. 
diagnosis   of,    488. 
treatment  of,  489. 

of  radius,  471. 

of  scapula,    452. 
pain  in,  430. 
paralysis  after,  520. 
of  patella,  497. 

circumpatellar   suture   In, 
500. 

compound,   500. 

Malgaigne's       hooks       in, 
500. 

treatment  of,  498. 
operative,  499. 
of  the  pelvis.  480. 

complications  in,   481. 

vertical,  480. 
of  penis.  1068. 
perforating.  427. 
of  phalanges  of  fingers,  480. 

of  toes,  510. 
plaster-of-Paris    splints    in, 

436. 
Potts,   507. 
preternatural     mobility     in, 

430. 
provisional       dressings      of, 

434. 
reduction   of,    435. 
restoration        of        lunction 

after,  521. 
reversed  Colles's,  475. 
of  the  ribs,  442. 

treatment   of,    442. 
rotating     displacement     in, 

429. 
rupture  of  artery  in,  520. 
of  the  sacrum.  481. 

treatment  of,    482. 
of  the  scapula.  450. 
setting  of,   435. 
season  in.  425. 
sex  in.   425. 
of  shaft  of  femur,  492. 
in  children,  494. 
treatment  of,  492. 

of  fibula,  507. 

of  humerus,  458. 
treatment  of,  459. 

of  radius,  471. 
shortening    in,    consecutive, 

of  skull,  704. 

comminuted,  707. 

compound,   709. 

depressed,  709. 

diagnosis  of.  710. 

escape  of  brain-tissue  In, 
712. 
of    eerebro-spinal    fluid 
in.  712. 

fissured,   707. 

gunshot,   714. 

treatment   of.    715. 

mechanics   of.    704. 

penetrating,  707. 

prognosis  in.  713. 

repair  of.  709. 

symptoms  of,  710. 

treatment  of,  713. 
of  spine,  849. 
spiral.  428. 
splints  in,  436. 


Fractures,  sprain,  428. 

of  the  sternum,  444. 
treatment  of,  445. 

of  styloid  process  of  ulna, 
478. 

subperiosteal,   427. 

of  surgical  neck  of  hume- 
rus. 457. 

symptoms  of,  430. 

thrombosis  in,  520. 

of  tibia,  503. 

transverse.    428. 

treatment  of.  434. 

of  tuberosities  of  humerus, 
455. 

through  tuberosities  of  hu- 
merus,  454. 

of  ulna,   475. 

treatment  of,  476. 

ununited,   513. 

of  upper  end  of  fibula,  506. 
extremity  of  femur,  484. 
jaw,  438. 

treatment  of,   439. 
third  of  femur,  491. 

varieties  of,  426. 

of  zygomatic  arch.  439. 
Fragilitas  ossium,  524. 
Frenum,  elongation  of,  765. 

of      penis,      laceration      of, 
1068. 
Frontal     sinus,     diseases     of, 

757. 
Frost-bite,  194. 

of  auricle.  S90. 

treatment  of,  194. 
Furuncle,  45. 

of  face,  742. 

treatment  of,  46. 
Fusiform  aneurism,  357. 


G. 

Gall-bladder,  diseases  of,  921. 

tumors  of,  923. 
Gall-stones,  intestinal  obstruc- 
tion  from,   951. 
Galvano-cautery,  156. 
Galvano-puncture      in      aneu 

rism,  368. 
Ganglion,  419. 

compound,  419. 
Gangrene,  22,   101. 

after  amputation.  228 

from  caustics,  108. 

from  cold.   108. 

diabetic,  105. 

treatment  of,  106. 

dry,  102. 

embolic,  103. 

treatment  of,  104. 

emphysematous.  53. 

from  ergot,  104. 

foudroyante,  53. 

after  fracture,  520. 

from  heat.   108. 

hospital,  110. 

infective.   109. 

after   ligation   in   aneurism, 
367. 

moist.    106. 

neuropathic,   109. 

of  pancreas,  961. 

from  pressure,  10&. 

of  rectum.   1168. 

senile.   102. 

treatment  of,  103. 

symmetrical.    105. 

traumatic,   106. 
spreading,  109. 
treatment  of,  107. 

varieties  of,  101. 

white,  105. 
Gangrenous  periproctitis, 

1167. 

stomatitis,  762. 
Gas,  nitrous  oxide,  207. 
Gaseous  septic  infections,  20. 
Gasserian    ganglion,     removal 

of,  739. 
Gastric  fistula,  936. 


INDEX. 


1231 


Gastro-enterostomy,  933. 

with  Murphy's  button,  933. 

posterior  operation,  934. 

by  rubber  iigature,  934. 

in  stricture  of  pyiorus,  929. 

by  suture,  934. 
Gastrolysis     in     stricture     of 

pyiorus,   929. 
Gastroptosis,  927. 
Gastrostomy,  932. 

Stamm's  method  of,  932. 
Gastrotomy,  932. 
Gauze,  bichioride,  130. 

carbolized,  130. 

corrosive  sublimate,  130. 

dressings,  129. 

iodoform,  130. 

pads,  126. 

pledgets,  126. 

sterilized,  129. 
Gelatin     in     arterial     hemor- 
rhage, 334. 
Genitals,    female,    absence    of, 
1101. 
deformities  of  congenital, 

1101. 
reduplication  of.  1102. 
surgery  of,  1096. 
Genu  extrorsum,   675. 

recurvatum,  678. 

valgum,  672. 
Germs.   1. 

Giant-ceiled  sarcoma,  295. 
Glanders.   57. 

acute,  57. 

equine,  57. 

treatment  of,  58. 
Glands,    salivary,    injuries   of, 
793. 

thyroid,     inflammation     of, 
803. 
Gleet,  1217. 
Gliosarcoma,  295. 
Globe,  foreign  bodies  in,  886. 
Glossitis,   acute,   766. 

chronic  superficial,  767. 
Glottis.  (Edema  of,  810. 
Gluteal  aneurism,  376. 

artery,  ligature  of,  391. 
wounds  of.  339. 
Goitre,  exophthalmic.  806. 
Gonococcus,   13,   1208. 
Gonorrhoea,   1208. 

balanitis  in,  1214. 

balanoposthitis  in,  1214. 

bubo  in,  1215. 

cystitis  in,  1217. 

epididymitis  in.  1215. 

in  female,  1218. 
treatment  of,  1219. 

lymphangitis   in,    1215. 

paraphimosis  in,  1214. 

pathology  of,   1209. 

perilymphangitis  in,  1215. 

phimosis  in,  1214. 

prostatitis  in,   1216. 

pyosalpinx  in,  1220. 

retention  of  urine  in,  1213. 

salpingitis  in,   1220. 

symptoms  of,  1210. 

treatment  of,  1211. 

vaginitis  in,  1220. 

vesiculitis  in.  1217. 
Gonorrhceal  arthritis,   611. 
treatment  of,  611. 

peritonitis,   916. 

proctitis,    1166. 

prostatitis,  1090. 

septicsemia.  611.  1216. 

tenosynovitis^  419. 
Gout  in  operations,   87. 
Gouty  arthritis,  613. 
Greensticl:   fracture,  426. 

of  bones  of  forearm,  470. 
Groin,  spica  bandage  of,  142. 

double,    142. 
Guaiacol,  203. 
Gumma,   1199. 
Gummata  of  tongue,  770. 
Gummatous  osteomyelitis,  544. 
Gums,  epithelioma  of,  779. 

fibroma  of,  778. 


Gums,  hypertrophy  of,  775. 
injuries  of,  760. 
papilloma  of,  779. 
sarcoma  of,  778. 
spongy,  775. 
tumors  of,  778. 
Gunshot  fractures,  189. 
amputation   in,    190. 
of  the  sltuli,  714. 
wounds,  182. 

of  arteries,  324. 

treatment  of,  325. 
of  blood-vessels,   188. 
of  chest,  837. 
of  faseiffi,  188. 
of  joints,   560. 
from  large  shot,  187. 
of  muscles,  188. 
of  neck,   789. 
j  of  nerves,    188. 

I  of  the  skin,  188. 

from  small  shot,  185. 
of  tendons,  188. 

H. 

I  Habitual  dislocation,  562,  566. 
'  Haematocele,      intraperitoneal, 
1153. 
pelvic,  1153. 

of  tunica  vaginalis,  1087. 
Hsematoma  of  auricle.  890. 

of  sterno-mastoid,  788. 
Hsematometra,    1103. 
Hematosalpinx.  1146. 
Hsemophilia,  89. 
operations  in,  89. 
treatment  of.  90. 
Hajmostatic  forceps,  331. 
Hemothorax,  836. 
I  Hallux  flexus,  686. 
i       rigidus,  686. 
valgus,  687. 
Hammer-toe,  686. 
Hand    or    Hands,    amputation 
of,    234. 
atypical.  234. 
perforating  ulcer  of,  41. 
removal    of    plaster-of-Paris 

from.  149. 
sterilization  of,  118. 
Handkerchief  bandages,  135. 
Harelip,   744. 

operations  for,  745. 
suture,  166. 
treatment  of,  745. 
Head,  surgery  of.  697. 

recurrent  bandage  of,  137. 
Healing  by  apposition,  76. 
by  granulation,  77. 
of  wounds,  75. 
Heart,  foreign  bodies  in,  838. 

wounds  of,  838. 
Heat,  asepsis  from.  113. 
gangrene  from.  108. 
sterilization  by,  11. 
Heel,  bandage  of,  145. 
Hemiglossitis.  766. 
Hemorrhage,  325. 
in  amputation,  226. 
arrest  of.  spontaneous,  327. 
arterial,  326. 

adrenalin  in,  334. 
antipyrin  in,  334. 
cauterization  in,  331. 
cold  water  in,  333. 
compresses  in,  330. 
compression  in,  329. 
deep  sutures  In,  332. 
digital      compression     In, 

gela'tiii  in,  334. 
haemostatic      forceps      In, 

hot  water  in,  333. 

Ice  in,  333. 

ligature  in,  332. 

position  in,  329. 

pressure  in.  331. 

Spanish  windlass  In.  330. 

styptics  In,  333. 


Hemorrhage,    arterial,    torsion 
In.  332. 

tourniquets  In,  330. 
capillary,  326. 

treatment  of,  335. 
cerebral,  723. 

diagnosis  of,  724. 

treatment  of.  724. 
consecutive,  326. 
diagnosis  of.  328. 
extradural,  723. 
In  fracture  of  base  of  skull, 

711. 
intermediary,  326. 
intracranial,  723. 
Into  pancreas,  961. 
parenchymatous,  326. 

treatment  of,  335. 
primary,  326. 
secondary,  326. 

after     ligation     In     aneu- 
rism. 307. 

treatment  of,  335. 
from  skull,  738. 
symptoms  of,  constitutional, 

trealment  of.  328. 

of  constitutional,  328. 

local,  328. 
venous,  326. 

haemostatic      forceps      In, 
335. 

lateral  ligature  in,  334. 

ligature  in,  334. 

pressure  in,  334. 

treatment  of.  334. 
Hemorrhoids.  1173. 
arterial,  1175. 

treatment  of.  1176. 
caustics  in,  1177. 
clamp  and  cautery  in,  1178. 
electrolysis  in,  1180. 
excision  in,  1179. 
external,   1174. 
injections  in.  1177. 
internal,    1175. 
ligature  in,  1177. 
Whitehead's     operation     In, 

1179. 
Hereditary    syphilis,    bone    le- 
sions In.  545. 
Heredity  in  tumors.  270. 
Hermaphrodism,  1102. 
Hernia,  968. 
acquired,  971. 
of  bladder,  1018. 
congenital,  970. 
contents  of.  976. 
diagnosis  of,  979  et  seq. 
diaphragmatic,  976. 
encysted,   971. 
etiology  of.  969. 
femoral.  973. 

radical  cure  of.  987. 
incarcerated,  989. 
infantile,  971. 
inflamed,  989. 
inguinal,  970. 

direct.  971. 

oblique,  971. 

radical  cure  of,   985. 

Bassinl's  method. 


Halsted's 


method, 
method, 


Kocher's 
986. 

Macewen's       method, 
985. 
Injections     into     canal      In, 

985. 
intermuscular.  972. 
Interstitial,  972. 
Littre's,  976. 
lumbar.  975. 
of  lung,  836. 
of  muscles.  411. 
obstructed.  989. 
obturator.  975. 
pathology  of.  976. 
perineal,  975. 
properitoneal.  972. 


1232 


INDEX. 


Hernia,    radical    cure    of,    re- 
sults of,  988. 
Eichter's,  977. 
sac  of,  977. 
sciatic,  975. 

strangulated,  operations  for, 
993. 
taxis  in,  991. 
treatment  of,  991. 
strangulation  of,  978,  990. 

retrograde,  977. 
subfascial,  972. 
symptoms  of,  978. 
testis,  1079. 

treatment  of,  by  truss,  982. 
trusses  for,  982. 
umbilical,  973. 
adult,   974. 
infantile.  974. 
radical  cure  of,  987. 
In  umbilical  cord,  973. 
ventral,  974. 

radical  cure  of,  988. 
Hernial    protrusion    of   bursa, 

423. 
Hip,  dislocations  of,  591. 
anomalous,  596. 
backward,  593. 
downward    and    forward, 

594. 
everted  dorsal,  593. 
iliac,   592. 

treatment  of,  594. 
infracotyloid.  596. 
iscbiatic,  593. 

treatment  of,  594. 
old,  597. 
pubic,   595. 

treatment  of,  595. 
supracotyloid,   596. 
thyroid,  594. 

treatment  of,  595. 
upward      and     backward, 
592. 
and  forward,  595. 
Hip-disease,    abscess    in,    626, 
630. 
amputation  in,   632. 
diagnosis  of,  626. 
dislocation      of      head      of 

femur  in,  625. 
excision  in.  631. 
fixation  and  traction  splints 

in,  629. 
recumbency    and     extension 

in,   628. 
symptoms  of,  623. 
treatment  of,  628. 

operative,  631. 
tuberculous     meningitis     in, 

626. 
visceral  tuberculosis  in,  626. 
Hip-joint,    amputations  above, 
257. 
amputation  at,  254. 
ankylosis     and     flexion     of, 
680. 
treatment  of,    680. 
arthritis  of,  septic,  622. 

tuberculous,  622. 
disease,  623. 

dislocation     of,     congenital, 
681. 
treatment  of,  682. 
supracotyloid,   596. 
excision  of.  651. 

after-treatment  of,  653. 
anterior,  652. 
synovitis  of,   acute,   621. 
septic,  622. 
Holocaine,  203. 
Horse-hair  sutures,  128. 
Hospital  gangrene,  110. 
Hot  fomentations,  155. 
Housemaid's  knee,   422. 
Humerus,  anatomical  neck  of, 
fracture  of,  453. 
articular    process    of,   frac- 
tures of,  464. 
condyloid  fractures  of,  464. 
epiphysis  of.   lower,  separa- 
tion  of,   467. 


Humerus,  external  condyle  of, 
fracture  of,  465. 
fractures  of,  452. 
compound,   466. 
of  neck  of,  in  dislocations 

of  humerus.  581. 
through     tuberosities     of, 
454. 
head  of,  dislocations  of,  574. 

fracture  of,  453. 
internal     condvle    of,     frac- 
ture of,  464. 
epicondyle  of,  fracture  of, 
465. 
resection  of,   645. 
shaft  of,   fracture  of.   458. 
subluxation  of  head  of,  579. 
surgical    neck    of,    fracture 

of,  457. 
T-fracture    of    condyles    of, 

464. 
tuberosities      of,      fractures 

of,  455. 
upper   epiphysis   of,   separa- 
tion of,  455. 
Hunterian   operation   in  aneu- 
rism, 365. 
Hydatid  cyst  of  liver,  919. 

of  lung.  840. 
Hydrencephalocele,  726. 
Hydrocele.  1083. 

of  canal  of  Nuck,  1123. 
diagnosis  of.  1084. 
treatment  of.  1085. 
of  tunica  vaginalis,  1083. 
Hydrocephalus,   734. 
Hydrogen,   peroxide.    116. 
Hydronephrosis,    1052. 
Hydrophobia,  73. 
Hydrophobic  tetanus,  72. 
Hydrosalpinx,   1146. 
Hydrothorax,  840. 
Hyoid  bone,  fracture  of,  441. 
Hymen,  atresia  of,  1102. 
Hyperemia,   15. 
of  bone.   525. 
Hypertrophy  of  bone,  521. 
of  gums,  775. 
of  muscles.   412. 
of  prostate,   1025,   1093. 

treatment  of,    1027. 
of  skull,   699. 
Hypnotism,  214. 
Hypodermoclysis.  160. 
Hypospadias,  997. 
glandular.  997. 
peno-scrotal.  997. 
perineal,  997. 
treatment  of,  999. 
Hysterectomy,    abdominal,    in 
cancer  of  uterus,   1141. 
for      fibroid      tumors      of 
uterus,  1136. 
for      prolapse      of      uterus, 

1130. 
sacral,   in  cancer  of  uterus, 

1141. 
vaginal,  in  cancer  of  uterus, 
1140. 
for      fibroid      tumors     of 
uterus,    1136. 
Hysteria,   traumatic.   99. 
Hysterical  Joints,  615. 


I. 

Ichthyol.  117. 

Iliac  aneurism.   375. 

artery,  common,  ligation  of, 
389. 
external,   ligation  of,  390. 
internal,   ligation  of.   391. 

dislocation  of  hip.   592. 

vein,  wounds  of,  342. 
Ilium,  fractures  of,  482. 
Impacted  cerumen,  893. 

fracture,  428. 
Impotence,  1094. 
Impressed  fracture,  426. 
Improvised    aseptic    dressings, 

131. 


Incarcerated  hernia,  989. 
Incised  wounds,  172. 
of  arteries,   324. 
Incomplete  dislocation,  561. 

fracture,  426. 
Infantile  hernia,  971 

umbilical  hernia,   974. 
Infarction,  tuberculous,  64. 
Infected      wounds,     antiseptic 
treatment   of,   124. 
aseptic  treatment  of,  124. 
Infective  gangrene,  109. 

osteomyelitis,  530. 
Inferior    dental    nerve,    opera- 
tions on,  407. 
Infiltration  ansesthesia,  203. 

purulent,   22. 
Inflammation     from     bacteria, 
15. 
catarrhal,   43. 
chronic,  44. 
emigration  in,  17. 
etiology  of,  14. 
exudate  in,  17,  18. 
fever  in,  29. 
fibrinous.  43. 
induration  in,  29. 
of  mucous  membranes,  43. 
pain  in,  29. 
pathology  of,  14. 
resolution  in,  21. 
rigors  in,  29. 
of  serous  membranes,  44. 
suppurative,  43. 
symptoms  of,  25. 
of  synovial   membranes,   44. 
termination  of,  21. 
of  tonsils,  795. 
treatment  of,  26. 
Inflammatory  fever,  96. 
Infracotyloid     dislocation     of 

hip,  596. 
Ingrowing  toe-nail,  687. 
Inguinal  hernia,  970. 

radical  cure  of,  987. 
Inherited  syphilis,  1200. 
Injections  of  antiseptics  in  in- 
flammation,  28. 
in  hemorrhoids,  1177. 
Injuries,    conditions    affecting 
results  of,  84. 
from  electricity,  194. 
insanity  after,  98. 
Innominate  aneurism,   371. 
artery,  ligation  of,  380. 
Insanity  after  injuries,  98. 

after  operations,  98. 
Insects,  stings  of,  180. 
Instruments,    sterilization    of, 

120,  1006. 
Intercostal  artery,  wounds  of, 

338. 
Intermediary  hemorrhage,  326. 
Intermuscular  hernia,  972. 
Internal      carotid      aneurism, 
372. 
popliteal    nerve,    operations 

on,  409. 
uretlirotomy.  1010. 
Interphalangeal  joints,  arthri- 
tis of,  tuberculous,  640. 
excision  of,  649. 
Interrupted        plaster-of-Paris 
dressing.   148. 
sutures,  165. 
Interscapulo-thoracic    amputa- 
tion,  242. 
Interstitial  hernia,  972. 
Intestinal  anastomosis,  943. 
exclusion,  943. 
obstruction,  951. 

from  adhesions,  952. 
from  bands.   952. 
diagnosis  of,   956. 
from  diverticula.  952. 
from  fecal  impaction,  951. 
from  foreign  bodies,  951. 
.   from  gall-stones,  951. 
from  intussusception,  953. 
from  apertures,  952. 
from  paralysis,  951. 
from  stricture,  9o2. 


INDEX. 


1233 


Intestinal    obstruction,    treat- 
ment of,   955,   958. 
varieties  of,  951. 
from  volvulus,  953. 
Intestines,  carcinoma  of,  938. 
diseases  of,  936. 
foreign  bodies  in,  936. 
resection  of,  941. 
sarcoma  of,   938. 
stricture  of,  938. 
suture  of,  907. 
tubercular   inflammation  of, 

937. 
ulceration  of,   937. 
Intracranial  hemorrhage,  723. 
tumors,  734. 

diagnosis  of,  735. 
treatment  of,  736. 
Intraperitoneal       haematocele, 

1153. 
Intrathoracic  tumors,   846. 
Intravenous    injection    of    sa- 
line  solution,    160. 
Intubation    in    cicatricial    ste- 
nosis of  the  larynx,  832. 
of   larynx,   827. 

after-treatment  of,  830. 
operation  of,  829. 
tube,  828. 

removal  of,   830. 
retained,  832. 
Intussusception,  953. 
chronic,  955. 
of  the  dying,  953. 
Inversion  of  uterus,  1130. 

treatment  of,  1131. 
Iodoform,  114. 
collodion,   115. 
emulsion.  115. 
gauze,  130. 

injections     in     tuberculosis, 
66. 
Iritis,  syphilitic,  1201. 
Irreducible     dislocation,     562, 

566. 
Irrigation,  153. 
direct,   154. 
in  inflammation,  28. 
mediate,  155. 
Irritable  ulcer  of  anus,  1162. 
Ischiatic    dislocation    of    hip, 

503. 
Ischio-rectal  abscess,  1168. 
Ischium,  fracture  of,  483. 
Isinglass  plaster,  152. 
Itroi,  117. 


Jacob's  ulcer,  309. 
Jaw,  actinomycosis  of,  778. 
ankylosis  of.   783. 
carcinoma  of.  779. 
closure  of,  783. 
condyle  of,  excision  of,  660. 
deformities  of,  782. 
diseases  of,  775. 
lower,   dislocation  of,   566. 
congenital,  569. 

excision  of,  659. 

fracture  of,  440. 

subluxation  of,  567. 
necrosis  of,   777. 

from  phosphorus.   777. 
oblique  bandage  of,   137. 
osteoma  of,  779. 
periostitis  of,  777. 
sarcoma  of,  780. 
tumors  of,   778. 
upper,  excision  of,  658. 

fracture  of,  438. 

osteoplastic    resection    of, 
659. 
Je.1unostomy,  941. 
Joints,  abscess  of.  609. 
ankylosis  of,   617. 
contractures  of,    685. 
contusion  of.  557. 
cysts  of,  616. 
diseases  of.     See  under  each 

joint, 
excision  of,  642. 


Joints,     hysterical     affections 
of,  615. 
Injuries  of,   557. 
loose  bodies  in,  616. 
neoplasms  of,  616. 
neuralgia  of,   615. 
operations  upon,  642. 
sprains  of,   558. 
strapping   of,    153. 
wounds  of,  559. 
treatment  of,  560. 
gunshot,  560. 

treatment  of,  561. 
Jugular  viiu,  internal,  wounds 

of,  341. 
Junk-bags  In  fracture,  437. 


K. 

Kangaroo  tendons,  128. 
Keloid,  197,  278. 
Kidney,  anomalies  of,  1045. 
carcinoma  of.  1054. 
floating,   1045. 
inflammation  of,  1046. 
injuries  of,  1044. 
lipoma  of,  1053. 
movable,    1045. 
operations  on,   1057. 
polycystic    degeneration    of, 
.    1051. 

resection  of,  1061. 
sarcoma  of.  1054. 
solid  tumors  of,   1053. 
tuberculosis  of.  1050. 
treatment  of,  1051. 
tumors  of,   1051. 
diagnosis  of,   1055. 
Knee,  dislocations  of,  599. 
compound,  601. 
congenital,    601. 
figure-of-eight     bandage    of, 
143. 
Knee-joint,     amputation       at, 
252. 
ankylosis   of,    treatment   of, 

679. 
arthrectomy  of,  661. 
arthritis     of.      suppurative, 
acute.   632. 
tuberculous,  633. 
diseases  of,  632. 
excision  of,  653. 
synovitis  of.  acute  suppura- 
tive,  632. 
chronic,    632. 
simple,   632. 
Knock-knee,  672. 
osteoclasis  in,   673. 
osteotomy  in.  673. 
treatment  of.   673. 
unilateral,  673. 
Kreolin,  116. 
Kyphosis,  671. 


Labia,  adherent,  1102. 
Labial  abscess.  1116. 
Lacerated  wounds,  174. 
Laceration  of  arteries,  323. 

of  perineum,   1104. 

of  spinal  cord.   856. 
Laminectomy,  859. 
Larrey's  amputation  at  shoul- 
der-joint.  240. 
Laryngitis,  811. 

catarrhal,  811. 

membranous,  simple,  811. 

syphilitc,  812. 

tuberculous,  812. 
Laryngotomy.  826. 
Laryngo-traoheotomy.  827. 
Larynx,  abscess  of,  814. 

burns  of.  809. 

chondritis  of.    813. 

epithelioma  of,  816. 

excision  of.  818. 

fistula  of,  827. 

fracture  of,  809. 


Larynx,   Intubation  of,   827. 

malignant  growths  of.  816. 

perichondritis  of,   813. 

sarcoma  of,  816. 

scalds  of,  809. 

stricture  of,  814. 

tumors  of,  815. 
benign,  815. 

ulceration  of,  814. 

wounds  of,  808. 
Lateral     curvature    of    spine, 
668. 

ligature    in    venous    hemor- 
rhage, 334. 
Leather  splints,  151. 
Leeching,  159. 
Leg,  amputation  of,  250. 

artificial,  258. 

fracture   of   both    bones   of, 
501. 

spiral   reversed  bandage  of, 
145. 
Leiomyoma,  287. 
Lembert's  suture,  167. 
Lens,        crystalline,        foreign 

bodies  in,  S86. 
Leontiasis  ossea,  67,  521. 
Lepra,   67. 
Leprosy.   67. 
Leucocytosis,  20,  25. 
Ligamentum    patelise,    rupture 

of,  414. 
Ligation  in  aneurism,- 365. 
complications  after,   366. 

of  arteries.  376. 

of     special     arteries.       See 
under  each  artery. 
Ligature    in    arterial     hemor- 
rhage, 332. 

catgut,  127. 

double,   168. 

elastic,   169. 

in   hemorrhoids.    1177. 

multiple,   in   varicose   veins, 
350. 

quadruple,  169. 

single,  168. 

for  strangulation  of 

growths,    168. 

subcutaneous.    169. 

of    vas    deferens    in    hyper- 
trophy  of  prostate,   1028. 

in  venous  hemorrhage,   334. 
Lightning  stroke,  195. 
Linear   proctotomy.   1183. 
Lingual     arterv,     ligation    of, 
383. 
wounds  of,  337. 

nerve,   operations   on.   407. 
Lip,  carcinoma  of,  749. 

double,  751. 

lower,  clefts  of,  747. 
Lipoma,  281. 

of  breast,  881. 

of  scalp,  701. 

treatment  of,  283. 
Litholapaxy,  1034. 
Lithotomy,  1036. 

lateral,  1037. 

median,  1036. 

suprapubic,  1037. 
Lithotrity.   1034. 
Littre's  hernia,  976. 
Liver,  abscess  of,  919. 

hydatid  cyst  of,  919. 

tumors  of.  919. 

wounds  of,  918. 
Local  anffisthesia,  201. 
Localization,  cerebral,  737. 
Lockjaw,   68. 

Longitudinal  fracture.  428. 
Loose  bodies  in  joints.   616. 
Lumbar  hernia.  975. 
Lumpy  jaw.  59. 
Lung,  decortication  of,  845. 

hernia  of,  836. 

hydatid  cysts  of,  biO. 

operations  upon,  845. 
Lupus  of  tongue.  768. 
Luxatio  erecta,  579. 
Lymphangioma.  292. 

treatment  of.  293. 


1234 


INDEX. 


Lymphangitis,  318. 

erysipelatoid,   51. 

in  gonorrlicea.   1215. 
Lymptiatic   abscess,   treatment 
of,  320. 

cyst  of  breast,  880. 

fistula,  318. 

tumors,  320. 
Lymphatics,   abscess  of,   319. 

inflammation  of,  319. 
treatment  of,  320. 

injuries  of,  317. 

obstruction  of,  317. 

surgery  of,  317. 
Lymph-node,  318. 
Lysol,  116. 
Lyssa,  73. 


Macroglossia,  765. 
Malar  bone,  fracture  of,  439. 
Malformations    of    anus    and 
rectum,       congenital, 
1158. 
treatment  of,  1160. 
varieties  of,  1158. 
Malgaigne's  hooks  in  fracture 

of  patella,  500. 
Malignant  carbuncle,  55. 

oedema,  53. 

pustule,  55. 

tumors,  266. 
Malleolus,     external,     fracture 

of,  508. 
Mammary      artery,      internal, 
ligation  of.   386. 
wounds  of,  338. 

region,  tumors  of,  881. 
Manipulation   in   reduction   of 

dislocation,  564. 
Manubrium,     dislocation       of, 

from  body  of  sternum.  569. 
Many-tailed  bandages,  135. 
Massage,  157. 
Mastitis,  acute,  861. 

chronic,  864. 
interstitial,  864. 
suppurative,  864. 

non-puerperal,  863. 

puerperal,  862. 

sloughing,  863. 
Mastodynia,  865. 
Mastoid  disease,  896. 

treatment  of,  897. 
Mastoiditis,  896. 
Masturbation,  1095. 
Mattress  suture,  166. 
Maxillary       artery,     internal, 

wounds  of,  337. 
Meatus,  urethral,  narrow,  996, 
Meckel's  ganglion,  removal  of, 

406. 
Median   nerve,    operations   on, 

408. 
Mediastinal  abscess,  839. 
Mediastinum,    tumors   of,    840. 

wounds  of,  838. 
Medio-carpal  dislocations,  589. 
Medio-tarsal  amputation,  247. 
Melanotic  carcinoma,  309. 

sarcoma,  297. 
Membrana     tympani,    injuries 

of,  894. 
Membranous  laryngitis,  simple, 

811. 
Meningeal       artery,       middle, 

wounds  of,  338. 
Meninges   of  brain,    inflamma- 
tion of,  726. 
Meningitis,   726. 

treatment  of.  728. 

tubercular,    728. 

in  hip-disease,  626. 
Meningocele.  726. 

spinal,   853. 
Menorrhagia,   1101. 
Menstrual  disturbances,  1101. 
Menstruation,     etEect     of,     on 

operations,  87. 
Mento-vertico-occipital   cravat, 

136. 


Mercury,   bichloride,    113. 
Metacarpal  bones,  amputations 
of,  232. 
dislocation  of,  589. 
fracture  of,  479. 
resection  of,  648. 
separation     of     epiphyses 

of,  480. 
of  thumb,   dislocation  of, 
589. 
Metacarpo-phalangeal  amputa- 
tions, 231. 
joints,  arthritis  of,  tuber- 
culous, 640. 
excision  of,   649. 
Metacarpus,     dislocation      of. 

Metallic    splints,    436. 
Metastasis  of  sarcoma,  297. 
Metatarsal  bones,  amputations 
of,   244. 
dislocation  of,   607. 
fracture  of,  olO. 
resection  of,  657. 
Metatarsalgia.  695. 
Metatarso-phalangeai    amputa- 
tions, 243. 
Metritis,  1118. 
Metrorrhagia.    1101. 
Microcephalus,    734. 
Micrococcus  gonorrhoea,  13. 

lanceolatus,  13. 
Micro-organisms,  1. 

aerobic,  2. 

anaerobic,  3. 

facultative  anaerobic,   3. 
Micturition,      functional      dis- 
turbances of,  1044. 
Middle    ear,    inflammation    of, 

895. 
Mikulicz  pack.  115. 
Minor  surgery,  132. 
Mixed-celled  sarcoma,   295. 
Mixed  chancre,  1196. 

tumors,  314. 
Mobility  in  fracture,   430. 
Mollifies  ossium.  524. 
Mortification,  22. 
Motor  centres  of  brain,  739. 
Moulded  plaster  splints,  149. 
Mouth,  dermoid  cyst  of,  764. 

epithelioma  of,  763. 

sterilization  of,  121. 
Mucous  cysts,   316. 
of  lip,  751. 

membranes,  endothelioma  of, 
293. 
inflammation  of,  43. 
transplantation  of,   265. 
Multilocular    cysts    of    ovary, 

1148. 
Multiple   amputation,   229. 

fracture,  427. 
Muscles,  atrophy  of,   412. 

contracture  of,  412. 

diseases  of,  411. 

gunshot  wounds  of.  188. 

hernia  of,  411. 

hypertrophy  of,  412. 

injuries  of,  410. 

ossification  of,  412. 

repair  of,  79. 

rupture  of,  410. 

spasm  of,  in  stumps,  228. 

sterno-mastoid,       congenital 
tumor  of,  410. 

strains  of,  410. 

tumors  of,  412. 

wasting   of,    after    fracture, 
520. 

wounds  of,  410. 
subcutaneous,  411. 
Muscular    spasm    in    fracture, 

430. 
Musculo-spiral     nerve,     opera- 
tions on,  408. 
Myalgia,  411. 
Myelocele,  853. 
Myelocystocele,  853. 
Myoma,  287. 
Myomectomy.  1135. 

abdominal.   1136. 


Myositis,  411. 

ossificans,  412. 
Myringitis,  894. 
Myxoma,    283. 

of  antrum,  781. 

of  breast,  871. 

of  uterus,  1132. 


N. 


Nffivus  of  tongue,  771. 
Nasal  bones,  fractures  of,  437. 
cavities,     sterilization       of, 

121. 
sinuses,   diseases   of,   757. 
tumors  of,  759. 
Nasopharyngeal  polypus,  756. 

treatment  of,   757. 
Navel,  inflammation  of,  909. 
Neck,  abscesses  of,  790. 

adenitis       of,     tuberculous, 

791. 
bursiE  of,   793. 
carbuncle  of,   789. 
cellulitis  of,  789. 
congenital  sinuses  of,   793. 
inflammation  of,  789. 
injuries  of,  788. 
lymphatic   glands   of,    affec- 
tions of,  790. 
stab-wounds  of,  788. 
tumors  of,  792. 
wounds  of,   788. 
cutthroat,  788. 
gunshot,   789. 
Necrosis,  22. 
of  bone,  526. 
of  nose,  755. 
of  stumps,  229. 
of  jaw,   777. 
Needles,  surgical,   163. 
Neoplasms  of  joints,   616. 
Nephrectomy,  1059. 
extraperitoneal,  1061. 
partial,  1061. 
transperitoneal,   1060. 
Nephritis,  effect  of,  on  opera- 
tions, 88. 
in  operations,  88. 
suppurative,  1046. 
Nephro-lithotomy,  1057. 
Nephrorrhaphy,  1058. 
Nephrotomy,   1058. 
Nerve-avulsion,  405. 
Nerve-grafting,  403. 
Nerve-stretching,  404. 
Nerve-suture,  403. 
Nerves,  compression  of,  399. 
congenital   elephantiasis   of, 

279. 
contusions  of,  398. 
dislocation  of,  400. 
division  of,  partial.  402. 
fibroma  of,  plexiform,  279. 
gunshot  wounds  of,   188. 
implantation,  404. 
injuries  of,  398. 

in      dislocations     of      hu- 
merus, 581. 
in   fractures   of   the   base 
of  the  skull,  712. 
operations  upon.     See  under 

each  nerve, 
paralysis     of,     after     anaes- 
thesia, 215. 
repair  of.   83. 
suture  of,  secondary,  402. 
wounds  of,  400. 
incised,  400. 
lacerated,  400. 
punctured,   400. 

treatment  of,  402. 
treatment  of,  401. 

system  in  operations, 


Neural  anaesthesia,  204. 
Neuralgia.  397. 

epileptiform,  397. 

of  joints,   615. 
Neurasthenia,    traumatic,    99. 
Neurectasy,  404. 


INDEX. 


1235 


Neurectomy,  405. 
Neuritis,   396. 

acute,  396. 

chronic,  396. 
Neuroma,  288. 

plexiform,  279. 
Neuromata,  403. 

of  stumps,  228. 
Neuropathic  arthritis,  614. 

gangrene,  109. 
Neuroplasty,  403. 
Neurorrhaphy,  403. 
Neuroses  of  bladder,  1043. 
Neurotomy,  405. 
Nipple,  inflammation  of,  861. 

Paget's  disease  of,  879. 
Nitrous  oxide  gas,  207. 
Noma,   762. 
Nose,  deformities  of,  751. 

foreign  bodies  in,  755. 

injuries  of,  751. 

tumors  of,   756. 

necrosis  of  bones  of,  755. 

restoration  of,  752. 


Oblique  bandage  of  jaw,  137. 

fracture,  428. 
Obstructed  hernia,  989. 
Obturator  hernia,  975. 
Occipital    artery,    ligation    of, 

383. 
Odontoma,  275. 
Odontomata,  781. 
composite,  276. 
fibrous,  276. 
follicular,    275. 
treatment  of.  276. 
CEdema  of  glottis,  810. 

malignant,   53. 
CEsophagotomy.  801. 
CEsophagus,      diverticula      of, 
802. 
foreign  bodies  in,  800. 
hysterical  spasm  of,  800. 
injuries  of,  798. 
stricture  of,  cicatricial,  799. 
Old  dislocation,  562. 
of  hip,   597. 
of  humerus.  580. 
Olecranon    bursa,    bursitis    of, 
423. 
process  of  ulna,  fracture  of, 
476. 
Oophorectomy    in     fibroid    tu- 
mors of  uterus.  1135. 
Open  fracture,  427. 
Operation,    antiseptic,    details 
of.   124. 
aseptic,  details  of.  123. 
materials  for,  125. 
preparation      of      patient 
for,   122. 
of  room   for,   123. 
upon  bone,  661. 

plastic,   663. 
conditions    affecting    results 

of,   84. 
in  epidemics,  89. 
insa.nity  after,   98. 
upon  joints,  642. 
upon  nerves.  403. 
during  shock,  95. 
upon     special     parts.       See 
under  each  part. 
Orbit,   injuries  of,   887. 
Orbital  aneurism,  372. 
Orthoptedic  surgery,  665. 
Os    calcis    bursa,    bursitis    of, 
423. 
excision  of,  656. 
fracture  of.  509. 
magnum,      dislocation       of, 

589. 
pubis,  fractures  of.  483. 
Ossification  of  muscles,  412. 

of  tendons,  420. 
Osteitis.   529. 

of  bones  of  face,  743. 
chronic,   537. 


Osteitis,  chronic,  treatment  of, 
538. 
deformans,    525. 
non-suppurative,  529. 
suppurative,    acute,    529. 
syphilitic,  542. 
tuberculous,  538. 
Osteoarthritis,  613. 
of  spine,  667. 

of  temporo-maxlllary  articu- 
lation, 782. 
Osteoclasis  in   bow-legs,   676. 

in  Itnock-knee,  673. 
Osteoma,   284. 
of  jaw,   779. 
of  skull,   703. 
treatment  of,  285. 
Osteomalacia,  524. 
Osteomyelitis,   529. 
chronic.  537. 

treatment  of,  538. 
gummatous,    544.* 

treatment  of,  544. 
Infective,  530. 
causes  of,  531. 
diagnosis  of.   533. 
pathology  of,  532. 
symptoms  of,  532. 
treatment  of,  534. 
non-suppurative,  529. 
of  skull,  699. 
suppurative,   acute,   529. 
syphilitic,  542. 

treatment   of,    543. 
traumatic,  530. 
tuberculous,  538. 

ignipuncture  in,   541. 
parenchymatous  injec- 

tions in,  541. 
treatment  of,  541. 
operative,  541. 
Osteoperiostitis,      gummatous, 

544. 
Osteoplastic      amputation      of 
leg,  251. 
flap  of  skull,  737. 
resection,    643,    663. 

of  foot,  249. 
sequestrotomy,  535. 
Osteotomy,  661. 

after-treatment  of,  663. 
in  bow-legs,   676. 
cuneiform,   662. 
in  knock-knee,  673. 
linear,  662. 
Othsematoma.  890. 
Otitis  media  catarrhalis,  895. 

chronica,   896. 
Otorrhcea,  chronic,  896. 
Oval  amputation,   221. 
Ovarian  abscess,  1147. 

tumors,  diagnosis  of,  1151. 
symptoms   of,    1150. 
treatment  of.  1152. 
Ovary,     conservative     surgery 
of,  1146. 
cysts  of,  dermoid,  1149. 
follicular,   1147. 
multilocular.  1148. 
endothelioma  of,  294. 
surgery      of,      conservative, 

1146. 
tumors  of.  1147. 
solid,   1149. 


P. 

Paget's  disease  of  nipple.  879. 
Pain  in  inflammation,  29. 

in  fracture,  430. 
Palate,  abscess  of,  786. 

adenomata  of.   787. 

aneurism  of,   787. 

caries  of.  786. 

cleft.   783. 

cysts  of.  787. 

epithelioma  of.  787. 

injuries  of.  760. 

necrosis  of.  786. 

syphilitic  aSfections  of,  786. 

tuberculosis  of,   787. 


Palate,  tumors  of.  787. 

ulceration  of,  786. 
Palmar  abscess,  417. 

arch,  deep,   ligation  of.   389. 
superficial,      ligation      of, 

389. 
wounds  of,  338. 
Pancrea.s,  cysts  of,  061. 

diseases  of.  960. 

gangrene  of,  961. 

hemorhage  into.  060. 

inflammation  of,  961. 

injuries  of,  960. 

tumors  of,  961. 
treatment  of,  962. 
Pannus  synovitis,  619. 
Papilloma,  304. 

of  gums,  779. 

of  ovary,   1149. 

of  penis,  1071. 

of  tongue,  771. 

treatment  of,  306. 
Papillomata  of  vulva.  1121. 
Paquelin's  thermo-cautery.156. 
Paracentesis   pericardii.    847. 

thoracis,  842. 
Paralysis  of  bladder,  1043. 

after  fracture,  520. 

intestinal  obstruction  from, 
951. 

of  nerves  after  anjesthesia, 
215. 

in  tuberculosis  of  the  spine, 
548. 
treatment  of,  554. 
Paralytic  tetanus.  72. 
Paraphimosis,  1066. 

in  gonorrhoga,  1214. 
Parasitic    theory    of    tumors, 

269. 
Parenchymatous     hemorrhage, 
326. 
treatment  of,  335. 
Paronychia,  420. 
Paroophoron,  cysts  of,  1148. 
Parovarian  cysts.  1148. 
Passive   motion,    158. 
Patella,  dislocations  of,  597. 

excision  of,  655. 

fracture  of.  497. 
compound.   500. 
Pathological  dislocations.  562. 
Pedicles    in    abdominal   opera- 
tion,  treatment   of.   906. 
Pelvic  bones,  diastasis  of,  591. 
dislocation  of,  591. 

cellulitis,  1119. 

hEematocele,  1153. 

peritonitis.  1118. 
Pelvis,  fractures  of,  480. 

compound,  484. 
Pemphigus,  syphilitic.   1200. 
Penis,  ablation  of,  1068. 

amputation  of.  1073. 

cellulitis  of,  1069. 

constriction    of.    1068. 

diseases  of,   1064. 

dislocation   of,   1068. 

elephantiasis  of,  1070. 

epithelioma  of,   1071. 

extirpation  of,  1073. 

fracture  of.  1068. 

frenum     of,     laceration     of, 
1068. 

herpes  of,   1069. 

inflammation  of.  1069. 

injuries  of,  1067. 

malformations  of.  1064. 

papillomata  of,  1071. 

tuberculosis  of,  1070. 

tumors  of,  1070. 

varicose  veins  of,  1070. 
Perforating  fracture,  427. 

ulcer  of  foot,  41. 
of  hand.  41. 
Perforative  peritonitis.  914. 
Pericardium,  wounds  of,  838. 
Perichondritis  of  larynx,  813. 
Perilymphangitis      In      gonor- 
rhoea.  1215. 
Perineal  hernia,  975. 
Perineorrhaphy,  1105. 


1236 


INDEX. 


Perinephritis,  1049. 

treatment  of,  1050. 
Perineum,  laceration  of,  1104. 
treatment  of,   1105  et  seq. 
Periosteal  flaps  in  amputation, 

223. 
Periostitis,  527. 

acute  suppurative,  527. 
treatment  of,  528. 

albuminous,  528. 

chronic  suppurative,  528. 

of  jaw,  777. 

non-infective,  527. 

syphilitic,   529. 

tuberculous,  528. 
Periphlebitis.  347. 
Periproctitis.  1167. 

diffused,  1167. 

gangrenous,   1167. 

localized,  1167. 
Perirectal  abscess,  1167. 
Peritoneal     adhesions     in    ab- 
dominal operations,  906. 
Peritoneum,    inflammation    of, 
911. 

injuries  of,  910. 

tumors  of,  918. 
Peritonitis,  911. 

general,  S5l5. 

gonorrhoeal,  916. 

localized,  914. 

pelvic,  1118. 

perforative,  914. 

traumatic,  913. 

treatment  of.  914. 

tubercular,  916. 
Periurethritis,  1002. 
Permanganate    of     potassium, 

117. 
Pernio.  193. 

Peroxide  of  hydrogen,  116. 
Pes  cavus,  695. 

Pessaries   in   uterine  displace- 
ments, 1127. 
Petit's  tourniquet,  330. 
Phagedena  in  chancroid,  1205. 
Phagedenic   ulceration,   39. 
Phagocytosis,  19. 
Phalanges   of   fingers,   disloca- 
tions of,  590. 

of  toes,  dislocations  of,  607. 
Pharyngotomy,  798. 

subhyoid,  798. 
Pharynx,  adenoids  of,  798. 

foreign  bodies  in,  797. 

inflammation  of,   797. 

injuries  of,  797. 

stricture  of,  797. 

tumors  of,  798. 
Phelps's     operation     in     club- 
foot,  693. 
Phimosis,  1064. 

in  gonorrhoea,*  1214. 

treatment  of,  1065. 
Phlebitis,   344. 

plastic,  344. 

treatment  of,  345. 

of  sinuses  of  brain,  728. 

suppurative,  345. 
treatment  of,  346. 
Phleboliths,   343. 
Phlegmonous  erysipelas,  49. 
Phosphorus    necrosis    of    jaw, 

777. 
Pigeon  toe,  687. 
Pisiform  bone,   dislocation  of, 
•  589. 

Plantar  aneurism,  378. 
Plantaris,  rupture  of,  413. 
Plaster-of-Paris    bandage,    ap- 
plication of.  147. 
removal  of.  150. 

dressing,  fenestrated,  149. 
interrupted,  148. 

removal     of,     from     hands, 
149. 

splints  in  fracture,  436. 
moulded,  149. 
Plasters,  152. 

isinglass,  152. 

resin,  152. 

rubber  adhesive,  152. 


Plasters,  soap,  152. 

zinc  oxide,  152. 
Plastic  arteritis,  352. 

phlebitis,  344. 

surgery,  260. 
Plate  suture,   167. 
Pleural  effusions,  840. 
purulent,  841. 
serous,    840. 
Plexiform  angioma,  351. 

fibroma  of  nerves,  279. 

neuroma,  279. 
Pneumatocele  of  scalp,  703. 
Pneumococcus,  13. 
Pneumonectomy,  846. 
Pneumonotomy,  845. 
Pneumothorax.   836. 
Poisoned  wounds,  178. 
Polymazia,  860. 
Polypi  of  auditory  canal,  893. 
Polypus,  nasopharyngeal,  756. 

of  rectum,   1187. 
adenoid,  1187. 
fibroid,  1187. 
treatment  of,  1188. 
villous,  1188. 
Popliteal  aneurism,  377. 

artery,  ligation  of,  393. 
wounds  of,  339. 

bursa,   bursitis  of,  423. 
Porous  felt  splints.  152. 
Position     in     arterial     hemor- 
rhage, 329. 
Posterior   curvature   of   spine, 
671. 

thoracotomy.   847. 

urethritis,  1210. 
Potassium  permanganate,  117. 
Pott's    disease    of    the    spine, 
546. 

fracture,   507. 
Powder  burns,   184. 
Pregnancy,  extra-uterine,  1154. 

in  operations,  87. 
Prepatellar  bursa,   bursitis  of, 

422. 
Priapism,    1070. 
Primary  hemorrhage,  326. 
Proctectomy,  1191. 
Proctitis,  1165. 

acute  catarrhal,  1166. 

chronic  catarrhal,   1166. 

dysenteric,  1166. 

gonorrhoeal,   1166. 

traumatic,  1166. 
Proctotomy,  linear,  1183. 
Progressive  septiceemia,  32. 
Prolapse  of  rectum.  1183. 
with  invagination,  1186. 

of  uterus,  1125. 

operations  for,  1129. 
Preperitoneal  hernia,  972. 
Prostate,  abscess  of,  1092. 

diseases  of,  1090. 

enlargement  of,  1025. 

hypertrophy  of,   1025,   1093. 
castration  in,  1028. 
catheterization  in,  1027. 
drainage  in,  1028. 
ligature    of   vas    deferens 
in,   1028. 

tuberculosis  of,  1091. 
Prostatectomy,  1029. 
Prostatitis,  catarrhal.   1090. 

gonorrheal,  1091,  1216. 
Prostatotomy,  1029. 
Prosthetic  apparatus  after  am- 
putation, 257. 
Protective,  129. 
Pruritus  ani,  1162. 
Pseudarthrosis,  515. 
Ptomaines,  3. 

Pubic  dislocation  of  hip,  595. 
Pudic  aneurism,  376. 

artery,    ligation   of,    391. 
Puerperal  mastitis,  862. 
Punctured  wounds.  176. 

of  arteries,  323. 
Purulent  effusion,  21. 

infiltration,  22. 
Pus,  18. 

physical  signs  of,  29. 


Pyaemia,  34. 

treatment   of,   36. 
Pyelitis,  1047. 
Pylorectomy,   935. 

Kocher's  method,   936. 
Pyloroplasty,   929. 
Pylorus,  gastro-enterostomy  in 
stricture  of.  929. 
resection  of,  in  stricture  of, 

929. 
stenosis  of,  929. 

Loreta's  method  in,  929. 
stricture  of,  pyloroplasty  in, 
929. 
Pyonephrosis,  1048. 
Pyosalpinx,   1144. 
gonorrhoeal,  1220. 
treatment  of,  1145. 


Q. 

Quadriceps      extensor      bursa, 
bursitis  of,  423. 
femoris,   rupture  of,   414. 
Quadruple  ligature,  169. 
Quilled  suture,  166. 


R. 

Rabies,   73. 

Radial  aneurism,  374. 
artery,    ligation   of,    387. 

wounds  of,  338. 
nerve,  operations  on,  408. 
Radicular  tumors,  276. 
Radio-humeral        dislocations, 

582. 
Radius,    dislocations    of    head 
of.   582. 
head  of,  fracture  of,  471. 
lower    end    of,    fracture   of, 

472. 
lower   epiphysis   of,   separa- 
tion of.  475. 
neck  of.  fracture  of,  471. 
resection  of,  647. 
shaft  of.  fracture  of,  471. 
subluxation  of  head  of,  586. 
Ranula,  763. 
acute,   764. 
Raw-hide  splints,  151. 
Ray-fungus,  59. 
Raynaud's  disease,  105. 
Recent  dislocation,  562. 
Rectal  abscess,  1168. 

fistula,       examination       of, 

1170. 

sinus.    1170. 

Rectocele.  1105. 

treatment  of,  1107. 
Recto-urethral  fistula,  1193. 
Recto-vaginal  fistula,  1193. 
Recto-vesical  fistula,  1193.  . 
Rectum,   burns  and   scalds  of, 
1157. 
cancer  of,  1188. 
carcinoma  of,  1188. 

treatment  of.  1190. 
diseases  of.  1165. 
encysted,  1181. 
examination  of,  1160. 
excision  of,  1191. 

Bardenheuer's.  1192. 
Eraske's,    1192. 
foreign  bodies  in.  1157. 
gangrene  of,  1168. 
malignant  growths  of,  1188. 
polypus  of,  1187. 
adenoid,  1187. 
fibroid,  1187. 
villous,  1188. 
prolapse  of,   1183. 
complete.  1184. 
partial.   1183. 
treatment  of.  1185. 
sarcoma  of,   1189. 
sterilization  of,  121. 
stricture  of,   non-malignant, 

1182. 
ulceration  of,  1180. 


1237 


Rectum,    ulceration   of,    catar- 
rhal, IISO. 
dysenteric,  llSl. 
syphilitic,  1181. 
traumatic,  1180. 
tuberculous,  1180. 
wounds  of,  1156. 
Recurrent    bandage    of    head, 
13T. 
of  stump,  145. 
Reef  knot,  164. 
Regional  ansesthesia,  204. 
Reid's    method    in    aneurism, 

365. 
Relaxation  sutures,  163. 
Renal  aneurism.  376. 
calculus,   1055. 

treatment  of,  1059. 
colic,  1056. 
Repair     of     fracture     of     the 

skull,  709. 
Resection  of  bones,  642. 
osteoplastic,   643,   663. 
of  pylorus  in  stricture.  929. 
of  special  bones.     See  under 

each   bone, 
subperiosteal,  643. 
Resin  plaster,  152. 
Resolution     in     inflammation, 

21. 
Respiration,  artificial,  161. 

forced,  162. 
Restoration  of  nose,   752. 
Retention  cysts,  316. 
of  breast,  880. 
of  urine  in  gonorrhoea,  1213. 
Retroflexion  of  uterus,   opera- 
tions for,  1128. 
Retrograde     '   catheterization, 

1014. 
Retromammary  abscess,  863. 
Retroperitoneal  tumors,  968. 
Retropharyngeal  abscess.  790. 
in     tuberculosis     of     the 
spine,  548. 
Retroversion  of  uterus,  1124. 

operations  for,  1128. 
Rhabdomyoma,  287. 
Rhachitis,   554. 
pathology  of,  555. 
treatment  of,  556. 
Rheumatic  arthritis,   612. 

chronic,  613. 
Rheumatism  in  operations,  87. 
Rhigolene,   201. 
Rhinoscleroma.   757. 
Rib.  cervical,   793. 
dislocation  of,  569. 
fracture  oi   442. 
resection  of,   650. 
Richter's  hernia,  977. 
Rickets,  554. 
Rodent  ulcer,  309. 
Round-celled  sarcoma,  295. 
Round     ligaments    of    uterus, 

shortening  of,  1129. 
Rubber  adhesive  plaster,  152. 
bandage,   146. 
dam,  129. 
gloves,   119. 
tissue,    129. 
Rupture  of  bladder.  1019. 
treatment  of,  1020. 
of  tendons,  413. 


Sacculated  aneurism,  358. 
Sacral  hysterectomy  in  cancer 

of  uterus,  1141. 
Sacro-iliac  disease,  640. 

treatment  of,  641. 
Sacrum,   fractures  of,  481. 
Salicylic  acid,  117. 
Saline  solution,  117. 

intravenous    injection    of, 
160. 
Salivary  calculi,  795. 
fistula,  793. 

glands,      inflammation       of, 
794. 


Salivary    glands,    injuries    of, 
793. 
tumors  of,  795. 
malignant,  795. 
mixed,  795. 
Salpingitis,    1143. 

gonorrhceal,   1220. 
Saprtemia.  31. 

treatment  of,  32. 
Sarcoma,  294. 

alveolar,  296. 

of  antrum,  781. 

of  bone,  299. 

of  breast,  869. 

treatment  of,  870. 

diagnosis  of,  301. 

erysipelas-inoculation         in, 
302. 

giant-celled,  295. 

of  gums,  778. 

of  intestine,  938. 

of  jaw,   780. 

of  kidney,   1054. 

of  larynx,  816. 

melanotic,  297. 

metastasis  of,  297. 

pathology  of,  294. 

of  rectum,   1189. 

round-celled.  295. 

of  scalp,  702. 

of  skull,  702. 

spindle-celled,  295. 

of  stomach,  930. 

of  testicle,  1082. 

of  tongue,   772. 

treatment  of,  302. 

of  uterus,  1138. 

of  vagina,  1122. 

of  vulva,  1122. 
Scalds,  190. 

of  anus,  1157. 

of  conjunctiva,  885. 

constitutional      effects      of, 
191. 

of  cornea,  885. 

of  larynx,  809. 

mortality  in,  191. 

of  tongue,  760. 

treatment  of,  191. 
Scalp,  angioma  of,  701. 

aneurism  of,  703. 
cirsoid,  703. 

avulsion  of,  175,  698. 

burns  of,  698. 

cicatrices  of,   699. 

cirsoid  aneurism  of,  703.   • 

contusions  of,  697. 

cysts  of,  dermoid,  701. 
sebaceous,  700. 

epithelioma  of,  702. 

fibroma  of,  702. 

hajmatoma  of,  697. 

inflammation  of,  698. 

Injuries  of,  697. 

lipoma  of,  701. 

pneumatocele  of,  703. 

sarcoma  of,  702. 

scalds  of,  698. 

sterilzation  of,  121. 

tumors  of,   700. 

wounds  of,  697. 
Scapula,  dislocation  of  inferior 
angle  of,  573. 

fractures  of.  450. 
of  body  of,  450. 
of  neck  of,  452. 

resection  of,  650. 
Scarification.  158. 
Schede's    operation    for    vari- 
cose veins.  350. 

thoracoplasty,   844. 
Schleich's  anaesthetic  mixture, 

214. 
Sciatic  aneurism,  376. 

artery,  ligation  of,  391. 
wounds   of,    339. 

hernia,   975. 

nerve,  operations  on,  409. 
Sclrrhus  carcinoma  of  breast, 

874. 
Scoliosis,   668. 
Scrofula,   67. 


Scrotum,      elephantiasis       of, 
1076. 
inflammation  of,  1075. 
injuries  of,  1075. 
tumors  of,   1076. 
Scultetus,  bandage  of,  135. 
Sebaceous  cysts,  315. 
of  face,  751. 
of  scalp,  701. 
Secondary  dislocations,   562. 
hemorrhage,  326. 

treatment  of,  335. 
shock,   95. 
sutures,  164. 
syphilis,   1196. 
Semilunar  bone,  dislocation  of, 
589. 
cartilages  of  knee,  displace- 
ment of,  601. 
Seminal  vesicles,  inflammation 
of,  1093. 
tuberculosis  of,  1093. 
Senile  gangrene,  102. 
Separation  of  epiphyses.     See 

Epiphyses. 
Septic  infection,  gaseous,  20. 
intoxication,  32. 
treatment  of,  32. 
Septicemia,  32. 

gonorrhceal,  611,  1216. 
progressive,   32. 
treatment  of,  33. 
Septum,  deflected,  752. 
Seguestrotomy,   534. 
osteoplastic,   535. 
Serous   membranes,    inflamma- 
tion of,  44. 
Sex    in    etiology    of    tumors, 
269, 
in  operations,  S6. 
Shell  wounds,  187. 
Shock,  91. 

amputation  during,  223. 
in  amputation,  226. 
in  burns,   191. 
diagnosis  of.  92. 
operations  during,  95. 
pathology  of,  91. 
prophylaxis  of,  93. 
reaction  from,  93. 
secondary,  95. 
symptoms  of,  92. 
treatment  of,   94. 
Shotted  suture,   167. 
Shoulder,    spica    bandage    of, 

140. 
Shoulder-joint,        amputations 
at,  239. 
arthritis       of,     tuberculous, 
637. 
tuberculosis  of,  638. 
caries  sicca  of,  638. 
diseases  of,  637. 
dislocations  of,  574. 
excision  of,  644. 
synovitis     of,     tuberculous, 

637. 
tuberculosis  of,  dry.  639. 
Silicate  of  potassium  bandage, 
151. 
of  sodium  bandage,  151. 
Silk,   126. 
Silkworm-gut,   126. 
Silver,    117. 
Silver-foil,  129. 
Simple  fracture.  427. 
Simultaneous  amputation,  229. 
Single  Jigature,  168. 
Sinus.  41. 

of  brain,  phlebitis  of,  728. 
venous,  wounds  of,  725. 
congenital,  of  neck.  793. 
nasal,  diseases  of,   757. 
rectal,  1170. 
treatment  of,  41. 
Skin,  endothelioma  of,  293. 
gunshot  wounds  of,   188. 
sterilization  of,  121. 
Skin-flaps,    transplantation   of, 


A 


1238 

Skin-grafting,  Thiersch's,  264. 
Skull,  atrophy  of,  699. 

diastasis  of  sutures  of,  706. 
epithelioma  of,  702. 
fractures  of,  704. 
of  base  of,  711. 

escape        of        cerebro- 
spinal fluid  in,  712. 
hemorrhage  in,  711. 
comminuted,  707. 
compound,  709. 
from  contre-eoup,  705. 
depressed,  709. 
diagnosis  of,  710. 
Assured,   707. 
gunshot,  714. 
mechanics  of,   704. 
penetrating,  707. 
repair  of,  709. 
symptoms  of,  710. 
treatment  of,  713. 
hemorrhage  from,  738. 
hypertrophy   of,    699. 
necrosis  of,  699. 

treatment  of,  700. 
operations    upon,    technique 

of,  736. 
osteoma  of,  703. 
osteomyelitis  of,  699. 
syphilitic,  700. 
tubercular,  700. 
osteoplastic  flap  of,  737. 
sarcoma  of,  702. 
tumors  of,  700. 
venous    sinuses    of,    wounds 
of,   341. 
Slings,    135. 
Sloughing,   22. 
Snake-bites,  181. 

treatment  of,  181. 
Soap  plaster,  152. 
Sodium  chloride,  117. 
Spanish  windlass,  330. 
Spasm  of  bladder,  1043. 
of  oesophagus,  800. 
of  urethra,  1015. 
Spermatic    cord,    injuries    of, 

1087. 
Spermatorrhoea,  1095. 
Sphacelus,  22. 

Sphenoidal      sinuses,    diseases 
of,  759. 
tumors  of,  759. 
Spica  bandage  of  foot,  144. 
of  groin,  ascending,  142. 

double,  142. 
of  shoulder,  140. 
of  thumb.  138. 
Spina  bifida,   852. 
occulta.  854. 
treatment  of,  855. 
Spinal    abscess,   treatment   of, 
553. 
accessory   nerve,    operations 

on,  408. 
arthropathy,  614. 
braces  in  tuberculosis  of  the 

spine,  552. 
cord,  compression  of,  857. 
concussion  of,  856. 
contusion  of,  856. 
inflammation  of,  855. 
injuries   of,    856. 
lacerations  of,  856. 
lesions    of,    diagnosis    of, 
857. 
symptoms  of,  857. 
treatment  of.  858. 
operations  upon,  859. 
surgery  of,  848. 
tumors  of,  855. 
wounds  of,  857. 
membranes,  inflammation  of, 

855. 
meningocele,  853. 
subarachnoid  injection,  204. 
Spindle-celled  sarcoma,  295. 
Spine,  curvature  of,  668. 
anterior.  672. 

treatment  of,  672. 
lateral,   668. 
causes  of,  669. 


Spine,    curvature    of,    lateral, 
symptoms  of,   669. 
treatment  of,  670. 
posterior,  671. 

treatment  of,  671. 
dislocation  of,  848. 
fracture  of,   849. 
fracture-dislocation  of,   849. 
spinal   cord  symptoms  In, 

850. 
symptoms  of,  850. 
treatment  of,  851. 
osteoarthritis  of,   667. 
Pott's  disease  of,  546. 
railway,   856. 
tuberculosis  of,  546. 
abscess  in,   554. 
diagnosis  of,  548. 
fixation      apparatus      in, 

551. 
paralysis  in,   548. 
recumbency  in,  551. 
symptoms  of,  547. 
treatment  of,  550. 
Spiral  bandage  of  finger,  138. 
fracture,  428. 
reversed  bandage,  133. 
of  arm,  138. 
of  leg,  145. 
Spleen,  abscess  of,  962. 
diseases  of.  962. 
tumors  of,  963. 
wandering,  962. 
Splenectomy,   963. 
Splenic  fever.  55. 
Splints,    binder's     board,    151, 
436. 
felt    436. 
in  fracture,  436. 
in  hip-disease,  629. 
leather,  151. 
metallic,    436. 
plaster-of-Paris,        moulded, 

149. 
porous  felt,  152. 
raw-hide,   151. 
Volkmann's,  502. 
wooden,  436. 
Splint-sore,   109. 
Spondylitis  deformans,  667. 
Sponges,  125. 
Spores,  3. 

endogenic,  3. 
Sprain  fracture.  428. 
of  joints,   558. 

treatment  of,  558. 
Staphylococcus    epidermis    al- 
bus,    12. 
pyogenes  albus,  12. 
aureus,   12. 
Staphylorrhaphy,  784. 
Starched  bandage,  151. 
Status  lymphatlcus,  321. 
Stenosis  of  pylorus,   929. 
Sterility,  1094. 

Sterilization  of  bladder,   121. 
of  bougies,  120. 
of  catheters,   120. 
of  feet,  122. 
fractional,   11. 
of  hands,  118. 
by  heat,  11. 

of  instruments,   120,   1006. 
methods  of.  10,  117. 
of  mouth,  121. 
of  nasal  cavities,   121. 
of  rectum.   121. 
of  scalp,  121. 
of  skin.    121. 
of  stomach,   121. 
of  urethra,  121. 
of  vagina,   121. 
Sterilized  bandages,  131. 
cotton,   131. 
gauze,  129. 
water,  125. 
Sternal  end  of  clavicle,  dislo- 
cations of,  570. 
Sterno-clavicular    articulation, 

tuberculosis  of,  640. 
Sterno-mastoid  muscle,  hsema- 
toma  of,  788. 


Sternum,  dislocation  of,  569. 
fractures  of.  444. 
resection  of,  650. 
Stings  of  insects,  180. 
Stomach,  carcinoma  of,  930. 
dilatation  of,  930. 
diseases  of,  926. 
foreign  bodies  in,  927. 
hour-glass     contraction    of, 

930. 
malignant  tumors  of,  treat- 
ment of,  931. 
operations   upon^   932. 
resection  of,  935. 
sarcoma  of,  930. 
sterilization  of,  121. 
suture  of.  907. 
tumors  of,  930. 
ulcer  of,  927. 
Stomatitis,  761. 
gangrenous,  762. 

treatment  of,  763. 
syphilitic,  761. 
Strangulated     hernia,     opera- 
tions for.  993. 
taxis  in,  991. 
treatment  of,  991. 
Strangulation  of  hernia,  990. 
of  tissues,  171. 

treatment  of,  171. 
Strapping,  153. 
joints,   153. 
of  testicle,   153. 
ulcers,  153. 
Streptococcus  pyogenes,   12. 
Streptothrix      actinomycotlca, 

59. 
Stricture  of  anus,   1165. 
aspiration     of     bladder     in, 

1014. 
of  cervix  uteri,  1102. 
diagnosis  of,  1009. 
dilatation  of,  1010. 
extravasation  of  urine  from, 

1005. 
of  intestines,  938. 

obstruction  from,  952. 
of  larynx,  814. 
of     (esophagus,     cicatricial, 

treatment  of,  799. 
of  pharynx,  797. 
of     rectum,     dilatation     of, 
1183. 
non-malignant,  1182. 
of  trachea,  814. 
treatment  of.   1010. 
of  ureter,  1062. 
of  urethra,   1002. 

Stumps,  affections  of,  228. 
conical,   228. 
contraction    of    tendons    in, 

229. 
dressing  of,  225. 
necrosis  of  bone  in,  229. 
neuromata  of,  228. 
recurrent  bandage  of,  145. 
spasm  of  muscles  in,  228. 
ulcer  of,  228. 

Styloid  process  of  ulna,   frac- 
ture of,  478. 

Styptics     in     arterial     hemor- 
rhage   333. 

Subarachnoid  injection,  spinal, 
204. 

Subastragaloid        amputation, 
247. 

Subclavian  aneurism,  373. 
artery,   ligation  of,   384. 

wounds  of,  338. 
vein,  wounds  of,  341. 

Subclavicular     dislocation     of 
humerus,  575. 

Subcoracoid  dislocation  of  hu- 
merus, 575. 

Subcutaneous  ligature.   169. 

Subcuticular  suture,  165. 

Subdeltoid   bursa,   bursitis   of, 
423. 

Subfascial  hernia,   972. 

Subglenoid   dislocation   of  hu- 
merus,  574. 


1239 


Subgluteal   bursa,   bursitis   of, 

423. 
Subhyoid    bursa,    bursitis    of, 
423. 

pharyngotomy.  798. 
Subligamentous  bursa,  bursitis 

of.  423. 
Subluxation    of    liead    of    liu- 
merus,  579. 

of  liead  of  radius.  586. 

of  lower  jaw.  567. 
Subperiosteal  excision,  643. 

fracture,  427. 

resection,  643. 
Subphirenic  abscess,  917. 
Subspinous   dislocation   of  liu- 

merus,  578. 
Sulphocarbolate  of  zinc,  116. 
Sunburn,    193. 
Superior       maxillary       nerve, 

operations  on,  406. 
Supernumerar.y  auricles,  889. 
Suppuration,   21. 

after-treatment  of,  30. 

fluctuation  in.  29. 

incision  in,  28. 
Suppurative  arteritis,   352. 

arthritis,  609. 

bursitis.    421. 

nepliritis,   1046. 

periostitis,  acute,  527. 
chronic,  528. 

phlebitis,  345. 

thecitis.   417. 
Supracondyloid      fracture      of 
femur,  495. 
of  humerus,  461. 
Supracoracoid     dislocation    of 

humerus.    579. 
Supracotyloid     dislocation    of 

hip,  596. 
Supra-orbital       nerve,      opera- 
tions  on.   406. 
Suprapubic  lithotomy.  1037. 
Suprarenal  tumors,  1053. 
Surgeon  s  knot,  164. 
Surgery,   abdominal,  tectinique 
of,   903. 

minor,   132. 

orthopsedic.  665. 

plastic,  260. 
Surgical  bacteriology,   1. 

needles,  163. 

operating-bag.   131. 
Sutures,   163. 

of  approximation,  164. 

of  arteries.   333. 

buried,  165. 

button,   167. 

catgut,  127. 

of  coaptation.  164. 

continued,  165. 

deep,     in     arterial     hemor- 
rhage, 332. 

harelip,   166. 

horse-hair.  128. 

interrupted.   165. 

of  intestine,  907. 

Lembert's.   167. 

mattress,    166. 

plate.   167. 

quilled,   166. 

of  relaxation.   163. 

removal  of.   168. 

secondary,  164. 
of  nerves,  402. 

securing  of.  164. 

shotted,   167. 

of  stomach,  907. 

subcuticular,    165. 

of  tendons.  415. 

of  veins,  334. 
Sword  wounds,  178. 
Symmetrical  .gangrene,  105. 
Synchronous  amputation,  229. 
Synovial    membranes,    inflam- 
mation of.  44. 
Synovitis,  607. 

acute,   608. 

of   ankle-.ioint,   acute,    635. 

chronic,  608. 

of  hip-joint,  acute,  621. 


Synovitis  of   hip-joint,    septic, 

622. 
of  knee-joint,   632. 

chronic,  632. 

suppurative,   acute,    632. 
pannus.  619. 
of  special  joints.     See  under 

each  joint. 
Syphilis,  1194. 
alopecia  in,   1198. 
analgesia  in,  1198. 
bone  lesions  in,  542,  1199. 
of  breast,  865. 
eruptions  of,   1196. 

treatment  of.  1204. 
glandular    enlargements    in, 

1198. 
hereditary,   bone  lesions  in, 
545. 

teeth  in,  1201. 
hypodermic       injections     of 

mercury  in,  1203. 
initial  lesion  of,  1194. 
in  operations,   89. 
secondar.v,  1196. 
of  tongue,   primary,  769. 

secondary,   769. 

tertiary.   770. 
treatment  of,  1201. 
Syphilitic  affections  of  palate, 

786. 
arteritis,    354. 
arthritis.   612. 
bubo,   1196. 
bursitis,  422. 
cachexia,  1199. 
dactylitis,   1199,   1201. 
diseases  of  bone,  542. 
iritis.    1201. 
laryngitis.    812. 
osteitis,  542. 
osteomyelitis,  542. 
pemphigus.   1200. 
periostitis,   529. 
stomatitis.  761. 
tenosynovitis,  419. 
tubercle,  1199. 


T. 
Talipes,   689. 
calcaneus,  694. 
equino-varus.  691. 

open  incision  in,  693. 
equinus.  695. 
treatment  of,  689. 
valgus,  693. 
Tarsal  bones,  excision  of.  657. 
joints,  arthritis  of,  tubercu- 
lous,   637. 
diseases  of,  636. 
synovitis  of,  acute.  636. 
Tarsalgia.  696. 
Tarsectomy   in    club-foot.    691, 

692. 
Tarso-metatarsal    amputation, 

246. 
Taxis,  in  strangulated  hernia, 
991. 
accidents  in.   992. 
contraindications        to, 
992. 
T-bandage.  double,  134. 

single,    134. 
Teale's  method  in  amputation, 

221. 
Teeth    in    hereditary    syphilis, 

1201. 
Temporal    artery,    ligation   of, 

384. 
Temporo-maxillary        articula- 
tion, arthritis  of,  782. 
disease  of.   782. 
noisy  movements  of.   568. 
osteoarthritis  of.  782. 
Tendo     Achillis,     rupture     of, 

414. 
Tendons,     contraction     of.     in 
stumps.    229. 
dislocation  of.  416. 
gunshot  wounds  of.   188. 
lengthening  of,  416. 


Tendons,    ossification  of,   420. 

repair  of,   79. 

rupture  of.  413. 

suture  of,  415. 
secondary,  415. 

transplantation  of.   In  club- 
foot,  691. 

tumors  of,  420. 

wounds  of,  415. 
Tenosynovitis,  416. 

gonorrheal,  419. 

non-suppuratlve.  416. 

serofibrinous,  416. 

suppurative,  417. 

tuberculous,  418. 
Tenotomy    in    club-foot,     690, 

692. 
Teratoid  tumors,  270. 
Tertiary  syphilis,  1199. 
Testicle,     abscess     of,     metas- 
tatic, 1080. 

anomalies  of.  1076. 

carcinoma  of.  1082. 

contusion  of.   1078. 

cysts  of.  1081. 

dislocation  of,  1079. 

ectopic.  1077. 

hernia  of,  1079. 

inflammation  of.  1079. 

sarcoma  of,   1082. 

strapping  of.   153. 

torsion  of,  1078. 

tuberculosis  of.  1080. 

tumors  of.  1081. 

undescended.  1077. 

wounds  of,  1078. 
Tetanus,    68. 

facial,    72. 

hydrophobic.   72. 

paralytic,  72. 

treatment  of,  72. 
T-fracture  of  condyles  of  hu- 
merus, 464. 
Thecitis.  416. 

suppurative.  417. 
Thiersch's  skin-grafting.  264. 
Thigh,  amputations  of.  253. 
Thoracoplasty.    844. 

Bstlander's,  844. 

Schede's,   844. 
Thoracotomy.  842. 

anterior,  846. 

Bryant's,  847. 

Milton's,  846. 

posterior.  S47. 
Thrombosis.  34.  342. 

in  fracture.  520. 

treatment  of.  344. 
Thrombus,  mixed,  343. 

red.    343. 

white,  343. 
Thumb,  dislocations  of.  590. 

and  metacarpal  bone,  ampu- 
tation of.  233. 

spica  bandage  of,  138. 
Thyroglossal  cysts,  274. 

tumors,  274. 
Thyroid  artery,   inferior,   liga- 
tion of,  386. 
superior,   ligation  of,  382. 

dermoids.  272. 

dislocation  of  hip.  594. 

gland,  inflammation  of.  803. 
tumors  of.  804. 
malignant.   807. 
Thyroidectomy.  805. 
Thyrotomy.   817. 
Tibia,    curvature   of,   anterior, 
677. 

epiphysis     of     tuberde     of, 
separation  of.   504. 

fracture  of.  503. 

lower    end    of,    fracture    of, 
504,  505. 

lower   epiphysis    of.    separa- 
tion of.  504. 
'resection  of.  655. 

upper   epiphysis    of,    separa- 
tion of.  504. 
Tibial  aneurism.   378. 

artery,  anterior,  ligation  of. 
393. 


1240 


Tibial    artery,    posterior    liga- 
tion  of,    394. 
wounds  of,  339. 

nerves,  operations  on,  409. 
Tissues,  regeneration  of,  75. 

strangulation  of,  171. 
Toe-nail,  ingrowing,  687. 

treatment  of,  688. 
Toes,  amputations  of,  243. 

phalanges    of.    fracture    of, 
510. 
Tongue,  abscess  of,  767, 

actinomycosis  of,  771. 

burns  and  scalds  of,  760, 

carcinoma  of,  772. 

chancre  of,    769. 

excision  of,  774. 
Kocher's,  775. 
partial,  774, 
Whitehead's,  774. 

gummata  of,   770. 

lupus  of,  768. 

nsevus  of,   771. 

papilloma  of,  771. 

sarcoma  of,   772. 

syphilis  of,  primary,  769. 
secondary,  769. 
tertiary,   770, 

tuberculosis  of,  768. 

tumors  of,  771. 

ulceration  of.  768. 

wounds  of,  761. 
Tongue-tie.  765. 
Tonsils,  abscess  of,  796. 

hypertrophy  of.  796. 

inflammation  of,  795. 

tumors  of.   796. 
Torsion     in     arterial     hemor- 
rhage, 332. 

of  testicle,  1078, 
Torticollis,  665. 

open  incision  in,  667, 

subcutaneous    tenotomy    in, 
667. 

treatment   of,   666. 
Tourniquets,  217. 

in  arterial  hemorrhage,  330. 

Petifs,  330. 
ToxiBmia,   32. 
Toxalbumins.  4. 
Toxines,  3, 
Trachea,  fistula  of,  827. 

fracture  of,  809. 

stricture  of,  814, 

tumors  of,   819. 

wounds  of,  808. 
Trachelorrhaphy,  1111. 
Tracheocele,  819, 
Tracheotomy.  821, 

after-treatment  of,   824. 

anfesthetic  in,  822, 

complications  after,  825. 

difficulty  in  removing  tubes, 
826.      . 

emphysema  after,  825. 

operation  of,   82,3. 
Tracheotomy-tubes,  822. 

difflcult.v  in  rfemoval  of.  826. 
Transfusion  of  blood,   160, 
Transperitoneal       ligation     of 

iliac  artery,  390. 
Transplantation     of      mucous 
membrane,   265, 

of  skin-tlap,  265. 

of  tendons  in  club-foot,  691. 
Transverse  fracture.  428. 
Traumatic  aneurism,  355. 

cataract,  882. 

delirium,  97. 

treatment  of,  97. 

dislocation,  562. 

epithelial  cyst,  268. 

exophthalmos,  888. 

fever,  95. 

treatment  of,  96, 

gangrene,   106. 

hysteria,   99. 

treatment  of,  99, 

neurasthenia,  99. 
treatment  of,  99, 

osteomyelitis,  530. 

peritonitis,  913, 


Traumatic  proctitis,   1166. 
spreading  gangrene.  109. 
theory  of  tumors,  268. 
Trendelenburg's   operation   for 
varicose  veins,  350. 
position  in  abdominal  oper- 
ations,  905, 
Trephining,  736. 

for  depressed  bone,   787. 
Trigger-flnger,  684. 
Trusses  for  hernia,  982, 
Tubercle  of  tibia  bursa,  bursi- 
tis of,  423. 
Tubercular     inflammation     of 
intestines,  937. 
meningitis,  728. 
peritonitis,  916. 
Tuberculosis,  61. 

of  acromio-clavicular  articu- 
lation, 640, 
bactericidal  applications  in, 

66. 
Blers's  constriction  in,  66, 
of  bladder,  1024, 
of  breast,  864. 
external  infection  in,  62, 
inoculation  in,  61. 
iodoform  injections  in,  66. 
of  the  kidney,  1050. 

treatment  of,  1051. 
of   knee-joint,    diagnosis   of, 

633. 
lymphatic  infection  in,  62. 
in  operations,  89. 
operative  treatment  of,  66, 
of  palate,  787. 
pathology  of,   61. 
of  penis,   1070. 
of  prostate,  1091. 
sclerogenic  method  in,  66, 
of  shoulder-joint,  dry,  630. 
of  the  spine,  546. 

spinal  braces  in,  552. 
of    sterno-clavicular    articu- 
lation, 640. 
of  testicle,  1080. 
of  tongue,  768. 
treatment  of,  65. 
tuberculin  in,  66. 
of  urethra,  1002. 
visceral,  in  hip-disease,  626. 
Tuberculous  abscess,  65. 
adenitis  of  neck,  791. 
arteritis,  354. 
arthritis.  618. 

of  ankle-joint,  635. 

treatment  of,  636. 
of     hip-joint.       See    Hip- 
disease, 
of  interphalangeal  joints, 

640. 
of  knee-joint.  633. 

treatment  of,  634, 
of      metacai-po-phalangeal 

joints,    640. 
of  shoulder-joint.   637. 

treatment   of,   638, 
of  tarsal  joints,   637. 

treatment  of,  637. 
of    the    wrist-joint,     639, 
640. 
infarction,   64. 
laryngitis,  812. 
osteitis,   538, 
osteomyelitis,  538. 

pathology  of,  539. 
periostitis,   528. 
synovitis    of    shoulder-joint, 
637. 
treatment  of.  637. 
of  the  wrist-joint,  639. 
tenosynovitis,  418. 
ulcer,   62. 
Tubular  carcinoma,   309. 
Tumors,   266. 

abdominal,  diagnosis  of,  963 

et  seq. 
age  in  etiology  of,  269. 
of  antrum,  781. 
of  back,   852, 
benign,   266. 
of  bladder,  1040. 


Tumors  of  bone,  526. 

of  the  breast,  866. 

of  callus.  519. 

classification  of,  267. 

dermoid,  270. 

effect  of  country  on,  270. 
of  race  on,  270. 

epithelial  cystic,  275. 

of  ethmoidal  sinuses,  759. 

etiology  of,  267. 

of  face,   747. 

fibrous,  277. 

foetal    inclusion    theory    of, 
267. 

of  gums,   778. 

heredity  in,  270. 

intracranial,   734, 
symptoms  of,  735, 

intrathoracic,  846, 

of  jaw,  778, 

of  larynx,  815. 
benign,   815, 

lymphatic,   320. 

malignant,  266. 

of  mediastinum,   840. 

mixed,  314. 

of  muscles,  412. 

of  neck,    792. 

of  nose,   756. 

of  palate,  787. 

parasitic  theory  of,  269, 
•    of  pharynx,   798. 

radicular,  276. 

retroperitoneal,  968. 

Ribbert's  theory  of,  268. 

of  salivar.v  glands,  795. 

sex  in  etiology  of,   269. 

of  sphenoidal  sinuses,  759, 

of  spinal  cord,  855, 

of  tendons,   420. 

teratoid,  270. 

thyroglossal.  274. 

of  thyroid  gland,   804, 
enucleation   of,    805. 
malignant,   807. 
treatment  of,  804. 

of  tongue,   771. 

of  tonsil.  796. 

of  trachea,  819. 

traumatic  theory  of,  268, 

trophic  influences  on,  269. 

of  urethra,  1016. 
Tunica    vaginalis,    hsematocele 
of,  1087, 
hydrocele  of,  1083. 
Turbinated  bones,  hypertrophy 

of,  755. 
Typhoidal  ulcers,  937, 


U. 
Ulcer,  37, 

of  anus,   irritable,   1162. 

chronic.  37. 

of  duodenum,  937. 

indolent,  37. 

Jacob's,  309. 

phagedena  in,  39. 

rodent.  309. 

simple,   37. 

venereal,   1204, 

of  stomach,  927. 
treatment  of,  928, 

strapping  of,  153, 

of  stump,  228. 

treatment  of,  39, 

tuberculous,  62. 

varicose,  38, 
Ulceration  of  larynx,  814, 

of  palate,  786. 

phagedenic,   39. 

of  rectum,   1180. 

of  tongue,  768. 
Ulcerative  stomatitis,   761. 
Ulna,      coronoid     process     of, 
fracture   of,   478. 

fractures  of,   475. 

lower   epiphysis   of,    separa- 
tion of,  478. 

olecranon    process    of,    frac- 
ture of.  476. 

resection  of,   647. 


Ulnar  aneurism,  374. 
artery,  ligation  of,  388. 

wounds  of,  338. 
nerve,  operations  on,  408. 
Unabilical  cord,  hernia  in,  973. 
hernia,  973. 

adult,   974. 

infantile,   974. 

radical  cure  of,  987. 
Umbilicus,      inflammation      of, 

909. 
Ununited    fracture,    513. 

drilling  in,  516. 

excision    and    fixation    In, 
517. 

friction  in.  516. 

mechanical   apparatus   In, 
516. 

treatment  of,  515. 

varieties  of,   514. 
Uranoplasty,  785. 
Ureteral   calculus,   1063. 

fistula,   1062. 
Ureters,  anomalies  of,  1062. 
diseases  of,  1062. 
wounds  of,  1062. 
Urethra,  atresia  of,  997. 
calculi  in,  996. 
congenital      deformities    of, 

996. 
diverticula  of,  1001. 
examination  of,  1007. 
follicles  of,  enlargement  of, 

1001. 
foreign  bodies  in,  996. 
inflammation  of,  1001. 
injuries  of,  995. 
introduction  of  instruments 

in,  1007. 
spasm  of,  1015. 
sterilization  of,  121,   1006. 
stricture  of,  1002. 

of  large  caliber,  1004. 
tuberculosis  of.  1002. 
tumors  of,  1016. 
Urethral  caruncle,  1001. 
fever,   1006. 
fistula,  1015. 
meatus,  narrow,  996. 
mucous    membrane,    prolap- 
sus of,  1001. 
Urethritis,   1001. 
chronic,  1217. 

treatment  of,  1218. 
posterior,   1213. 
Urethrotomy,   external,   1012. 

with  guide,  1012. 

without  guide,  1013. 
internal,  1010. 
Urinary   fistula,   1021. 
infiltration,  1005. 
organs,  surgery  of,  995. 
Urine,   extravasation  of,   from 

stricture,  1005. 
in  operations,  88. 
retention   of.   In  gonorrhoea, 

1213. 
Uterus,  adenoma  of,  1132. 
anteflexion  of,  1124. 

operations  for,  1130. 
anteversion  of.  1124. 

operations  for.  1130. 
carcinoma  of,  1138. 
displacements  of.  1124. 
pessaries  in.  1127. 

treatment  of,    1126. 
fibroid  tumors  of,  oophorec- 
tomy In.   1135. 
fibromyoma  of,   1132. 
inversion  of,  1130. 
myxoma  of,   1132. 
prolapse  of,  1125. 

hysterectomy  for,   1130. 

operations  for.  1129. 
retroflexion  of,   1124. 


INDEX. 

Uterus,  retroversion  of.  1124. 
round  ligaments  of,  shorten- 
ing of,  1129. 
rupture  of.  1103. 
sarcoma  of.   1138. 
tumors  of,  1132. 
vaginal  fixation  of,  1128. 
ventrofixation  of,   1128. 
ventrosuspension   of,   1128. 


V. 

Vagina,  cicatrices  of,  1115. 
cysts  of,  congenital,  1121. 
epithelioma  of,   1122. 
fibromyomata  of,  1122. 
injuries  of,  1104. 
laceration  of.   1104. 
sarcoma  of,  1122. 
sterilization  of,  121. 
tumors  of,   1120. 
Vaginal    fistula,    1112. 
fixation  of  uterus,  1128. 
hysterectomy    in    cancer    of 
uterus,  1140. 
for      fibroid      tumors      of 
uterus.  1136. 
Vaginismus,    1123. 
Vaginitis,  1115. 

in  gonorrhoea.   1220. 
Varicocele,  1087. 

treatment  of.  1088. 
Varicose  aneurism,  355. 
ulcer,  38. 
veins,   347. 

of  vulva,   1123. 
Varix,  347. 

aneurismal.   354. 
arterial,  351. 
Vas    deferens,    ligature   of,    in 
hypertrophy      of      prostate, 
1028. 
Ve§:etatIons  of  anus.  1164. 
Veins,  contusion  of,  339. 
entrance  of  air  into,  340. 
injuries  of,   339. 
laceration  of,   339. 
rupture  of,  339. 
suture  of,  334. 
varicose.  347. 
excision  in,  350. 
multiple  ligatures  in,  350. 
operative     treatment     of, 

350. 
phlebitis  of,  349. 
rupture   of,    348. 
Schede's       operation      in, 

350. 
thrombosis  of.  348. 
treatment  of,   349. 
Trendelenburg's  operation 
in,  350. 
Velpeau's  bandage,  140. 
Venereal  diseases.  1194. 
ulcer,  simple,  1204, 
warts,  1220. 

treatment  of.  1220. 
Venesection,  159. 
Venous  hemorrhage,  326.  334. 
sinuses    of    brain,    phlebitis 
of,  728. 
wounds  of,  725. 
of  skull,  wounds  of,  341. 
Ventral  hernia,  974. 

radical  cure  of,  988. 
Ventrofixation    of    sigmoid    In 
prolapse  of  rectum,  1186. 
of  uterus,   1128. 
Ventrosuspension     of     uterus, 

1128. 
Vertebrse,   surgery  of,   848. 
Vertebral    artery,    ligation   of, 
385. 
wounds  of,  338. 


1241 

Vesical  calculus,  1030. 
diagnosis  of,  1032. 
in  female,  1040. 
treatment  of,  1033. 
Vesicants,  156. 
Vesi  co-vaginal  fistula,  1112. 
Vesiculitis,  1217. 
Villous     polypus     of     rectum, 

1188. 
Volkmann's   splint.    502. 
Volvulus,  953. 
Vulva,  elephantiasis  of,   1123. 

epithelioma  of,    1122. 

papIUomata  of,  1121. 

sarcoma  of,  1122. 

tumors  of.   1120. 

varicose  veins  of,  1123. 

warts  of,  1121. 
Vulvitis,  1115. 


W. 

Wardrop's   operation   in   aneu- 
rism, 366. 
Warts  of  anus.  1164. 

venereal.  1220. 
Water,  sterilized.  125. 
Webbed  fingers,  683. 
Wet  cupping,  159. 
White  gangrene,  105. 
Wooden  splints,  436. 
Wool-sorter's  disease,  55. 
Wounds,  170. 
arrow,  178. 
bayonet,   178. 
from  blasting,   184. 
of  the  brain,  721. 
bullet,  186. 
contused,   175. 

treatment  of,  175. 
dissection,  178. 
of  face.   742. 
of  fascia,  412. 
foreign  bodies  In,  173. 
gunshot,  182. 
incised,  172. 
of  bone,  424. 
treatment  of,   172. 
infected,     antiseptic     treat- 
ment of,  124. 
aseptic  treatment  of,  124. 
of  joints.   559. 
lacerated,   174. 

treatment  of,  174. 
of  nerves,   400. 
poisoned,  178. 
punctured.   176. 

treatment  of,   176. 
repair  of.  75 
of  special  parts.     See  under 

each  part, 
sword,   178. 
of  tendons,   415. 
Wrist,  amputation  at.  235. 
dislocations  of,   587. 
compound.   588. 
Wrist-joint,  diseases  of,  639. 
excision  of,  647. 
synovitis     of,      tuberculous, 
639. 
Wry-neck,  665. 


Zinc  chloride.   116. 

oxide  plaster.   152. 

sulpho-carboiate,  116. 
Zygoma,  fracture  of.  439. 


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